1. Digital clubbing
2. Elevated temperature
3. Barrel-shaped chest
4. Diminished breath sounds
Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections. A nurse should report an elevated temperature to the provider, as this indicates a possible respiratory infection.
1. extra drainage system
2. suture removal set
3. container of sterile water
4. nonadherent pads
The nurse should plan to place the open end of the tubing if it becomes disconnected into the sterile water to prevent a pneumothorax. The tubing and sterile water are then placed below the client’s chest.
1. Fluctuation of drainage in the tubing with inspiration
2. continuous bubbling in the water seal chamber
3. drainage of 75mL in the first hour after surgery
4. several small, dark-red blood clots in the tubing
continuous bubbling in the water seal chamber suggests an air leak
1. gag reflex
2. pain level
4. redness at the IV insertion site
the greatest risk to the client is aspiration due to the depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag relfex
1. A client who has a closed-head injury and is lethargic
2. A client who has a fractured femur and reports severe pain
3. A client who has a ruptured appendix and a temperature of 39 C (102.2 F)
4. A client who has emphysema and respiration’s of 36/min
A recent head injury is a contraindication for nasopharyngeal suctioning because suctioning can increase intracranial pressure.
1. blood pressure
2. capillary refill
3. arterial blood gases
4. heart rate
when using the airway, breathing, circulation approach the client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.
1. increase in respiratory rate
2. increase in oxygen saturation
3. decrease in carbon dioxide retention
4. decrease in intercostal retractions
an increase in respiratory rate indicates increased work of breathing and the need for improvement in oxygen delivery.
2. insertion site pain
3. tracheal deviation to the unaffected side
4. temperature 37.3C (99.1F)
when using the airway, breathing, circulation approach to client care, the nurse should identify tracheal deviation as the priority assessment because this indicates a tension pneumothorax, which is a medical emergency
1. “I will take this medication with each meal.”
2. “I will take this medication during my asthma attacks.”
3. “I will take this medication up to three times per day when I begin to wheeze.”
4. “I will take this medication every evening, even when I do not have symptoms.”
Montelukast is used for prophylaxis of asthma exacerbation and is taken on a daily basis in the evening. The client should take montelukast every day as maintenance therapy for asthma.
1. decreased fremitus
2. SaO2 95% on room air
3. temperature 38.8C (101.8F)
An elevated temperature is an expected finding for a client who has bacterial pneumonia.
1. oxygen saturation 89%
2. productive cough with green sputum
3. clubbing of fingers
4. pursed-lip breathing with exertion
A nurse should report a productive cough with green sputum to the provider as this indicates an infection.
1. ringing in the ears is expected
2. purified protein derivative (PPD) skin test results will improve in 4 months
3. urine and other secretions will be orange.
4. take the medication with meals.
rifampin will turn urine and other secretions orange.
1. Nasal cannula
2. Nonrebreather mask
3. Simple face mask
4. partial rebreather mask
a nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This delivers greater than 90% FIO2, which provides the highest level of oxygen.
1. collapsed neck veins on the affected side
2. collapsed neck veins on the unaffected side
3. tracheal deviation to the affected side
4. tracheal deviation to the unaffected side
a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.
1. Apply supplemental oxygen
2. increase the rate of IV fluids
3. administer pain medication
4. initiate heparin therapy
when using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the firest action the nurse should take is to apply supplemental oxygen.
1. cromolyn sodium
3. fluticasone and salmeterol
the nurse should administer albuterol, a short-acting beta 2-adrenergic agonist, as it acts quickly to produce bronchodilation during an acute asthma attack.
1. schedule respiratory treatments following meals
2. have the client sit in a chair for 2-hr periods three times per day
3. provide a diet that is high in calories and protein
4. combine activities to allow for longer periods between activities
the nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.
the nurse should initiate airborne precautions for the client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air
1. excess secretions
2. kinks in the tubing
3. artificial airway cuff leak
4. biting on the endotracheal tube
An artificial airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound.
1. provide a quiet environment
2. encourage use of incentive spirometry every 1 to 2 hr
3. initiate continuous cardiac monitoring
4. administer heparin via continuous IV infusion
Using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.
1. blood-tinged sputum
2. decreased tactile fremitus
3. resonance with percussion
4. peripheral edema
the nurse should expect blood-tinged sputum secondary to bleeding from the tumor
1. bleeding at the surgical site
2. oxygen saturation
3. urinary retention
4. level of consiousness
Using the airway, breathing, circulation approach to client care, the nurse should identify the client’s oxygen saturation is the priority assessment. A client who is postoperative following a total laryngectomy is at risk for hypoxia due to airway obstruction and decreased oxygen saturation is an indication of obstructed airway
1. lateral position with a pillow over the chest to support the arm
2. high-fowler’s position with arms supported on the overbed table
3. semi-fowler’s position with pillows supporting both arms
4. supine position with the head of the bed elevated 15 degrees
the nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms on the overbed table
1. pH 7.50, PO2 95mm Hg, PaCO2 25 mm Hg, HCO3- 22mEq/l
2. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/l
3. pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/l
4. pH 7.30, PO2 80 mmHg, PaCO2 55 mm Hg, HCO3- 22 mEq/l
these ABG values indicate respiratory acidosis. The pH is less than 7.35 and the paCO2 is greater than 45 mmHG, which indicates respiratory acidosis
assisting with this procedure? (select all that apply)
1. wear goggles and make during the procedure
2. cleanse the area with an antiseptic solution
3. instruct the client to take deep breaths during insertion of the needle
4. position the client laterally on the affected side
5. apply pressure to the site after the needle is withdrawn
cleanse the area with an antiseptic solution–the use of antiseptic solution decreases the risk of infection, which is increased due to the invasive procedure
apply pressure to the site after the needle is withdrawn–the application of pressure decreases the risk of bleeding at needle insertion site.
1. use clean technique to suction the client’s endotracheal tube
2. use a rotating motion to remove the suction catheter
3. suction the oropharngeal cavity prior to suctioning the endotracheal tube
4. suction the client’s endotracheal tube every 2 hr
the nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue trauma
1. arterial pH 7.50
2. paCO2 25 mm Hg
3. SaO2 92%
4. PaO2 58 mm Hg
the nurse should expect the client who has acute respiratory failure to have a lower partial pressures of oxygen
1. a client who is 12 hr postoperative following a total hip arthroplasty
2. a client who is 8 hr postoperative following an open surgical appendectomy
3. a client who is 2 hr postoperative following an open reduction external fixation of the right radius
4. a client who is 4 hr postoperative following a laparscopic cholecystectomy
the nurse should identify the client who has undergone a total hip replacement surgery is a greatest risk for a pulmonary embolus due to decreased mobility of the affected extremity. Therefore, this is the priority finding.
1. “I need to inspect the stoma for signs of infection or skin irritation.”
2. “I will clean the cannula with half-strength peroxide and rinse with saline.”
3. “I can remove the old twill ties once the new ties are place.”
4. “I should apply suction while inserting the catheter into my tracheostomy.”
the client should apply suction only when withdrawing the catheter to prevent tracheal tissue trauma