Obstructive Airway Disorders
A nurse is caring for a client with COPD. Which position best promotes lung expansion and ventilation?
High Fowlers or leaning forward in a tripod position.
Which assessment finding is most consistent with pneumonia?
A. Clear breath sounds
B. Crackles
C. Bradycardia
D. Hyperactive bowel sounds
B. Crackles
Name three risk factors for pulmonary embolism.
A client develops sudden, sharp unilateral chest pain and shortness of breath following a central line placement. The nurse notes decreased breath sounds on the affected side and an SpO₂ of 89%.
Which complication should the nurse suspect?
A. Pleural effusion
B. Pneumothorax
C. Pulmonary edema
D. Atelectasis
B. Pneumothorax
A ventilator's high-pressure alarm sounds. Which problem should the nurse suspect?
Increased airway resistance, such as secretions, coughing, biting the tube, or kinked tubing.
Which oxygen delivery device provides the most precise concentration of oxygen and is commonly used for clients with COPD?
Venturi mask.
Which finding is more commonly associated with typical bacterial pneumonia?
A. Gradual onset with dry cough
B. Productive cough with purulent sputum
C. Mild symptoms with headache
D. Nonproductive cough only
B. Productive cough with purulent sputum
A client who is 2 days postoperative following a total hip replacement suddenly reports shortness of breath and anxiety. The nurse notes a heart rate of 118/min, respiratory rate of 28/min, and SpO₂ of 89% on room air. The client reports sharp chest pain that worsens with inspiration.
Which assessment finding would require the nurse to act most urgently?
A. Heart rate of 118/min
B. Sharp chest pain with inspiration
C. SpO₂ of 89% on room air
D. Sudden onset of respiratory distress
D. Sudden onset of respiratory distress
Which finding is most concerning for a tension pneumothorax?
A. Mild chest discomfort
B. Tracheal deviation with severe respiratory distress
C. Productive cough
D. Bilateral crackles
B. Tracheal deviation with severe respiratory distress
A ventilator's low-pressure alarm sounds. What is a likely cause?
A. Secretions
B. Patient coughing
C. Disconnected tubing
D. Bronchospasm
C. Disconnected tubing
A client experiencing an acute asthma attack has wheezing, dyspnea, and chest tightness. Which medication should the nurse expect to administer first?
A. Fluticasone
B. Albuterol
C. Montelukast
D. Salmeterol
B. Albuterol
A client develops severe respiratory distress following sepsis. Oxygen saturation remains low despite supplemental oxygen. The chest x-ray shows bilateral pulmonary infiltrates. Which condition should the nurse suspect?
Acute respiratory distress syndrome (ARDS).
A client suddenly develops severe dyspnea and an SpO₂ of 82%. What is the nurse's priority action?
Address the airway/breathing and apply supplemental oxygen while activating appropriate emergency assistance.
A client has a chest tube connected to a drainage system following treatment for a pneumothorax. During assessment, the nurse notes that the water-seal chamber is at the expected level, there is no tidaling, and the client's respiratory status has suddenly worsened.
Which action should the nurse take first?
A. Clamp the chest tube
B. Increase the wall suction
C. Assess the tubing for kinks or obstruction
D. Empty the drainage collection chamber
C. Assess the tubing for kinks or obstruction
Name three interventions that help prevent ventilator-associated pneumonia.
A client is admitted with status asthmaticus. Which medication should the nurse anticipate administering in addition to repeated short-acting bronchodilator treatments to decrease airway inflammation?
A. Furosemide
B. Methylprednisolone
C. Warfarin
D. Acetazolamide
B. Methylprednisolone
A client with pneumonia is receiving oxygen at 4 L/min via nasal cannula. Over the past hour, the nurse notes that the client has become increasingly restless and confused. The respiratory rate is 32/min, SpO₂ is 86%, and the client is using accessory muscles. Which action should the nurse take first?
A. Increase the oxygen flow rate to 6 L/min
B. Obtain an arterial blood gas
C. Notify the rapid response team and prepare to support the client's airway and ventilation
D. Administer the prescribed IV antibiotic
C. Notify the rapid response team and prepare to support the client's airway and ventilation
A client with a pulmonary embolism is receiving IV heparin. Which laboratory value is used to monitor the therapeutic effect of unfractionated heparin?
aPTT
The chest tube becomes accidentally disconnected from the drainage system. What should the nurse do?
Place the end of the chest tube in sterile water to create a temporary water seal, then obtain/reconnect to a new drainage system according to policy.
A mechanically ventilated client is receiving a continuous propofol infusion. The client is hemodynamically stable and has no evidence of active seizures or increased intracranial pressure. During the morning assessment, the nurse is preparing to perform a daily sedation interruption.
Which finding would cause the nurse to hold the sedation interruption and notify the provider?
A. The client has a RASS score of −4
B. The client has been mechanically ventilated for 4 days
C. The client becomes agitated when sedation is decreased
D. The client is receiving enteral nutrition
A. The client has a RASS score of −4
A client with obstructive sleep apnea asks why CPAP is prescribed.
CPAP maintains positive airway pressure to prevent upper-airway collapse during sleep.
A client with a pulmonary embolism is receiving supplemental oxygen. The client's SpO₂ remains 88% despite increasing oxygen delivery. Which explanation best describes why the client continues to experience hypoxemia?
A. The pulmonary embolism prevents the client from moving air into the alveoli.
B. The pulmonary embolism causes areas of the lung to be ventilated but inadequately perfused.
C. The pulmonary embolism causes excessive carbon dioxide production by the alveoli.
D. The pulmonary embolism causes fluid to accumulate inside the alveoli, preventing oxygen diffusion.
B. The pulmonary embolism causes areas of the lung to be ventilated but inadequately perfused.
A client is receiving an IV heparin infusion for treatment of a pulmonary embolism. Which finding should the nurse report immediately?
A. aPTT within the prescribed therapeutic range
B. Small amount of blood noted when brushing the client's teeth
C. New onset of severe headache and confusion
D. Mild bruising at previous venipuncture sites
C. New onset of severe headache and confusion
A client returns to the unit after a thoracentesis. Which finding requires the most immediate intervention by the nurse?
A. Mild discomfort at the puncture site
B. Respiratory rate of 22/min with SpO₂ of 86%
C. Small amount of drainage on the dressing
D. Improved breath sounds over the previously affected lung
B. Respiratory rate of 22/min with SpO₂ of 86%
A client has been mechanically ventilated for several days following acute respiratory failure. The client is awake and follows commands. Current findings include:
Which action should the nurse anticipate?
A. Increase the FiO₂ to 50% before attempting weaning
B. Continue deep sedation to prevent accidental extubation
C. Evaluate the client for a spontaneous breathing trial
D. Increase the PEEP to prevent alveolar collapse
C. Evaluate the client for a spontaneous breathing trial