ATI – Respiratory

Following a motor-vehicle crash a client is admitted with multiple trauma, including significant bruising of the left chest from striking the steering wheel. The client is alert and reports severe left pain on inspiration. The nurse should assess the client for manifestations of pneumothorax, including:
Absence of breath sounds

Which changing soiled Velcro ties for a client w a tracheotomy, the client suddenly coughs, dislodging the trach tube. Which nursing action is appropriate?
Reinsert the trach tube

A client is scheduled for a thoracentesis. Into which position should the nurse assist the client?
Sitting while leaning forward over the bedside table

A nurse is caring for a client who is admitted in an extremely anxious state. The client’s ABG values are pH 7.47, PO2 94, PCO2 30, and HCO3 25. What should the nurse do?
Have the client breathe slowly into a paper bag

An older adult client is admitted with respiratory acidosis as a complication of COPD. The nurse suspects that this is related to which of the following?
Decreased exhalation of co2

A nurse is reviewing a care plan for a client admitted following chest tube placement for a spontaneous pneumothorax. Which of the following interventions is appropriate?
Tape all connections between the chest tube and drainage system

While a nurse is reinforcing preop teaching for a client scheduled for a r pneumonectomy, the client tells the nurse I cough all the time, and I’m really afraid it will hurt when I cough after surgery. What is an appropriate response?
I will show you how to splint your incision while coughing

A nurse is caring for a client transferred from the PACU following a l pneumonectomy for adenocarcinoma. Which type of chest drainage?
No chest drainage

A nurse is assisting with the care of a client who has a trach in place. The nurse determines that the client’s airway secretions require suctioning after auscultating the lung fields and prepares to apply suction using the open method.
1. Explain the procedure
2. Increase the flow of oxygen
3. Insert the suction catheter
4. Apply suction

A client is admitted to the emergency dept following a motorcycle crash. The nurse notes a crackling sensation while palpating the skin on the client’s r chest. The nurse notifies the charge nurse and documents the presence of?
Crepitus

A nurse is caring for a client who has a trach with an inflated cuff in place. Which of the following indicates that the nurse should suction the client’s airway secretions?
The nurse auscultates coarse crackles in the lung fields

A nurse is reinforcing teaching for a client with emphysema about pursed lip breathing. The nurse reminds the client that pursed lip breathing will help do which of the following?
Promote carbon dioxide elimination

Following a bronchoscopy, a client is sleepy but asks for a drink. Nurse’s first action?
Check the client’s gag reflex

A nurse is reviewing the discharge teaching plan with a client hospitalized following an acute exacerbation of reactive airway disease. When reminding the client how to prevent acute asthma attacks, what should the nurse plan to discuss first?
The client’s perception of the disease process and what may have triggered the current attack

When collecting data from a client with reactive airway disease who is experiencing an acute asthma attack, the nurse should expect to auscultate for which of the following?
An expiratory wheeze

To meet the goal of maintaining an adequate nutritional status for a client who has pneumonia, the nurse includes?
Provide oral hygiene care after respiratory aerosol therapy treatments and before meals

A client diagnosed with pneumonia is prescribed chest physiotherapy (CPT) q4h. in planning the client’s care, the nurse understands that the purpose of CPT is which of the following?
Mobilize secretions in the airway

A pulse oximeter reading from a client diagnosed with smoke inhalation is 85% with a 40% face mask. The provider prescribes an increase of the o2 to 50%. Because the client is at high risk for adult respiratory distress syndrome (ARDS), the nurse must observe for which?
Increased restlessness

A nurse is caring for a client who has acute respiratory failure and is being treated with mechanical ventilation. The low pressure alarm on the ventilator begins to sound continuously. Which of the following is an appropriate nursing action?
Look for loose connections

While observing a client who is unconscious following major trauma, the nurse notes that a portion of the client’s chest pulls inward on inspiration. On expiration, the same portion expands outward. The nurse documents the presence of which of the following?
Flail chest

A nurse is caring for a client who has lung cancer. which of the following assessment findings should the nurse expect? Blood-tinged sputum A nurse is caring for a client who is 4 hr postoperative following a total laryngectomy for …

A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? A. Lateral position with a pillow at the back and over the chest …

A nurse working in the emergency department is caring for a client following a chest trauma. What findings indicates a tension pneumothorax? Tracheal deviation to the unaffected side. Rat.: a tension pneumothorax results from free air filling the chest cavity, …

A nurse is caring for a client who is taking albuterol. For which of the following adverse effects should the nurse monitor the client? 1. Hyperkalemia 2. Dyspnea 3. Tachycardia 4. Candidiasis Tachycadia A nurse is assessing a client who …

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company? Fit all employees with protective masks. A recent immigrant is diagnosed with pulmonary …

1. A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for this client? a. Avoid activities that elicit the Valsalva maneuver. b. …

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