CA II: Respiratory

Chest Tubes may be used for drainage in what types of situations?
1. pleural effusion – drains fluids
2. hemothorax – drains blood
3. pneumothorax – drains air
Assessment Data prior to beginning drainage care should include what?
1. Vitals
2. RR (in Vitals) & O2 SAT
3. Lung Sounds
4. Pain
Prior to beginning make your assessment make sure to address and provide appropriate care of what?
Pain, administer analgesic prn/prescribed
What is the most important assessment in the draining system? (in red) Give rationale
Observe the dressing around the chest tube insertion site and ensure that it is dry, intact, and occlusive. If the dressing is not intact an occlusive, air can leak into the space, causing displacement of the lung tissue, and the site could be contained. Some pt.’s experience significant drainage or bleeding at the insertion site, and the dressing needs to be replaced to maintain occlusion of the site.
When checking all connections securely taped palpate what? What will you hear?
1. Gently palpate the insertion site – feel for emphysema (air/gas under skin)
2. Emphysema will sound crunchy, spongy or like popping under fingers
How/where do you apply Kelly clamps when changing the drainage system? (in red) The Kelly clamps prevent what?
Apply Kelly clamps 1.5 – 2.5 inches from insertion site and 1 inch apart, going in opposite directions. Kelly clamps prevent air from entering the pleural space through the chest tube
What is important while using padded clamps and unrolling the foam tape? (in red)
DO NOT PULL ON CHEST TUBE
You must keep the end of the chest tube _________ upon insertion of the end of the new drainage system into the chest tube.
1. sterile
Prolonged clamping may result in what?
1. pnuemothorax
Prior to the removal of the chest you should give what? (in red)
1. assess pain and give anelgesic prn; rationale: procedure is uncomfortable and painful
After the physician has removed chest tube and secured the occlusive what should you assess? (in red)
1. Assess lung sounds, RR, O2 SAT, Pain Level
Who removes the chest tube?
Typically the physician removes the chest tubes, but some institutions train nurses to remove the chest tube
The physician WILL order what after the chest tube removal?
1. Chest X-Ray
If respiratory distress occurs after the procedure and and lung sounds are absent what is this a potential sign for? What should you do?
1. Notify physician immediately
2. sign that the lung is not re-inflated
How often do you change the dressings?
1. q. 24 hours
What should you assess for upon changing the dressing? (2)
1. erythema
2. drainage
Replace the occlusive dressing with _______ technique.
1. sterile
What is included in the Respiratory Assessment for prior to chest tube drainage and before removing the chest tube?
1. RR & O2 SAT for baseline
2. Tachypenia, Hyopxia – Respiratory Distress
3. Lung sounds
4. Pain
A “closed water seal” drainage system prevents what?
The “suction control chamber” prevents what?
1. Air from entering the chest once it has escaped
2. suction pressure from being applies to the pleural cavity
It is important that you observe what to ensure the drainage system is working properly once connected? (in red)
1. The presence of bubbling in the water-seal chamber. Add water prn to maintain levels at 2-cm mark.
Fluctuation of the level of the water in the water-seal chamber with inspiration and expiration is a ____________ finding. Bubbles upon initial insertion or when air is being removed is a __________ finding. Constant bubbles is an _________ finding and indicates what?
1. normal
2. normal
3. abnormal, air leak
The drainage amount recorded should be a __________ ________ since the drainage system is __________ _________ because if you open the system it will lose its _____________ pressure.
1. running total
2. never emptied
3. negative
What steps should you take if the chest tube separates from the drainage device?
1. Put tube in normal saline bottle to create water seal while new drainage system is being placed.
2. Do not leave Patient
3. Notify Physician
4. Assess respiratory distress
What steps should you take become dislodged?
1. Apply occlusive dressing (foam tape or Vaseline impregnated Gauze) STAT
2. Notify Physician – physician will determine if chest tube needs replacement
3. Assess respiratory rate
If you notice a lack of drainage in the tubing where it was present before you should NOT do what? Why? Notify who?
1. Milking or Stipping the tube
2. Dangerous negative pressure in pleural space, bruising and trauma to the lung tissue
3. Physician
What is an indication of “fresh bleeding” and requires notification to physician STAT?
Drainage exceeds 100 mL/hr OR becomes bright red
If the chest tube drainage suddenly decreases and the water seal chamber is not tidaling you should notify the physician as this may be a sign of what?
The tube is blocked
What should you keep at bedside to ensure you are prepared should a complication occur with the tubing?
1. sterile solution bottle
2. Two Kelly clamps
3. Additional dressing material
If the patient has a small pneumothorax what may be used?
Heimlich valve
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which of the following problems is a priority when the nurse develops a nursing plan of care?
1. Infection.
2. Confusion.
3. Ineffective coughing and deep breathing.
4. Difficulty chewing solid foods.
3.
In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from airways, ineffective coughing and deep breathing should receive priority attention.
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
1. Elevate the head of the bed 30 to 45 degrees.
2. Encourage the client to cough and deep breathe.
3. Auscultate the lungs to detect abnormal breath sounds. 4. Contact the physician.
1.
Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client’s status, but the priority in this case is alleviating the symptoms.
A 79-year-old female client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client’s health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most likely be a predisposing factor for the diagnosis of pneumonia?
1. Age.
2. Osteoarthritis.
3. Vegetarian diet.
4. Daily bathing.
1.
The client’s age is a predisposing factor for pneumonia; pneumonia is more common in elderly or debilitated clients. Other predisposing factors include smoking, upper respiratory tract infections, malnutrition, immunosuppression, and the presence of a chronic illness. Osteoarthritis, a nutritionally sound vegetarian diet, and frequent bathing are not predisposing factors for pneumonia.
Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
1. Quality of breath sounds.
2. Presence of bowel sounds.
3. Occurence of chest pain.
4. Amount of peripheral edema.
5. Color of nail beds.
1, 3, 5.
A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the client with pneumonia.
A client with bacterial pneumonia is to be started on I.V. antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins?
1. Urinalysis.
2. Sputum culture.
3. Chest radiograph.
4. Red blood cell count.
2.
A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Neither a urinalysis, a chest radiograph, nor a red blood cell count needs to be obtained before initiation of antibiotic therapy for pneumonia.
When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following laboratory values?
1. Serum sodium.
2. Serum potassium.
3. Serum creatinine.
4. Serum calcium.
3.
It is essential to monitor serum creatinine in the client receiving an aminoglycoside antibiotic because of the potential of this type of drug to cause acute tubular necrosis. Aminoglycoside antibiotics do not affect serum sodium, potassium, or calcium levels.
A client with pneumonia has a temperature of 102.6 ° F (39.2 ° C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
1. Position changes every 4 hours.
2. Nasotracheal suctioning to clear secretions.
3. Frequent linen changes
4. Frequent offering of a bedpan.
3.
Frequent linen changes are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client’s productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.
Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client’s:
1. Decreased cellular demand for oxygen.
2. Reduced episodes of coughing.
3. Diminished pain when breathing deeply.
4. Ability to expectorate secretions more easily.
1.
Exudate in the alveoli interferes with ventilation and the diffusion of gases in clients with pneumonia. During the acute phase of the illness, it is essential to reduce the body’s need for oxygen at the cellular level; bed rest is the most effective method for doing so. Bed rest does not decrease coughing or promote clearance of secretions, and it does not reduce pain when taking deep breaths.
The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?
1. Decreased cardiac output.
2. Pleural effusion.
3. Inadequate peripheral circulation.
4. Decreased oxygenation of the blood.
4.
A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation. Decreased cardiac output may be a comorbid condition in some clients with pneumonia; however, it is not the cause of cyanosis. Pleural effusions are a potential complication of pneumonia but are not the primary cause of decreased oxygenation. Inadequate peripheral circulation is also not the cause of the cyanosis that develops with bacterial pneumonia.
A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for:
1. A mild but constant aching in the chest.
2. Severe midsternal pain.
3. Moderate pain that worsens on inspiration.
4. Muscle spasm pain that accompanies coughing.
3.
Chest pain in pneumonia is generally caused by friction between the pleural layers. It is more severe on inspiration than on expiration, secondary to chest wall movement. Pleuritic chest pain is usually described as sharp, not mild or aching. Pleuritic chest pain is not localized to the sternum, and it is not the result of a muscle spasm.
Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?
1. Encourage the client to breathe shallowly.
2. Have the client practice abdominal breathing.
3. Offer the client incentive spirometry.
4. Teach the client to splint the rib cage when coughing.
4.
The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain.
The nurse administers two 325 mg aspirin every 4 hours to a client with pneumonia. The nurse should evaluate the outcome of administering the drug by assessing which of the following? Select all that apply.
1. Decreased pain when breathing.
2. Prolonged clotting time.
3. Decreased temperature.
4. Decreased respiratory rate. 5. Increased ability to expectorate secretions.
1, 3.
Aspirin is administered to clients with pneumonia because it is an analgesic that helps control chest discomfort and an antipyretic that helps reduce fever. Aspirin has an anticoagulant effect, but that is not the reason for prescribing it for a client with pneumonia, and the use of the drug will be short term. Aspirin does not affect the respiratory rate, and does not facilitate expectoration of secretions.
Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? 1. Coma.
2. Apathy.
3. Irritability.
4. Depression.
3.
Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.
The client with pneumonia develops mild constipation, and the nurse administers docusate sodium (Colace) as ordered. This drug works by:
1. Softening the stool.
2. Lubricating the stool.
3. Increasing stool bulk.
4. Stimulating peristalsis.
1.
Docusate sodium (Colace) is a stool softener that allows fluid and fatty substances to enter the stool and soften it. Docusate sodium does not lubricate the stool, increase stool bulk, or stimulate peristalsis.
Which of the following is an expected outcome for an elderly client following treatment for bacterial pneumonia? 1. A respiratory rate of 25 to 30 breaths/ minute.
2. The ability to perform activities of daily living without dyspnea.
3. A maximum loss of 5 to 10 lb of body weight.
4. Chest pain that is minimized by splinting the rib cage.
2.
An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/ minute indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 lb is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.
The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order should the nurse explain the steps to the client?
1. “Breathe in normally through your nose for 2 counts (while counting to yourself, one, two).”
2. “Relax your neck and shoulder muscles.”
3. “Pucker your lips as if you were going to whistle.”
4. “Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two, three, four).”
2, 1, 3, 4.
The nurse should instruct the client to first relax the neck and shoulders and then take several normal breaths. After taking a breath in, the client should pucker the lips, and finally breathe out through pursed lips.
The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PC02 62; PO2 70; HCO3 34 The nurse should:
1. Apply a 100% non-rebreather mask.
2. Assess the vital signs.
3. Reposition the client.
4. Prepare for intubation.
2.
Clients with chronic COPD have CO2 retention and the respiratory drive is stimulated when the PO2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation.
When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the the client to expect to:
1. Develop respiratory infections easily.
2. Maintain current status.
3. Require less supplemental oxygen.
4. Show permanent improvement.
1.
A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.
Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands his care plan?
1. The client promises to do pursed-lip breathing at home. 2. The client states actions to reduce pain.
3. The client says that he will use oxygen via a nasal cannula at 5 L/ minute.
4. The client agrees to call the physician if dyspnea on exertion increases.
4.
Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the nurse should notify the physician. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/ minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.
.
Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)?
1. Increased anteroposterior chest diameter.
2. Underdeveloped neck muscles.
3. Collapsed neck veins.
4. Increased chest excursions with respiration.
1.
Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.
When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which of the following?
1. Participate regularly in aerobic exercises.
2. Maintain a high-protein diet.
3. Avoid exposure to people with known respiratory infections.
4. Abstain from cigarette smoking.
4.
Cigarette smoking is the primary cause of COPD. Other risk factors include exposure to environmental pollutants and chronic asthma. Participating in an aerobic exercise program, although beneficial, will not decrease the risk of COPD. Insufficient protein intake and exposure to people with respiratory infections do not increase the risk of COPD.
Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?
1. To promote oxygen intake.
2. To strengthen the diaphragm.
3. To strengthen the intercostal muscles.
4. To promote carbon dioxide elimination.
4.
Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.
Which of the following is a priority goal for the client with chronic obstructive pulmonary disease (COPD)?
1. Maintaining functional ability.
2. Minimizing chest pain.
3. Increasing carbon dioxide levels in the blood.
4. Treating infectious agents.
1.
A priority goal for the client with COPD is to manage the signs and symptoms of the disease process so as to maintain the client’s functional ability. Chest pain is not a typical symptom of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.
A client’s arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3 −, 36 mEq/ L. The nurse should assess the client for?
1. Cyanosis.
2. Flushed skin.
3. Irritability.
4. Anxiety.
2.
The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but are associated with hypoxia.
When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract?
1. Friction between the cilia.
2. Force of gravity.
3. Sweeping motion of cilia.
4. Involuntary muscle contractions.
2.
The principle behind using postural drainage is that gravity will help move secretions from smaller to larger airways. Postural drainage is best used after percussion has loosened secretions. Coughing or suctioning is then used to remove secretions. Movement of cilia is not sufficient to move secretions. Muscle contractions do not move secretions within the lungs.
When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects:
1. While inhaling through an open mouth.
2. While exhaling through pursed lips.
3. After exhaling but before inhaling.
4. While taking a deep breath and holding it.
2.
Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias.
The nurse teaches a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan?
1. Clubbing of nail beds.
2. Hypertension.
3. Peripheral edema.
4. Increased appetite.
3.
Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxemia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected?
1. Normal breath sounds.
2. Prolonged inspiration.
3. Normal chest movement.
4. Coarse crackles and rhonchi.
4.
Exacerbations of COPD are commonly caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD?
1. High oxygen concentrations will cause coughing and dyspnea.
2. High oxygen concentrations may inhibit the hypoxic stimulus to breathe.
3. Increased oxygen use will cause the client to become dependent on the oxygen.
4. Administration of oxygen is contraindicated in clients who are using bronchodilators.
2.
Clients who have a long history of COPD may retain carbon dioxide (CO2). Gradually the body adjusts to the higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidified, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators.
Which of the following diets would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)?
1. Low-fat, low-cholesterol diet.
2. Bland, soft diet.
3. Low-sodium diet.
4. High-calorie, high-protein diet.
4.
The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated. There is no need for the client to eat bland, soft foods.
The nurse administers theophylline (Theo-Dur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate?
1. Suppression of the client’s respiratory infection.
2. Decrease in bronchial secretions.
3. Relaxation of bronchial smooth muscle.
4. Thinning of tenacious, purulent sputum.
3.
Theophylline (Theo-Dur) is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions.
The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which of the following instructions should be included?
1. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation.
2. Lie flat on the back, splint the thorax, take two deep breaths, and cough.
3. Take several rapid, shallow breaths and then cough forcefully.
4. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.
1.
The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process three or four times, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation (” huff” cough). Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing.
A client uses a metered-dose inhaler (MDI) to aid in management of his asthma. Which action by the client indicates to the nurse that he needs further instruction regarding its use? Select all that apply.
1. Activation of the MDI is not coordinated with inspiration. 2. The client inspires rapidly when using the MDI.
3. The client holds his breath for 3 seconds after inhaling with the MDI.
4. The client shakes the MDI after use. 5. The client performs puffs in rapid succession.
1, 2, 3, 4, 5.
Utilization of an MDI requires coordination between activation and inspiration; deep breaths to ensure that medication is distributed into the lungs, holding the breath for 10 seconds or as long as possible to disperse the medication into the lungs, shaking up the medication in the MDI before use, and a sufficient amount of time between puffs to provide an adequate amount of inhalation medication.
A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/ minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, which action should the nurse take to initiate care of the client?
1. Initiate oxygen therapy and reassess the client in 10 minutes.
2. Draw blood for an arterial blood gas analysis and send the client for a chest X-ray.
3. Encourage the client to relax and breathe slowly through the mouth.
4. Administer bronchodilators.
4.
In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, I.V. corticosteroids and, possibly, I.V. theophylline (Theo-Dur). Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis and obtaining a chest X-ray. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention.
A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; Pco2 48; Po2 58; HCO3 26. Which of the following orders should the nurse perform first?
1. Albuterol (Proventil) nebulizer.
2. Chest x-ray.
3. Ipratropium (Atrovent) inhaler.
4. Sputum culture.
1.
The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.
A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma?
1. Promote bronchodilation.
2. Act as an expectorant.
3. Have an anti-inflammatory effect.
4. Prevent development of respiratory infections.
3.
Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.
The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply.
1. The inhaler is held upright.
2. The head is tilted down while inhaling the medicine.
3. The client waits 5 minutes between puffs.
4. The mouth is rinsed with water following administration. 5. The client lies supine for 15 minutes following administration.
1, 4.
The client should shake the inhaler and hold it upright when administering the drug. The head should be tilted back slightly. The client should wait about 1 to 2 minutes between puffs. The mouth should be rinsed following the use of a corticosteroid MDI to decrease the likelihood of developing an oral infection. The client does not need to lie supine; instead, the client will likely to be able to breathe more freely if sitting upright.
A client is prescribed metaproterenol (Alupent) via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverse effects of metaproterenol? 1. Irregular heartbeat.
2. Constipation.
3. Pedal edema.
4. Decreased pulse rate.
1.
Irregular heartbeats should be reported promptly to the care provider. Metaproterenol (Alupent) may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.
A client who has been taking flunisolide (AeroBid), two inhalations a day, for treatment of asthma.has painful, white patches in his mouth. Which response by the nurse would be most appropriate?
1. “This is an anticipated adverse effect of your medication. It should go away in a couple of weeks.”
2. “You are using your inhaler too much and it has irritated your mouth.”
3. “You have developed a fungal infection from your medication. It will need to be treated with an antifungal agent.”
4. “Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem.”
3.
Use of oral inhalant corticosteroids such as flunisolide (AeroBid) can lead to the development of oral thrush, a fungal infection. Once developed, thrush must be treated by antifungal therapy; it will not resolve on its own. Fungal infections can develop even without overuse of the corticosteroid inhaler. Although good oral hygiene can help prevent development of a fungal infection, it cannot be used alone to treat the problem.
Which of the following is an appropriate expected outcome for an adult client with well-controlled asthma?
1. Chest X-ray demonstrates minimal hyperinflation.
2. Temperature remains lower than 100 ° F (37. 8 ° C).
3. Arterial blood gas analysis demonstrates a decrease in PaO2.
4. Breath sounds are clear.
4.
Between attacks, breath sounds should be clear on auscultation with good air flow present throughout lung fields. Chest X-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal.
Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?
1. Incorporate physical exercise as tolerated into the daily routine.
2. Monitor peak flow numbers after meals and at bedtime. 3. Eliminate stressors in the work and home environment. 4. Use sedatives to ensure uninterrupted sleep at night.
1.
Physical exercise is beneficial and should be incorporated as tolerated into the client’s schedule. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Peak flow does not need to be monitored after each meal. Stressors in the client’s life should be modified but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep.
The nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack?
1. Occupational exposure to toxins.
2. Viral respiratory infections.
3. Exposure to cigarette smoke.
4. Exercising in cold temperatures.
2.
The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Some asthmatic attacks are triggered by exercising in cold weather.
Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma?
1. Cough productive of yellow sputum.
2. Bilateral expiratory wheezing.
3. Chest tightness.
4. Respiratory rate of 30 breaths/ minute.
1.
A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms- wheezing, chest tightness, and increased respiratory rate- are all findings associated with an asthma attack and do not necessarily mean an infection is present.
Pediatric pulmonary disease accounts for what percent of hospitalizations and deaths in kids?
Pediatric Pulmonary disease accounts for 20% of hospitalizations in children; 50% of deaths in children <1 year old
What are some causes of airway obstruction?
Airway obstruction is a common problem in children due to a narrow airway; causes can include viral syndromes, malformations, foreign body, etc.
From the nares, what is the path of airflow in the respiratory tract?
Nasal and oral cavities-→pharynx -→ larynx–→ trachea -→R/L Bronchi -→ Terminal bronchioles and alveoli
What are the normal respiratory rates in and infant, 1yr old, 5 yr old and 10 yr old?
– Infant < 1yr 40-50 breaths/min awake, 25-35 sleeping – Infant > 1yr 30-40 breaths/min
– 5 yr old 25 breaths/min
– 10 yr old 20 breaths/min
What are some patterns of breathing?
• “Periodic breathing” of infancy
• Retractions, accessory muscle use, nasal flaring
• Increased effort to breath commonly seen in airway obstruction
What is stridor?
o Stridor: inspiratory sound, harsh/gasping noise from upper airway; usually due to airway obstruction; if occurs with respiratory distress this is an emergency
What is grunting?
o Grunting: forced exhalation with grunting sound; seen with significant wheezing, hypoxia, other lung diseases
What is a wheeze?
end expiratory sound, squeaky, musical, high pitched noise; produced from lower airways when constricted/obstructed
What is rhonchi?
“snoring” sound, congested, secretions in airway
What are crackles and rales?
“popping” sound, “crinkling cellophane”, fluid in alveoli, suggests pneumonia or pulmonary edema
What are the 5 diagnostic aids?
1. Pulse oximeter:
2. Pulmonary Function Tests (we will discuss with asthma)
3. ABG if in-patient
4. Sputum Culture (usually not possible in peds)
5. Imaging: CXR PA/LAT (can show airway obstruction, pneumonia, edema, hyperinflation); CT; MRI
A pulse ox of >95% is:
PO2 is fine
A pulse ox of 92-95% is:
acceptable, but needs intervention
A pulse ox of <92% is:
concerning, and oxygen may need to be administered with other intervention
What are 3 therapeutic measures you can use?
1. O2
2. Bronchodilators
3. Pulmonary chest PT
What does O2 offer as a therapeutic meausure?
• Decreases work of breathing and resp sxs
• Out-patient: via nasal cannula or mask
• Goal of PO2 >92%
What do bronchodilators offer as a theapeutic meaure?
– B adrenergic agonists: temporarily open up tightened airways
– Used in bronchiolitis, wheezing, asthma, CF
– Delivered by nebulizer or inhaler
– Nebulizer used in infants and young children with a mask
– Inhaler used with spacer device & mouthpiece/mask; convenient, portable, less time consuming
What does pulmonary chest PT offer as a therapeutic measure?
uses percussion and positional drainage to clear secretions; used daily in CF patients (20 min treatment in various body positions over sections of lung- done multiple times/d
What is croup?
• Croup: otherwise known as Acute Laryngotracheobronchitis
o Viral disease of the upper airway, causing edema and narrowing of the subglottic space
o Very commonly seen in pediatrics
What is the epidemiology of croup?
primarily seen in ages infancy to 6 yrs, peak age 2; season- late fall, early winter
What pathogens cause croup?
parainfluenzae virus 1,2,3, RSV
What are the clinical features of croup?
o Prodrome of cold sxs, cough and hoarseness develops barking “seal like” cough, waxes and wanes, worse at night and early morning, normal to low grade fever; sxs usually last 3-5 days
What would you find on physcial exam with croup?
possible stridor on inspiration, transmitted upper airway sounds, classic cough and hoarseness; respiratory distress possible
How is croup diagnosed?
usually based on history and exam
What would you see on imaging with croup?
neck x-ray shows classic “Steeple Sign” (subglottic narrowing in trachea) Unusual to order x-ray for croup
How would you treat croup?

Mild Croup: No distress by hx or exam; treatment at home with humidifier, fluids, cold air > steam, education for parents on worsening sxs, consider oral steroids

Moderate: Respiratory distress, poor feeding, dehydration, low PO2→admit to hospital: croup tent (humidified air/O2),oral or IV steroids

Severe: Respiratory distress with risk of obstruction: steroids, humidified air/O2, consider intubation

What dose of oral prednisone would you use?
1mg/kg QD-BID
What dose of prednisolone would you use?
15mg/5ml (teasponn)
What causes laryngitis?
Influenza A, adenovirus, rhinovirus
What are the symptoms of laryngitis? How would you diagnose and treat this?
• Symptoms: Sore throat, cough, hoarse voice
• Diagnosis: by hx and exam; mild erythema in posterior pharynx, hoarse voice or loss of voice
• Treatment: voice rest, humidifier, steam
What is epiglotitis?
• Inflammation and swelling of the epiglottis or subglottic structures
• This is a true medical emergency
What causes epiglotitis?
rare since vaccination with HIB; causes are H.influenza type b and Group A beta-hemolytic strep
What are the sign and symptoms of epiglotitis?

dysphagia, drooling, fever, inspiratory stridor, retractions, sore throat, lethargy, toxic appearance, muffled voice

Classic “sniffing position”: sxs are worse when supine, so pt sits upright leaning forward with neck hyper extended, tongue protruded and drooling

What would you not do on physical exam with epiglotitis?
Do NOT try to visualize the epiglottis, depressing the tongue could cause laryngeal spasm and airway obstruction
What would you find find on lateral neck x-ray with epiglotitis?
“thumb” sign, classic swelling of epiglottis
How do you treat epiglotitis?

Antibiotics such as ceftriaxone to cover H.flu; airway management, isolation for 24hrs after abx

Prophylaxis of household members, or other direct contacts with rifampin

What is congenital subglottic stenosis?
o subglottic stenosis not otherwise caused by trauma/intubation, compression
o May present with normal health/growth/dev’t, along with prolonged episode of croup, cough, hoarseness, weak/unusual cry
o Stridor is biphasic (inspiratory and expiratory)
How would you diagnose and treat congenital subglotic stenosis?
o Diagnosis: lateral neck film; bronchoscopy
o Treatment: most outgrow with watchful waiting, some need dilation
What causes acquired subglottic stenosis?
o Causes: trauma by intubation, infection, FB, chemical
o History of FB, intubation or chemical aspiration usually noted
How does acquired subglottic stenosis present? How would you treat it?
o Presentation same as with congenital stenosis
o Treatment: may require corticosteroids, epinephrine, or intubation (acquired usually more severe than congenital
What is tracheomalacia and laryngolmalacia?
o Cartilage of the trachea and larynx has not hardened in some infants and can interfere with airway patency
o Pressure outside the airway > intraluminal pressure and can cause degrees of airway collapse
What are the symptoms and treatment of tracheomalacia and laryngomalacia?
o Symptoms: croupy cough, expiratory phase prolonged, coarse upper airway sounds
o Treatment: usually conservative with observation; improves over time, however, can coexist with vascular rings and tracheoesophageal fistulas (which can compress airway)
At what age is aspiration of a foreign body most common?
o Aspiration most common in ages 6months-4years old
What objects are high risk for foreign body aspiration?
small toys, large pieces of food, foods such as peanuts, hard candy, popcorn, grapes, hotdogs
What are the symptoms of foreign body aspiration?
o Symptoms: abrupt onset of cough, wheeze, choking
What type of obstruction can you have in the upper respiratory tract if you have aspirated a foreign body?
o Can be complete obstruction: pt can’t talk or cough(Heimlich
o Partial obstruction: cough, drooling, or stridor; try to get child to cough in order to extrude
How would a foreign body aspiration present in the lower respiratory tract?
• sxs depend on site of obstruction
• Many times aspiration not witnessed
• Consider aspiration in differential dx for: chronic cough, persistent wheeze, recurrent pneumonia, asymmetric BS or localized wheezing
What is the diagnosis and treatment of foreign body aspiration?
o Diagnosis: History, exam, CXR (inspiratory and expiratory films!)
o Treatment: Bronchoscopy, Heimlich
What is bronchiolitis and what is the MCC?
o A viral illness in young children caused by inflammation and constriction in the small airways
o RSV (Respiratory Syncytial Virus) is the most common cause; other causes are parainfluenza, influenza, rhinovirus
o Disease most common in winter and spring, and usually lasts 10-14 days
What are the clinical symptoms of bronchiolitis?
o Clinical Symptoms: onset of rhinorrhea, sneezing, low grade fever, and cough. Followed by wheezing and possible tachypnea; and usually lasts 10-14 days
o Symptoms can progress to retractions, prolonged expiration, resp. distress, cyanosis
o Wheezing should be scattered throughout the chest
o Isolated/localized wheezing should suggest……….?
How do you diagnose and treat bronchiolitis?
o Diagnosis: clinical, but RSV Cx or antigen assay by nasal swab can confirm
o CXR: hyperinflation, atelectasis, peribronchial cuffingo Treatment: Most can be managed out-pt
o Fluids, O2, Bronchiodilators (B2agonists), possible oral steroids
o 5% require hospitalization
o Reasons for hospitalization: age<6months, hypoxemia, po2 < 92%, moderate respiratory distress, RR >50-60 sleeping, chronic cardiopulmonary disease, prematurity

What type of bronchodilators would you use for bronchiolitis, at what dose and dosage?
Bronchiodilators include: Albuterol, Proventil, Xopenex, Accuneb, Maxair, Ventolin
o Dosing: 1 vial of pre-mixed neb solution, or 2 puffs of MDI
o Bronchodilators used Q 4 hrs for out-pt tx with significant wheezing, Q 4-6 hrs for mild wheezing
How can you prevent bronchiolitis and for whom is it indicated?
“Synagis” a RSV immune globulin; used for premature infants, infants with chronic cardiopulmonary disease, or immunodeficiency
Is bronchitis a common disease in kids? What would cause it and what symptoms would you find?
No (unless an underlying medical condition). Is inflammation of large airways, usually caused by a viral infection. Would find a chronic, dry or productive cough with expiratory rhonchi
What are the common causes of chronic cough in kids?
Asthma, GERD, Allergies, Sinusitis, Pertussis
What are the causes of pneumonia?

Viral, bacterial, fungal, parasitic, rickettsial, inflammatory (SLE), toxic (smoke, molds, aspiration)

Children: Majority viral; Infants (CMV, RSV, Influenza); <5y/o (RSV, adenovirus, influenza); >5y/o (influenza)
o 10-30% bacterial: Infants( Staph aureus, H flu, Strep pneumo); <5y/o (same as infants); >5y/o (Strep pneumo, H flu, Mycoplasma, C. pneumoniae) (Ages 5-15 mycoplasma quite common)
o Often unable to distinguish viral from bacterial cause

Where can pneumonia be located?
o Lobar: localized to 1 or more lobes (not usually in young children)
o Interstitial: alveoli, sacs/ducts, bronchioles
o Bronchopneumonia: bronchioles, patchy consolidation of multiple lobes
What findings would you expect with bacterial pneumonia?
Signs/sxs depend on age, organism, and severity of disease
• Infants sxs are few and non-specific; often afebrile
• Sxs: onset of fever, cough and chest pain acute; URI sxs, ill appearing, fever (usually higher with bacterial), respiratory distress, increased RR
• Chest exam: rales, decreased BS, egophony over area of pneumonia
• Extrapulmonary Sxs: abdominal pain (lower lobes), neck stiffness, OM
• Labs: WBC > 15,000
• CXR: alveolar consolidation, or patchy infiltrates; pleural effusion. Mycoplasma=interstitial infiltrates; round pulmonary infiltrates= S pneumo
What findings would you expect with viral pneumonia?
• Sxs: usually starts with URI sxs, respiratory sxs may be insidious; cough, wheeze, HA, fatigue, afebrile or low grade
• Exam: same as with bacterial (possible to have dullness to percussion or egophony over area of consolidation)
• Labs: CBC: WBC usually normal, increased lymphs
• CXR: diffuse, streaky infiltrates (not lobar)
What type of antibiotics would you use for bacterial pneumonia?
• Azithromycin 10 mg/kg QD x 5d (covers mycoplasma best- think age > 5 with low grade fever, and slower onset of sxs). Resistance concerns
• Augmentin (45 mg/kg in 2 divided doses x 10d) (covers S. pneumo best, think of for high fever with acute onset of sxs ) Preferred Rx for lobar pneumonia; or concurrent influenza (S.aureus)
What are the indications for hospitalization d/t pneumonia?
mod/severe respiratory distress, immunosuppression, underlying chronic cardiopulmonary disease, failure to respond to oral Abx, unable to take fluids or Abx
o Infants require hospitalization and IV Abx
o In-patient treatment guided by: CXR, age, hx, sputum cx, gram stain
What is CF?

Autosomal recessive disorder that is the most common deadly genetic disease in the U.S in whites; median survival 31yrs old.

Disease of exocrine glands resulting in thick secretions. Defect in CFTR protein involved in Chloride transport; chloride cannot exit cells. Respiratory epithelium has decreased permeability to Cl and increased absorption of sodium; this leads to decreased hydration in airway secretions, impaired mucociliary transport, and airway obstruction. Defect in Chloride channels seen in pancreas, sweat glands, salivary glands, intestines, respiratory tract, and reproductive system

What are the pulmonary presentations of CF?
cough, rales, wheeze, sputum production, hyperinflation, bronchiectasis (dilation of bronchi, destruction of bronchial walls, loss of mucociliary transport, mucus hypersecreation)
What organisms are CF patients often colonized with and what virus are they commonly infected with?
CF patients colonized with H flu, Staph aureus, pseudomonas. RSV infection quite common
What are the pulmonary and GI complications of CF?

Pulmonary complications: bronchiectasis, bronchiolits, pneumonia, atelectasis, pneumothorax, nasal polyps, asthma, respiratory failure, sinusitis, hemoptysis

Gastrointestinal complications: peitonitis, ileus, intussusception, vovulus, pancreatitis, intestinal atresia, biliary cirrhosis, GER, cholelithiasis, growth failure/malabsorption, vitamin deficiency, insulin deficiency

What are the indications for a sweat test?
o Suspect in any patient with chronic respiratory or GI sxs
o Pulmonary: chronic cough, pneumonia, or bronchiolitis; hemoptysis, psuedomonas in respiratory tract
o GI: meconium ileus or plug, steatorrhea, malabsorption, pancreatitis, rectal prolapse, Vitamin K defieciency
o Miscellaneous: clubbing, failure to thrive, FamHx, aspermia, recurrent sinusitis
How is CF diagnosed?
o Sweat test: Chloride > 60mEq/L
o Chronic obstructive lung disease
o Pancreatic insufficiency
o FamHx
o Acronym: CF PANCREAS: Chronic cough, Failure to thrive, Pancreatic insufficiency, Alkalosis, Nasal polyps, Clubbing, Rectal prolapse, Electrolytes increased in sweat, Absence of vas, Sputum mucoid
How is CF treated?
o Patient needs to be followed by a Pediatric Endocrinologist (preferable at multispecialty center)
o For lung disease: Chest PT, bronchodilators, Abx for chronic infections, monitoring of pulmonary flora
o Pancreatic insufficiency: oral pancreatic enzymes, high calories and added sodium diet, fat soluble vitamins (A,D,E,K)
What is pertussis (whooping cough)?
o Highly contagious infection caused by Bordetella pertussis
o Usually spread by adolescents and adults with waned immunity after childhood vaccinations
o Most contagious during “catarrhal stage”; most common and severe in infants
What are the symptoms and stages of pertussis?
“100 day cough”
Catarrhal stage: sxs begin with mild URI x 2-3 weeks (most contagious-but seems like common cold)Paroxysmal stage: cough becomes
persistent with multiple forceful coughs ending in an inspiratory “whoop” sound (vomiting often follows this); this stage lasts 2-4 weeks

Convalescent stage:”Whooping” cough improves, and chronic congestive cough then persists for another 2-3 weeks, sometimes lasting months

What are your laboratory findings with pertussis?
CBC with WBC 20,000-30,000; elevated lymphocytes
– Diagnosis confirmed by B pertussis nasopharyngeal swab on culture or fluorescent antibody test
What are the complications of pertussis?
pneumonia, atelectasis, viral respiratory infections, apnea
How would you prevent pertussis?
Vaccinate in infancy with DTaP series, and new booster vaccination in adolescents and adults with Tdap
How do you treat pertussis?
Abx treatment with Erythromycin for patient and direct contacts
o Unfortunately Abx have NO effect once “catarrhal” stage is over
o Corticosteroids and Albuterol not usually indicated (meds can mask superinfection, cause paroxysms)
o Fluids, nutrition support
o Risk in infancy for severe disease or death high
What is the MC chronic disease in children?
Asthma; a chronic lung disease characterized by airway obstruction and narrowing, airway inflammation, mucous plugging and airway hyper-responsiveness
What is the pathophysiology of asthma? What are the stages?
Pathophysiology: chronic inflammatory disorder with early and late phase responses
– Early phase: mast cells release histamine, leukotrienes, and prostaglandins into airway and bloodstream airway hyperresponsiveness, bronchoconstriction, edema, and vasodilation
– Late phase: cytokines released prolonging inflammation; eosinophils, basophils, lymphocytes, and mast cells activated
What are the s/s of asthma?
o 80% of patients will have positive IgE testing to allergens (dust mites, mold, animals, cockroaches, pollen, indoor/outdoor allergens)
o Wheezing is “classic” (except cough variant asthma), prolonged cough, chest congestion, recurrent bronchiolitis or pneumonia, exercise intolerance, dyspnea, “tightness” with deep breaths, eczema
o Sxs may be worse at night or early morning
o Hx of irritants common: tobacco smoke, wood stoves/fireplaces, perfumes, cleaning agents
o Triggers: cold air, URI’s, exercise, stress, environmental allergens, GERD
What would you find on exam with asthma?
prolonged expiratory phase & wheezing (esp. with forced exhalation); if mild &/or child won’t take deep breaths making them laugh or irritating them may produce late expiratory “tightness” or wheeze
• As constriction worsens it is easier to hear more high pitched wheezing and diminished breath sounds; when obstruction severe often don’t hear wheeze because of poor air movement, but you likely will find retractions, accessory muscle use, nasal flaring, and tachypnea
What type of testing should you order for asthma?
o All patients with asthma or suspected asthma should undergo skin testing and IgE blood testing for allergens
o Pulmonary Function Tests should be performed: FEV 1 is reduced, as is FVC and FEF; flow volume curve shows “scooping out” at end expiratory portion of loop
o Following bronchodilator treatment: FEV1 >12% increase
o Pulse oximetry: >96% is OK, 92-95% acceptable, <92% concerning
o Asthma = obstructive pattern on PFTs
When is a short acting beta-2 agonist used?
Is a rescue medication; provides short term relief of symptoms over 4-6 hours; rapidly relax bronchial smooth muscle
• Drug of choice for exercise induced bronchospasm
What are the 3 neutralized beta-2 agonists? What are the doses, dosage?
1. Albuterol: Q 4-6hrs, prn
2. Xopenex: Q 4-6hrs, prn; for >4yo kids
3. Accuneb: Q 4-6hrs >2yo kids
What are the 5 inhaled beta-2 agonists? At what age can pts use them?
• Proventil HFA: age >4
• Ventolin HFA: age >4
• ProAir: age >4
• Maxair: age >12
• Xopenex HFA: age > 4
• All are dosed as 2 inhalations Q 4-6 hours prn or 15 min before exercise
• All except Maxair should be administered with spacer device
When are inhaled corticosteriods used? What do they so for the pt? What is a possible side effect?
• Preferred medication for long-term control of asthma; taken daily for prevention
• Provide effective anti-inflammatory response, improves pulmonary function, reduces bronchial hyperresponsiveness, can reduce airway remodeling and modify disease progression
• Improper use or excessive doses of ICS may inhibit growth velocity
• ICS do not provide immediate relief, and does not quickly stop disease
What are your 4 choices of inhaled corticosteroids?

1. Flovent (fluticasone): Ages 4-11: Starting dose varies based on severity

2. Asmanex (mometasone): Ages 4-11

3. Pulmicort (budesonide): Nebulized or inhaler
• Nebulized:12months- 8 years old
• Turboinhaler: >6yrs

4. Asmacort (triamcinolonce); ages 6-12. Not routinely used.

What are the 2 long acting beta-2 agonists?
1. Foradil: age >5
2. Serevent (salmeterol):age >4
Can you prescribe a LABA as the sole asthma drug?
No. Must be combined with an inhaled corticosteriod.
What are the 2 combination drugs?

1. Advair: Fluticasone and salmeterol (Flovent and Serevent). Low dose for ages 4-11, medium or high dose ok in kids >12

2. Symbicort: Budesonide and formoterol (Pulmicort and Foradil);not yet rec. in children

What is singulair (monoleukast)?
A leukotririene antagonist. Dosed 1x at night. Lower dose for kids 6-14; higher dose kids <15
What is singulair used for?
• Singulair efficacious against EIA, allergies, and used as prevention in asthma, used as a sole treatment and add on to ICS in asthma control
What two mast cell stabilizers are approved for use in kids?
Intal and Tilade
What oral steriods ae approved for use in kids?
Prednisone, prednisolone (Orapred); typically dosed 1mg/kg BID x 3-5 days
How would you treat exercise induced asthma?
Short acting B2 Agonist alone or with ICS; Singulair
Describe otitis media.
One of the most common illnesses in infants and child
Effusion and infection or blockage of middle ear.
Highest in winter months
Bactertial OM is often preceded by viral resp. infection.
Common viruses are: resp synctytial virus and flu.
Describe acute OM?
Effusion and inflam in the middle ear that occurs suddenly and is ass. with other signs of illness.
What are the common bacterias that cause otitis media?
H. influenza
S. Pneumoniae
What is the patho for otitis media?
Result of dysfunctioning eustachian tube
Mechanical and functional obstruction of the tube causes accumulation of secretions in the middle ear.
Causes negative middle ear pressure
Why do infants and toddlers get otitis media more easily?
Efficient drainage is inhibited by shorter and more horizontal eustachian tubes.
Tube is more distensible
lack of cartilage support causes the tube to collapse eaisly, restricting drainage.
What are the risks for otitis media?
Attendance at daycare centers
Ethnicity
Males slightly more
Exposure to household cigg smoking
Pacifier use
Bottle feeding: postion of baby durign feeding (supine) can cause reflux of formula.
What are the manifestations of AOM?
Otalgia (earache): infants may pull ears
Drainage: yellow, green, purulent
Irritability
Sleep disturbances
Infants: persistent crying, fever, vomiting, anorexia, or diarrhea.
When is AOM recurrent or chronic?
3 episodes over a 6-18m period
What is the treatment for otitis media?
Analgesics for pain (ibuprofen, acetaminophen)
First line abx: amoxicillin
Second line for resistant bacteria: azithromycin and cephalosporins
IM Rocephin when parents dont follow regimen
What are the surgical options for otitis media?
Myringotomy: surgical incision of eardrum to alleviate pain
Tympanostomy tubes: to treat recurrent OM. Equalizes pressure on both sides of tympanix membrane to keep aerated. Falls out on own in 6-12m
What are the nursing concerns for otitis media?
Compliance
Recurrent
Hearing loss can lead to speech impediments
Pain and fever management
Describe tonsillitis.
Inflammation of the tonsils that usually occurs with an upper resp. infection.
Usually 2 pallatine tonsils are infected.
What is the purpose of the lymphoid tissue and how does it cause tonsillitis?
To filter and protect the resp and digestive tracts from invasion of pathogens, but the tonsils become the site for infection.
What is the patho for tonisillitis?
Tonsils masses of lymphoid tissues
Often occurs with pharyngitis
Viral or bacterial
Most common is group A strep, but rare before age 3, spread by close droplet.
Why do young kids get tonsilitis?
They have an abundance of lymphoid tissue and have a frequency of URI.
What are the manifestations of tonsilitis?
Enlarged and edematous tonsils, bright red
Difficulty breathing and swallowing
Mouth breathing when adenoids are swollen
Sore throat
Older kids and adolecents can have a peritonsillar abscess.
What is the treatment for tonsilitis?
Acetaminphen and Ibuprofen for pain
Older kids can gargle with salt water
Cool bland liquids
Group A strep = pen regimen
New studies show amoxicillin is shorter and more effective
Not infectious after 24h of pen therapy.
When do kids get a tonsillectomy?
Not before age 3.
Indications: malignancy, recurrent peritonsilar abscess and airway obstruction.
When is a tonsillectomy contraindicated?
Active infection: removal of tonsils when infected can result in spread of organism or sepsis.
Cleft palate: tonsils help prevent air escape durign speech
What is the nursing pre-op for tonsillectomy?
Assess for signs of infection
Bleeding history bc area is very vascular
Checked for loose teeth, aspiration
Explain kid will be in a semi prone position with head turned to side post op
What are things to watch out for post op tonsillectomy?
Bleeding is most important
Excessive swallowing
Elevated pulse and decreased Bp
Vomiting bright red blood
Restlessness
What do we teach parents about kids post op tonsillectomy?
Encourage lots of fluids, avoid citrus
Do not give straws and forks
Pain should not perisist after 1st week
Discourage kid from coughing or gargling
Bleeding 7-10 days post op is tissue sloughing and immediate med attention.
Kid can go to school 10 days after
No red liquids, look like blood in vomit
What is Croup?
General term applied to a symptom complex characterized by hoarseness, a resonant cough (barking, brassy, croupy), respiratory stridor, adn varying degress of resp. distress from swelling or obstruction in the larynx.
What is the patho fro Croup?
Mucoosal inflam and edema narrow airway – sudden onset of harsh cough, stridor and hoarseness – resp distress – substernal or suprasternal retractions, agitation, pallor and cyanosis – increased heart rate, restelessness – hypoxia.
Describe LTB as a form of croup.
Laryngo-tracheobronchitis
3m-3y
VIral
Gradual onset, usually at night
Tx: humidity, epi, IV fluids, may need hospital.
What are the manfestations of LTB?
URI
Stridor
Brassy cough
Hoarseness
Dyspnea
Restlessness
Irritability
Low grade fever
Non toxic appearance
What is the tx for Croup?
Patent airway
Racemic epi to decrease edema
Oral dexamethasone to decrease inflam
Acetamenophen for fever
Severe s/s: humidified O2 and IV fluids
Hypoxia: intubated 3-5d
What is thye nursing care for Croup?
Maintain patent airway
Assess resp status
O2 or cool mist as req.
Med administration
Decrease parent and child anxiety
maintain fluid balance
Why are sedatives contraindicated for Coup?
Depress resp
Mask restlessness (early sign of hypoxia)
Describe bronciolitis.
Incidence peaks by 6m, sig cause of hospitalization under 1y and by 2 every kid has had it.
Caused by RSV (resp syncytial virus)
Immunity does not occur, but incidence and severity decrease with age.
How is RSV acquired?
From older adult or child
Contact with contamianted surfaces
Can live on skin or paper for 1h and nonpourous surfaces for 6h
Mostly by unwashed hands
common on winter and spring
What is the patho for bronciolitis/RSV?
RSV affects the epi cells so they swell, protrude into lumen and lose cilia – fusion occurs (giant cell with lot of nuclei), mucosa swells and lumen is filled with exudate and mucous – bronchioles infiltrated with inflam cells – obstruction (on expiration) – hyperinflation , obstructive emphysema and patchy areas of atelectasis.
What are the manifestations of bronchiolitis?
mild resp infection usually precedes (pharyngitis)
Serous nasal drainage, sneezing, low grade fever and amorexia present for several days.
Onset of resp distress: tachy, tachypnea, wheezing and crackles, intercostal and subcostal retractions, cyanosis.
Other: otitis media
What are the severe disease manifestations of bronchiolitis?
Tachypnea
Listlessness
Apnea
Decreased air exchange
Resp failure
What are the diagnostics for bronchiolitis?
Chest radiographs = hyperinflation and increased chest diameter. Maybe scattered areas of consolidation.
DFA (direct flourescent antibody) staining and ELISA (enzyme linked immunosorbent assay) to detect RSV from nasal secretions.
What can I do if my baby is high risk for bronchiolitis?
Synagis (pavilizumab) given every month during RSV season can reduce chances for premature infants, and those with chronic lung disease or congenital heart disease.
What is the treatment for bronchiolitis?
Airway maint.
Ensure fluids since infant cant eat and breathe at same time due to secretions
Humidified air or O2
Fever management with aceta.
Treat other illnesses like otitis media with abx
Bronchodilators
Racemic epi nebulized
What is the nursing care for bronchiolitis?
Contact precautions
Handwashing to prevent spread
Parent teaching for home management
Suction nares with NS drops
Parent support
Encourage fluids
What are the causative agents for pneumonia in children?
Strep pneumoniae is most common bacterial for community acquired in infants and uner 5y.
Mycoplasma p. and Chlamydia p. are most common cause of bacterial in kids 5y and older.
Viral: RSV in infants and parainfluenza, human metapneumovirsus and adenovirus in older kids.
Most pneumonia is viral/
What are the manifestations for viral pneumonia?
Low to high fever
Cough
crackles and wheezing (RSV)
headache
Malaise
Myalgia
Ab pain
Infiltrates seen on chest radiography
Usualyl lasts 5-7d
What are the manifestations of bacterial pneumonia?
Preceded by upper resp infection.
Abrupt onset of high fever, chills, cough, chest pain, decreased breath sounds, signs of resp distress, restlessness and apprehension.
Infants: GI s/s, chest pain and abnormal breath sounds.
Radiography: consolidation and WBC is elevated.
How do we manage viral pneumonia?
Supportive
May be hospitalized for O2 and fluid therapy.
Rest
Antipyretics
Cool mist
chest physiotherapy
How do we manage bacterial pneumonia?
Abx: pens and cephs or erythro if allergy
Hospital for really ill, chest tube drainage amy be necc to drain cavity.
Fluids, rest.
What are the complications of pneumonia?
pneumothorax
empyema
sepsis
Describe asthma.
Chronic inflam disorder of airways characterized by recurrent episodes of wheezing, breathlessness, chest tightness and cough.
What is the etiology for asthma?
Onset before 6y usually
Triggered by: cold air, smoke, fumes, viral infection, stress, excercise, odors and meds.
Why are kids prone to asthma?
They have smaller more narrow airways and decreased elastic recoil = easy obstruction.
They have flexible rib cage and underdeveloped chest muscles = exhaustion when resp effort increases.
What are 3 basic components of asthma?
Airway inflam
Bronchospasm
Obstruction
What are the 3 mechanisms responsible for the obstructive symptoms of asthma?
Inflam and edema of mucous membranes
accumulation of tenacious secretions
spasm of the smooth muscle of bronchi and bronchioles
What are some of the complications of severe asthma?
CO2 retention
Hypoxemia
Resp acidosis
Resp. failure
What are the manifestations of asthma?
Non productive cough
SOB
pronlonged expiratory phase
audible wheeze
restlessness
apprehension
sweating
Infants: retractions and nasal flaring
Older: tripod stance, speak with short broken phrases
tachypnea
What are the diagnostics for asthma?
Older than 5: measure by spirometry
Chest radiographs are usually normal unless severe
PFT’s: decreased forced expiratory volume and increased residual volume from air trapping and decreased vital capacity.
Skin test for allergens
CBC: increased eosinophils
What other problems are also usually present in kids with asthma?
Nasal polyps
Rhinitis
Sinusitis
What are the overall goals of asthma?
Manitain normal activity levels
Maintain normal pulmonary function
Prevent chronic symptoms and recurrent exacerbations
Provide optimum drug therapy
What are the rescue meds for asthma?
Short acting beta 2 (SABA): albuterol, levelbuterol, terbutaline
Anticholenergics: Atrovent
Mast cell stabilizer: Intal
Systemic steroids: prednisone
What are the routine meds for asthma?
Inhaled steroids: fluticasone, beclomethasone
Long acting beta 2 (LABA): salmeterol
Leukotrienes: montelukast or anything ending in kast.
What is cyctic fibrosis?
Hereditary disease
Mucous produced by the exocrine glands (bronchioles, sm. intestine and pancreatic and bile ducts) is tenacious and thick = obstruction of the passageways for these organs.
Avg survival rate is 37y
Patho for cystic fibrosis?
Genetic defect – thick secretions – obstruction – Inflam, bronchospasm, hyperinflation, chronic infection – Impaired gas exchange, atelectasis, fibrosis, destruction of pulmonary tissue – pulmonary vasoconstrict, resistance, nelarged R ventricle, hemoptysis, spontaneous pneumothorax – CHF, resp failure and death
What are the manifestations in the lungs with Cf?
Early: wheezing,dry unproductive cough and repeated bouts of pneumonia and bronchitis, chronic infection
Progession: crackles, wheezes, diminished breath sounds, accessory muscle use, retractions, hypoxia and cyanosis.
Late: spontaneous pneumothorax, hemoptysis, nasal polyps, sinusitis, clubbing, barrell chest.
More: hyperinflation, pulmonary HTN
What are the manifestations in the GI tract for CF?
Steatorrhea: foul smelling bulky stools
Malnutrition even tho gettign calories
Fat soluble vitamin deficient (A, D, E, K) bc cant absorb fat
Vit K deficiency = bleeding in infants
Rectal prolapse from bulky stools
Growth failure/failure to thrive
Newborn: meconium ileus, earliest manifestation
Liver disease from biliary cirrhosis, HTN and varices seen in first 10y of life.
DM is in play bc we have extended life expectancy
What are the exocrine manifestations for CF?
High concentrations of salt and Cl in sweat
Skin tastes salty, salty kisses…early sign of CF
High risk for E- imbalance in summer = hyponatremia and hypochloremia, dehydration.
Complain of dry mouth
What are the reproductive manifestations in CF?
infertility in men
problems with labor in females
What features would a cystic fibrosis kid have?
Short
Increased chest diameter
Protuberant abdomen
Digital clubbing
Wasted buttocks
What are the diagnostics for CF?
Family hx
Newborn: elevated immunoreactive trypsinogen
Sweat Cl test: >60
Pulmonary radiograph: patchy atelectasis and obstructive emphysema
absence of pancreatic enzymes
What is the treatment for CF?
No cure
Prevent or minimize pulmonary complications: remove secretions, CPT, treat infection, bronchodilators.
Ensure adequate nutrition: give fat soluble vitamins, pancreatic enzymes, high protein
Monitor blood sugar, carb counting, excercise
Lung and heart transplants
What are the pediatric differences in respiratory?
Smaller lower airways = increased risk for obstruction
Infants are obligatory nose breathers, cant use mouth
Diaphragm is neonates maj resp muscle, intercostals are not well developed.
Brief periods of apnea are common
Increased metabolic rate = increased O2 needs
Lung surface increases utnil 5-8y, lung growth cont. into adolescence.
Eustachian tubes are horizontal = bacteria can get in
Infants and kids use ab muscles to inhale until 5-6y
Flexible larynx – more spasms
WETFROG for resp disress>
Wheezing
Effort and equality
Tachypnea
Flaring
Retractions
O2 sats
Grunting

A client is undergoing a complete physical examination as a requirement for college. When checking the client’s respiratory status, the nurse observes respiratory excursion to help assess:

a) lung vibrations
b) vocal sounds
c) breath sounds
d) chest movements

d) chest movements

What is the normal pH range for arterial blood?

a) 7 to 7.49
b) 7.35 to 7.45
c) 7.50 to 7.60
d) 7.55 to 7.65

b) 7.35 to 7.45

A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter. Management of her care would include:

a) scheduling her for annual tuberculin skin testing.
b) placing her in quarantine until sputum cultures are negative.
c) gathering a list of persons with whom she has had recent contact.
d) advising her to begin prophylactic therapy with isoniazid (INH).

d) advising her to begin prophylactic therapy with isoniazid (INH).

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

a) “Clean the tracheostomy tube with alcohol and water.”
b) “Family members should continue to talk to the client.”
c) “Oral intake of fluids should be limited for 1 week only.”
d) “Limit the amount of protein in the diet.”

b) “Family members should continue to talk to the client.”

The physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which of the following?

a) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years
b) Isolation until 24 hours after antitubercular therapy begins
c) Nothing, until signs of active disease arise
d) Daily doses of isoniazid, 300 mg for 6 months to 1 year

d) Daily doses of isoniazid, 300 mg for 6 months to 1 year

The nurse is caring for a client with pneumonia. As part of prescribed therapy, the client must use a bedside incentive spirometer to promote maximal deep breathing. The nurse checks to make sure the client is using the spirometer properly. During each waking hour, the client should perform a minimum of how many sustained, voluntary inflation maneuvers?

a) One to two
b) Three to four
c) Five to seven
d) Eight to ten

d) Eight to ten

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

a) Check for an apical pulse.
b) Suction the client’s artificial airway.
c) Increase the oxygen percentage.
d) Ventilate the client with a handheld mechanical ventilator.

b) Suction the client’s artificial airway.

A 29-year-old client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

a) Droplet precautions
b) Airborne and contact precautions
c) Contact and droplet precautions
d) Contact precautions

b) Airborne and contact precautions

The nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

a) Nonproductive cough and normal temperature
b) Sore throat and abdominal pain
c) Hemoptysis and dysuria
d) Dyspnea and wheezing

d) Dyspnea and wheezing

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client’s teenage daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

a) 3 to 5 days
b) 1 to 3 weeks
c) 2 to 4 months
d) 6 to 12 months

d) 6 to 12 months

The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

a) helping him communicate.
b) keeping his airway patent.
c) encouraging him to perform activities of daily living.
d) preventing him from developing an infection.

b) keeping his airway patent.

A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?

a) Monitor vital signs and oxygen saturation every 15 to 30 minutes.
b) Suction the client as needed to obtain a sputum specimen for culture and sensitivity.
c) Assess intake and output and maintain adequate hydration.
d) Reassure the client that intubation and mechanical ventilation will be temporary.

a) Monitor vital signs and oxygen saturation every 15 to 30 minutes.

A client who weighs 175 lb (79.4 kg) is receiving aminophylline (Aminophyllin) (400 mg in 500 ml) at 50 ml/hour. The theophylline level is reported as 6 mcg/ml. The nurse calls the physician who instructs the nurse to change the dosage to 0.45 mg/kg/hour. The nurse should:

a) question the order because the dosage is too low.
b) question the order because the dosage is too high.
c) set the pump at 45 ml/hour.
d) stop the infusion and have the laboratory repeat the theophylline measurement.

a) question the order because the dosage is too low.

A client who sustained a pulmonary contusion in a motor vehicle accident develops a pulmonary embolism. Which nursing diagnosis takes priority with this client?

a) Excess fluid volume related to excess sodium intake
b) Acute pain related to tissue trauma
c) Ineffective breathing pattern related to tissue trauma
d) Activity intolerance related to insufficient energy to carry out activities of daily living

c) Ineffective breathing pattern related to tissue trauma

or a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

a) Encouraging the client to drink three glasses of fluid daily
b) Keeping the client in semi-Fowler’s position
c) Using a high-flow Venturi mask to deliver oxygen as prescribed
d) Administering a sedative as prescribed

c) Using a high-flow Venturi mask to deliver oxygen as prescribed

The nurse assessing a client for tracheal displacement should know that the trachea will deviate toward the:

a) contralateral side in a simple pneumothorax.
b) affected side in a hemothorax.
c) affected side in a tension pneumothorax.
d) contralateral side in a hemothorax.

d) contralateral side in a hemothorax.

When a client’s ventilation is impaired, the body retains which substance?

a) Sodium bicarbonate
b) Carbon dioxide
c) Nitrous oxide
d) Oxygen

b) Carbon dioxide

On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client’s arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?

a) Fever
b) Tachypnea
c) Tachycardia
d) Hypotension

d) Hypotension

A 33-year-old woman with primary pulmonary hypertension is being evaluated for a heart-lung transplant. The nurse asks her what treatments she is currently receiving for her disease. She is likely to mention which treatments?

a) Oxygen
b) Aminoglycosides
c) Diuretics
d) Vasodilators
e) Antihistamines
f) Sulfonamides

a) Oxygen
c) Diuretics
d) Vasodilators

The nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?

a) Avoid contact with fur-bearing animals.
b) Change filters on heating and air conditioning units frequently.
c) Take prescribed medications as scheduled.
d) Avoid goose down pillows.

c) Take prescribed medications as scheduled.

A trauma victim in the intensive care unit has a tension pneumothorax. Which signs or symptoms are associated with a tension pneumothorax?

a) Decreased cardiac output
b) Flattened neck veins
c) Tracheal deviation to the affected side
d) Hypotension
e) Tracheal deviation to the opposite side
f) Bradypnea

a) Decreased cardiac output
d) Hypotension
e) Tracheal deviation to the opposite side

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He’s placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

a) 0.21.
b) 0.35.
c) 0.5
d) 0.7

c) 0.5

Inspiratory and expiratory stridor may be heard in a client who:

a) is experiencing an exacerbation of goiter.
b) is experiencing an acute asthmatic attack.
c) has aspirated a piece of meat.
d) has severe laryngotracheitis.

c) has aspirated a piece of meat.

A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn’t want to be placed on a ventilator. What action should the nurse take?

a) Notify the physician immediately so he can determine client competency.
b) Have the client sign a do-not-resuscitate (DNR) form.
c) Determine whether the client’s family was consulted about his decision.
d) Consult the palliative care group to direct care for the client.

a) Notify the physician immediately so he can determine client competency.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

a) They help prevent subcutaneous emphysema.
b) They help prevent pneumothorax.
c) They help prevent cardiac arrhythmias.
d) They help prevent pulmonary edema.

c) They help prevent cardiac arrhythmias.

For a client with an acute pulmonary embolism, the physician prescribes heparin (Liquaemin), 25,000 U in 500 ml of dextrose 5% in water (D5W) at 1,100 U/hour. The nurse should administer how many milliliters per hour?

a) 8
b) 22
c) 30
d) 50

b) 22

On auscultation, which finding suggests a right pneumothorax?

a) Bilateral inspiratory and expiratory crackles
b) Absence of breath sounds in the right thorax
c) Inspiratory wheezes in the right thorax
d) Bilateral pleural friction rub

b) Absence of breath sounds in the right thorax

A client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature?

a) Inflamed lung tissue
b) Sudden onset
c) Responsiveness to penicillin
d) Elevated white blood cell (WBC) count

a) Inflamed lung tissue

A client is admitted to the emergency department with an acute asthma attack. The physician prescribes ephedrine sulfate, 25 mg subcutaneously (S.C.). How soon should the ephedrine take effect?

a) Rapidly
b) In 3 minutes
c) In 1 hour
d) In 2 hours

a) Rapidly

The nurse is caring for a client with chest trauma. Which nursing diagnosis takes highest priority?

a) Impaired gas exchange
b) Anxiety
c) Decreased cardiac output
d) Ineffective cardiopulmonary tissue perfusion

a) Impaired gas exchange

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

a) Nausea or vomiting
b) Abdominal pain or diarrhea
c) Hallucinations or tinnitus
d) Light-headedness or paresthesia

d) Light-headedness or paresthesia

The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

a) suctioning the tracheostomy tube frequently.
b) using a cuffed tracheostomy tube.
c) using the minimal air leak technique with cuff pressure less than 25 cm H2O.
d) keeping the tracheostomy tube plugged.

c) using the minimal air leak technique with cuff pressure less than 25 cm H2O.

A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac isn’t bubbling. Which nursing assumption would be most invalid?

a) The tubing from the client to the chamber is blocked.
b) There is a leak somewhere in the tubing system.
c) The client’s affected lung has reexpanded.
d) The tubing needs to be cleared of fluid.

b) There is a leak somewhere in the tubing system.

A client is prescribed rifampin (Rifadin), 600 mg P.O. daily. Which statement about rifampin is true?

a) It’s usually given alone.
b) Its exact mechanism of action is unknown.
c) It’s tuberculocidal, destroying the offending bacteria.
d) It acts primarily against resting bacteria.

c) It’s tuberculocidal, destroying the offending bacteria.

A slightly obese client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client’s chest wall, the nurse expects to elicit:

a) resonant sounds.
b) hyperresonant sounds.
c) dull sounds.
d) flat sounds.

a) resonant sounds.

A client with severe acute respiratory syndrome (SARS) privately informs the nurse that he doesn’t want to be placed on a ventilator if his condition worsens. The client’s wife and children have repeatedly expressed their desire that everything be done for the client. The most appropriate action by the nurse would be to:

a) inform the family of the client’s wishes.
b) assure the family that everything possible will be done.
c) support the client’s decision.
d) assure the client that everything possible will be done.

c) support the client’s decision.

A client, confused and short of breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the client’s current respiratory problem, the physician orders a chest X-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurse sees many abbreviations. What does a lowercase “a” in an ABG value represent?

a) Acid-base balance
b) Arterial blood
c) Arterial oxygen saturation
d) Alveoli

b) Arterial blood

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

a) pH
b) Bicarbonate (HCO3-)
c) Partial pressure of arterial oxygen (PaO2)
d) Partial pressure of arterial carbon dioxide (PaCO2)

c) Partial pressure of arterial oxygen (PaO2)

Prednisone (Deltasone) is prescribed to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:

a) hyperglycemia and glycosuria.
b) acute adrenocortical insufficiency.
c) GI bleeding.
d) restlessness and seizures.

b) acute adrenocortical insufficiency.

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

a) Simple mask
b) Nonrebreather mask
c) Face tent
d) Nasal cannula

b) Nonrebreather mask

A client with chronic obstructive pulmonary disease is admitted to an acute care facility because of an acute respiratory infection. When assessing the client’s respiratory rate, the nurse notes an abnormal inspiratory-expiratory (I:E) ratio of 1:4. What is a normal I:E ratio?

a) 1:2
b) 2:1
c) 1:1
d) 2:2

a) 1:2

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

a) Respiratory alkalosis
b) Respiratory acidosis
c) Metabolic alkalosis
d) Metabolic acidosis

d) Metabolic acidosis

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

a) Vital capacity
b) Functional residual capacity
c) Tidal volume
d) Maximal voluntary ventilation

c) Tidal volume

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

a) chronic obstructive pulmonary disease (COPD).
b) bronchial asthma.
c) adult respiratory distress syndrome (ARDS).
d) renal failure.

c) adult respiratory distress syndrome (ARDS).

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

a) Instruct the client to breathe into a paper bag.
b) Administer oxygen by nasal cannula as prescribed.
c) Auscultate breath sounds bilaterally every 4 hours.
d) Encourage the client to deep-breathe and cough every 2 hours.

b) Administer oxygen by nasal cannula as prescribed.

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction?

a) “I will have to take the medication for up to a year.”
b) “This disease may come back later if I am under stress.”
c) “I will stay in isolation for at least 6 weeks.”
d) “I will always have a positive test for tuberculosis.”

c) “I will stay in isolation for at least 6 weeks.”

The nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

a) Inspection
b) Chest X-ray
c) Arterial blood gas (ABG) levels
d)Auscultation

d)Auscultation

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/min. He’s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation is 86%, and he’s still wheezing. The nurse should plan to administer:

a) alprazolam (Xanax).
b) propranolol (Inderal).
c) morphine.
d) albuterol (Proventil).

d) albuterol (Proventil).

Before administering ephedrine, the nurse assesses the client’s history. Because of ephedrine’s central nervous system (CNS) effects, it is not recommended for:

a) clients with an acute asthma attack.
b) clients with narcolepsy.
c) clients under age 6.
d) elderly clients.

d) elderly clients.

The home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met?

a) Decreased oxygen requirements
b) Increased sputum production
c) Decreased activity tolerance
d) Normothermia

a) Decreased oxygen requirements

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find?

a) Decreased respiratory rate
b) Dyspnea on exertion
c) Barrel chest
d) Shortened expiratory phase
e) Clubbed fingers and toes
f) Fever

b) Dyspnea on exertion
c) Barrel chest
e) Clubbed fingers and toes

Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?

a) Fluid intake for the past 24 hours
b) Baseline arterial blood gas (ABG) levels
c) Prior outcomes of weaning
d) Electrocardiogram (ECG) results

b) Baseline arterial blood gas (ABG) levels

A client with end-stage chronic obstructive pulmonary disease requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP?

a) The client will remain infection-free.
b) The client will maintain adequate oxygenation.
c) The client will maintain adequate urine output.
d) The client will remain pain-free.

b) The client will maintain adequate oxygenation.

The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

a) Respiratory rate of 22 breaths/minute
b) Dilated and reactive pupils
c) Urine output of 40 ml/hour
d) Heart rate of 100 beats/minute

a) Respiratory rate of 22 breaths/minute

A client with advanced acquired immunodeficiency syndrome (AIDS) is diagnosed with active tuberculosis. Which of the following regimens would the nurse expect the physician to prescribe?

a) isoniazid (Laniazid) and rifampin (Rifadin)
b) ethambutol (Myambutol), pyrazinamide, and isoniazid
c) isoniazid, rifampin, ethambutol, and pyrazinamide
d) ethambutol, ciprofloxacin (Cipro), pyrazinamide, and streptomycin

c) isoniazid, rifampin, ethambutol, and pyrazinamide

After receiving an oral dose of codeine for an intractable cough, the client asks the nurse, “How long will it take for this drug to work?” How should the nurse respond?

a) In 30 minutes
b) In 1 hour
c) In 2.5 hours
d) In 4 hours

a) In 30 minutes

Which task can be safely delegated to a licensed practical nurse (LPN)?

a) Teaching a newly diagnosed diabetic about insulin administration.
b) Admitting a client who underwent a thoracotomy to the nursing unit from the postanesthesia care unit.
c) Changing the dressing of a client who underwent surgery two days ago.
d) Administering an I.V. bolus of morphine sulfate to a client experiencing incisional pain

c) Changing the dressing of a client who underwent surgery two days ago.

The nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome (SARS). Which action by the employee requires immediate intervention by the nurse?

a) The employee wears a gown, gloves, N95 respirator, and eye protection when entering the room.
b) The employee doesn’t remove the stethoscope, blood pressure cuff, and thermometer that are kept in the room.
c) The employee removes all personal protective equipment and washes her hands before leaving the client’s room.
d) The employee enters the room wearing a gown, gloves, and a mask.

d) The employee enters the room wearing a gown, gloves, and a mask.

A client has a sucking stab wound to the chest. Which action should the nurse take first?

a) Draw blood for a hematocrit and hemoglobin level.
b) Apply a dressing over the wound and tape it on three sides.
c) Prepare a chest tube insertion tray.
d) Prepare to start an I.V. line.

b) Apply a dressing over the wound and tape it on three sides.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation?

a) Chickenpox
b) Impetigo
c) Measles
d) Cholera

c) Measles

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?

a) Nonproductive cough and abdominal pain
b) Hypertension and lack of fever
c) Bradypnea and bradycardia
d) Chest pain and dyspnea

d) Chest pain and dyspnea

During inspiration, which of the following occurs?

a) Lungs recoil.
b) Diaphragm descends.
c) Alveolar pressure is positive.
d) Inspiratory muscles relax.

b) Diaphragm descends.

A client recovering from a pulmonary embolism is receiving warfarin (Coumadin). To counteract a warfarin overdose, the nurse would administer:

a) heparin.
b) vitamin K1 (phytonadione).
c) vitamin C.
d) protamine sulfate.

b) vitamin K1 (phytonadione).

The physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on her knowledge of palliative care?

a) Decreasing administration of pain medications
b) Reducing oxygen requirements
c) Increasing the need for antianxiety agents
d) Decreasing the use of bronchodilators

c) Increasing the need for antianxiety agents

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

a) Administering oxygen, coughing, breathing deeply, and maintaining bed rest
b) Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer
c) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
d) Administering pain medications, frequent repositioning, and limiting fluid intake

c) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say “ninety-nine” several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?

a) Bronchophony
b) Tactile fremitus
c) Crepitation
d) Egophony

a) Bronchophony

A client with a history of type 1 diabetes is admitted to the hospital with community-acquired pneumonia. The client’s blood glucose level in the emergency care unit was 576 mg/dl. The physician prescribes an I.V. containing normal saline solution, an insulin infusion, and I.V. levofloxacin (Levaquin). The nurse piggybacks the insulin infusion into the normal saline solution. She questions whether she can also piggyback the levofloxacin into the same I.V. line. Which health team member should she collaborate with to check the compatibility of these solutions?

a) The physician who prescribed the medications
b) The coworker with 20 years nursing experience
c) The pharmacist covering the floor
d) The infectious disease nurse

c) The pharmacist covering the floor

A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client’s history and physical findings, the physician suspects Legionnaires’ disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What is the drug of choice for treating Legionnaires’ disease?

a) Erythromycin (Erythrocin)
b) Rifampin (Rifadin)
c) Amantadine (Symmetrel)
d) Amphotericin B (Fungizone)

a) Erythromycin (Erythrocin)

The nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

a) Make inhalation longer than exhalation.
b) Exhale through an open mouth.
c) Use diaphragmatic breathing.
d) Use chest breathing.

c) Use diaphragmatic breathing.

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?

a) Immediately before a meal
b) At least 2 hours after a meal
c) When bronchospasms occur
d) When secretions have mobilized

b) At least 2 hours after a meal

The physician prescribes triamcinolone (Azmacort) and salmeterol (Serevent) for a client with a history of asthma. What action should the nurse take when administering these drugs?

a) Administer the triamcinolone and then administer
the salmeterol.
b) Administer the salmeterol and then administer the triamcinolone.
c) Allow the client to choose the order in which the drugs are administered.
d) Monitor the client’s theophylline level before administering the medications.

b) Administer the salmeterol and then administer the triamcinolone.

After receiving the wrong medication, the client’s breathing stops. The nurse initiates the code protocol, and the client is emergently intubated. As soon as the client’s condition stabilizes, the nurse completes an incident report. What should the nurse do next?

a) Place the incident report on the client’s chart.
b) Document the incident in the nurses’ notes.
c) Document in the nurses’ notes that an incident report was completed.
d) Make a copy of the incident report for the client.

b) Document the incident in the nurses’ notes.

The nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

a) It helps prevent early airway collapse.
b) It increases inspiratory muscle strength.
c) It decreases use of accessory breathing muscles.
d) It prolongs the inspiratory phase of respiration.

a) It helps prevent early airway collapse.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/min. These signs are associated with which condition?

a) Hypoxia
b) Delirium
c) Hyperventilation
d) Semiconsciousness

a) Hypoxia

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

a) pH, 7.5; PaCO2 30 mm Hg
b) pH, 7.40; PaCO2 35 mm Hg
c) pH, 7.35; PaCO2 40 mm Hg
d) pH, 7.25; PaCO2 50 mm Hg

d) pH, 7.25; PaCO2 50 mm Hg

A client is receiving conscious sedation while undergoing bronchoscopy. Which assessment finding should receive the nurse’s immediate attention?

a) Absent cough and gag reflexes
b) Blood-tinged secretions
c) Oxygen saturation of 90%
d) Respiratory rate of 13 breaths/min

c) Oxygen saturation of 90%

The nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. This change occurred because:

a) the attack is over.
b) the airways are so swollen that no air can get through.
c) the swelling has decreased.
d) crackles have replaced wheezes.

b) the airways are so swollen that no air can get through.

A client with chronic obstructive pulmonary disease tells the nurse that he feels short of breath. The client’s respiratory rate is 36 breaths/min and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer a prescribed nebulizer treatment. The therapist says, “I have several more nebulizer treatments to do on the unit where I am now. As soon as I’m done, I’ll come assess the client.” The nurse’s most appropriate action is to:

a) notify the primary physician immediately.
b) stay with the client until the therapist arrives.
c) administer the treatment by metered-dose inhaler.
d) give the nebulizer treatment herself.

d) give the nebulizer treatment herself.

The nurse is planning care for a client after a tracheostomy. One of the client’s goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the care plan?

a) Make an effort to read the client’s lips to foster communication.
b) Encourage the client’s communication attempts by allowing him time to select or write words.
c) Answer questions for the client to reduce his frustration.
d) Avoid using a tracheostomy plug because it blocks the airway.

b) Encourage the client’s communication attempts by allowing him time to select or write words.

A 21-year-old client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician prescribes acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client’s history for asthma. Acetylcysteine must be used cautiously in a client with asthma because:

a) it’s a respiratory depressant.
b) it’s a respiratory stimulant.
c) it may induce bronchospasm.
d) it inhibits the cough reflex.

c) it may induce bronchospasm.

The nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

a) The system is functioning normally.
b) The client has a pneumothorax.
c) The system has an air leak.
d) The chest tube is obstructed.

c) The system has an air leak.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

a) metabolic acidosis.
b) metabolic alkalosis.
c) respiratory acidosis.
d) respiratory alkalosis.

d) respiratory alkalosis.

A client’s chest X-ray reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from:

a) cardiogenic pulmonary edema.
b) respiratory alkalosis.
c) increased pulmonary capillary permeability.
d) renal failure.

c) increased pulmonary capillary permeability.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

a) Shock
b) Stroke
c) Seizures
d) Hyperglycemia

a) Shock

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can’t produce an effective cough, the nurse should monitor closely for:

a) pleural effusion.
b) pulmonary edema.
c) atelectasis.
d) oxygen toxicity.

c) atelectasis.

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?

a) Partial pressure of arterial oxygen (PaO2)
b) Partial pressure of arterial carbon dioxide (PaCO2)
c) pH
d) Bicarbonate (HCO3-)

a) Partial pressure of arterial oxygen (PaO2)

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

a) Hypotension, hyperoxemia, and hypercapnia
b) Hyperventilation, hypertension, and hypocapnia
c) Hyperoxemia, hypocapnia, and hyperventilation
d) Hypercapnia, hypoventilation, and hypoxemia

d) Hypercapnia, hypoventilation, and hypoxemia

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

a) Call the physician.
b) Remove the malfunctioning cuff.
c) Add more air to the cuff.
d) Suction the client, withdraw residual air from the cuff, and reinflate it.

d) Suction the client, withdraw residual air from the cuff, and reinflate it.

A home care nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

a) “I lubricate my lips and nose with K-Y jelly.”
b) “I make sure my oxygen mask is on tightly so it won’t fall off while I nap.”
c) “I have a ‘no smoking’ sign posted at my front entry-way to remind guests not to smoke.”
d) “I clean my mask with water after every meal.”

b) “I make sure my oxygen mask is on tightly so it won’t fall off while I nap.”

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client’s arterial blood oxygen saturation?

a) Endotracheal suctioning
b) Encouragement of coughing
c) Use of cooling blanket
d) Incentive spirometry

a) Endotracheal suctioning

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client’s paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the:

a) frontal sinuses only.
b) sphenoidal sinuses only.
c) frontal and maxillary sinuses.
d) sphenoidal and ethmoidal sinuses.

c) frontal and maxillary sinuses.

A 47-year-old male client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

a) lobar pneumonia.
b) empyema.
c) Pneumocystis carinii pneumonia.
d) infected chest tube wound site.

b) empyema.

A nurse detects bilateral crackles when auscultating a client’s lungs. Which statement about crackles is true?

a) They’re usually heard on expiration and may clear with a cough.
b) They’re usually heard on inspiration and sometimes clear with a cough.
c) They’re hissing or musical and are usually heard on inspiration and expiration; if severe, they may be heard without a stethoscope.
d) They’re creaking and grating and are usually heard over the problem area on both inspiration and expiration.

b) They’re usually heard on inspiration and sometimes clear with a cough.

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn’t breathing. What maneuver should the nurse use to open his airway?

a) Head tilt-chin lift
b) Jaw-thrust
c) Heimlich
d) Seldinger

b) Jaw-thrust

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should:

a) instruct the client to drink 2 L of fluid daily.
b) maintain the client on bed rest.
c) administer anxiolytics, as prescribed, to control anxiety.
d) administer pain medication as prescribed.

a) instruct the client to drink 2 L of fluid daily.

An elderly client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza?

a) Septicemia
b) Pneumonia
c) Meningitis
d) Pulmonary edema

b) Pneumonia

A recent immigrant from Vietnam is diagnosed with pulmonary tuberculosis (TB). Which intervention is most important for the nurse to implement with this client?

a) Client teaching about the cause of TB
b) Reviewing the risk factors for TB
c) Developing a list of people with whom the client has had contact
d) Client teaching about the importance of TB testing

c) Developing a list of people with whom the client has had contact

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client’s condition?

a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
b) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.
c) The client exhibits restlessness and confusion.
d) The client exhibits bronchial breath sounds over the affected area.

a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

For a client with an endotracheal (ET) tube, which nursing action is most essential?

a) Auscultating the lungs for bilateral breath sounds
b) Turning the client from side to side every 2 hours
c) Monitoring serial blood gas values every 4 hours
d) Providing frequent oral hygiene

a) Auscultating the lungs for bilateral breath sounds

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

a) report fluctuations in the water-seal chamber.
b) clamp the chest tube once every shift.
c) encourage coughing and deep breathing.
d) milk the chest tube every 2 hours.

c) encourage coughing and deep breathing.

A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first?

a) The client with anorexia, weight loss, and night sweats
b) The client with crackles and fever who is complaining of pleuritic pain
c) The client who had difficulty sleeping, daytime fatigue, and morning headache
d) The client with petechiae over the chest who’s complaining of anxiety and shortness of breath

d) The client with petechiae over the chest who’s complaining of anxiety and shortness of breath

A client with acute bronchitis is admitted to the health care facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?

a) The water level in the humidifier reservoir is too low.
b) The oxygen tubing is pinched.
c) The client has a nasal obstruction.
d) The oxygen concentration is above 44%.

b) The oxygen tubing is pinched.

A client suffers adult respiratory distress syndrome as a consequence of shock. The client’s condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

a) Kinking of the ventilator tubing
b) A disconnected ventilator tube
c) An ET cuff leak
d) A change in the oxygen concentration without resetting the oxygen level alarm

a) Kinking of the ventilator tubing

The most important action the nurse should do before and after suctioning a client is:

a. Placing the client in a supine position
b. Making sure that suctioning takes only 10-15 seconds
c. Evaluating for clear breath sounds
d. Hyperventilating the client with 100% oxygen

d. Hyperventilating the client with 100% oxygen

The position of a conscious client during suctioning is:

a. Fowler’s
b. Supine position
c. Side-lying
d. Prone

a. Fowler’s

Position a conscious person who has a functional gag reflex in the semi fowler’s position with the head turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you.

Presence of overdistended and non-functional alveoli is a condition called:

a. Bronchitis
b. Emphysema
c. Empyema
d. Atelectasis

Answer: B.

An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of pus in the lung.

23. The accumulation of fluids in the pleural space is called:

a. Pleural effusion
b. Hemothorax
c. Hydrothorax
d. Pyothorax

a. Pleural effusion

2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate?

a. Do nothing, because this is an expected finding.
b. Immediately clamp the chest tube and notify the physician.
c. Check for an air leak because the bubbling should be intermittent.
d. Increase the suction pressure so that bubbling becomes vigorous.

Answer A.

Continuous gentle bubbling should be noted in the suction control chamber.

Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy).

Option C is incorrect. Bubbling should be continuous and not intermittent.

Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

4. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:

a. Call the physician.
b. Place the tube in a bottle of sterile water.
c. Immediately replace the chest tube system.
d. Place the sterile dressing over the disconnection site.

Answer B.

If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.

While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:

a. Call the physician to reinsert the tube.
b. Grasp the retention sutures to spread the opening.
c. Call the respiratory therapy department to reinsert the tracheotomy.
d. Cover the tracheostomy site with a sterile dressing to prevent infection.

b. Grasp the retention sutures to spread the opening.

A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

a. Stridor
b. Occasional pink-tinged sputum
c. A few basilar lung crackles on the right
d. Respiratory rate of 24 breaths/min

Answer A.

The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea.

Stridor indicates airway edema and places the client at risk for airway obstruction

An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?

a. A low respiratory
b. Diminished breathe sounds
c. The presence of a barrel chest
d. A sucking sound at the site of injury

Answer B.

This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?

a. Hypocapnia
b. A hyperinflated chest noted on the chest x-ray
c. Increase oxygen saturation with exercise
d. A widened diaphragm noted on the chest x-ray

Answer B.

Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, – hypercapnia,
– dyspnea on exertion and at rest
– oxygen desaturation with exercise
– and the use of accessory muscles of respiration.

Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:

a. Dyspnea
b. Chest pain
c. A bloody, productive cough
d. A cough with the expectoration of mucoid sputum

Answer D.

One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum.

Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:

a. 1 L/min
b. 2 L/min
c. 6 L/min
d. 10 L/min

Answer B.

Oxygen is used cautiously and should not exceed 2 L/min.

Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:

a. Promote oxygen intake.
b. Strengthen the diaphragm.
c. Strengthen the intercostal muscles.
d. Promote carbon dioxide elimination.

Answer D.

Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease.

This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation.

Options A, B, and C are not the purposes of this type of breathing.

Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen?

a. Limiting fluids
b. Having the clients take three deep breaths
c. Asking the client to split into the collection container
d. Asking the client to obtain the specimen after eating

Answer B.

To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container.

The client should be encouraged to cough and not spit so as to obtain sputum.

Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning

A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians?

a. Dry cough
b. Hematuria
c. Bronchospasm
d. Blood-streaked sputum

Answer C.

If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours.

Frank blood indicates hemorrhage. A dry cough may be expected.

The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:

a. 1 minute
b. 5 seconds
c. 10 seconds
d. 30 seconds

Answer C. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention?

a. Continue to suction.
b. Notify the physician immediately.
c. Stop the procedure and reoxygenate the client.
d. Ensure that the suction is limited to 15 seconds.

Answer C.

During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of:

a. Metabolic acidosis
b. Respiratory acidosis
c. Overcompensated respiratory acidosis
d. Combined respiratory and metabolic acidosis

Answer A.

In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options B, C, and D are incorrect.

A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?

a. Dyspnea
b. Bradypnea
c. Bradycardia
d. Decreased respiratory

Answer A.

The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain

A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching?

a. Inhales the mist and quickly exhales
b. Removes the cap and shakes the inhaler well before use
c. Presses the canister down with the finger as he breathes in
d. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed

Answer A.

The client should be instructed to hold his or her breath for at least 10 to 15 seconds before exhaling the mist.

Options B, C, and D are accurate instructions regarding the use of the inhaler.

A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client?

a. Administering atropine intravenously
b. Administering small doses of midazolam (Versed)
c. Encouraging additional fluids for the next 24 hours
d. Ensuring the return of the gag reflex before offering food or fluids

Answer D.

After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after.

A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following?

a. Slow deep respirations
b. Rapid deep respirations
c. Paradoxical respirations
d. Pain, especially with inspiration

Answer D.

Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall.

Typical signs and Sx include
– pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation
– shallow respirations
– splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of:

a. Right pneumothorax
b. Pulmonary embolism
c. Displaced endotracheal tube
d. Acute respiratory distress syndrome

Answer A.

Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side.

Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds.

An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.

A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to:

a. Inhale quickly
b. Inhale through the nose
c. Hold the breath after inhalation
d. Take two inhalations during one breath

Answer C.

Instructions for using a metered-dose inhaler include
– shaking the canister,
– holding it right side up,
– inhaling slowly and evenly through the mouth,
– delivering one spray per breath,
– and holding the breath after inhalation.

A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome?

a. Bilateral wheezing
b. Inspiratory crackles
c. Intercostal retractions
d. Increased respiratory rate

Answer D.

The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. T

his is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis.

Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

A nurse is assessing a male client with chronic airflow limitations and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitations?

a. Emphysema
b. Bronchial asthma
c. Chronic obstructive bronchitis
d. Bronchial asthma and bronchitis

Answer A.

The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as “barrel chest.”

The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.

A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem?

a. Cough
b. High-grade fever
c. Chills and night sweats
d. Anorexia and weight loss

Answer B.

The client with tuberculosis USUALLY experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever

How often should a nurse assess the skin and nares of the patient with a nasal cannula?
The nurse should assess the client’s nares and ears for skin breakdown every 6 hours.
What does central cyanosis indicate?
Hypoexmia
Describe the clinical signs of RIGHT sided heart failure.
weight gain
distended neck veins
hepatomegaly and splenomegaly
dependent peripheral edema
What does FIO2 stand for?
Fraction of Inspired oxygen concentration
What is atelectasis?
collapse of the alveoli in the lung
prevents normal exchange of O2 and co2
hypoventilation occurs
Identify what is included during the assessment phase of the nursing process for a cardiopulmonary focus.
Assessment
• In-depth history of the client’s normal and present cardiopulmonary function
• Past impairments in circulatory or respiratory functioning
• Patient history including a review of drug, food, and other allergies
• Physical examination of the client’s cardiopulmonary status reveals the extent of existing signs and symptoms.
• Use PQRST for pain / HPI for other symptoms
• Review of laboratory and diagnostic test results
Describe Tachypnea
respirations > 35
clinical significance/contributing factors:
– respiratory failure
– response to fever
– anemia
– pain
– respiratory infection
– anxiety
(emergencies SNS system kicks in)
Identify initial assessment findings for a patient with EARLY STAGE LEFT sided heart failure
– fatigue
– breathlessness
– dizziness
– confusion
as a result of tissue hypoxia from the diminished CO

A seven-month-pregnant female is sitting quietly in the waiting room, and her respiratory rate is 20 and shallow. What does this finding suggest to the nurse?

a. She has a history of smoking.
b. She is using accessory muscles to breathe.
b. She is in pending respiratory failure.
c. Nothing. This is normal.

c. Nothing. This is normal.

The nurse is planning to assess the apex of a client’s lungs. Which area of the body will the nurse be assessing?

a. Left of the sternum, third intercostal space
b. Above the clavicles
c. Below the scapula
d. Right of the sternum, sixth intercostal space

b. Above the clavicles

The apex of each lung is slightly superior to the inner third of the clavicle.

A client with a strained trapezius muscle complains of having occasional shortness of breath. What might be the reason for this symptom?

a. The strained muscle is an accessory muscle of respiration.
b. The diaphragm muscle is also injured.
c. There is an undiagnosed heart problem.
d. There is a blood clot in his lung.

a. The strained muscle is an accessory muscle of respiration.

During a physical assessment, the nurse documents eupnea on the client’s medical record. What does this finding suggest?

a. Normal respirations
b. Slow respirations
c. Irregular respirations
d. Rapid respirations

a. Normal respirations

Prior to listening to a client’s lung sounds, the nurse palpates the sternum and feels a horizontal bump on the bone. What does this finding suggest to the nurse?

a. This is the angle of Louis.
b. The manubrium is damaged.
c. The costal angle is greater than normal.
d. The xiphoid process is misshaped.

a. This is the angle of Louis.

The nurse is assessing the client’s lung bases posteriorly. At which area can the nurse assess this portion of the lung?

a. Right anterior axillary line
b. Scapular line
c. Midsternal line
d. Left midclavicular line

b. Scapular line

The mother of a four-year-old child tells the nurse, “I think there’s something wrong with him; his chest is round like a ball.” Which of the following would be an appropriate response for the nurse to make to the mother?

a. I see what you mean. That seems odd.
b. The chest of a child appears round and is normal.
c. I wouldn’t worry about that.
d. Did you tell the doctor about this?

b. The chest of a child appears round and is normal.

After examining a 75-year-old male client, the nurse writes down “barrel chest.” What does this finding suggest?

a. The client has a history of smoking.
b. The client has osteoporosis.
c. The client has long-standing respiratory disease.
d. This is a change associated with aging.

d. This is a change associated with aging.

A 57-year-old client tells the nurse, “I need two to three pillows to sleep.” How should this information be documented?

a. Two to three pillow orthopnea
b. Dyspnea on excursion
c. Resting apnea
d. Dyspnea at rest

a. Two to three pillow orthopnea

The client tells the nurse he sometimes coughs up “thick yellow mucous.” What does this information suggest to the nurse?

a. He might have an allergy.
b. He might have a fungal infection.
c. He might have episodic lung infections.
d. He might have tuberculosis.

c. He might have episodic lung infections

Rationale: The color and odor of any mucus is associated with specific diseases or problems. Green or yellow mucus often signals a lung infection.

a 48-year-old client doesn’t smoke cigarettes yet is demonstrating signs of lung irritation. Which of the following questions could help with the assessment of this client?

a. Do you smoke or inhale marijuana or other herbal products?
b. Have you had allergy testing?
c. Have you received a flu or pneumonia vaccination?
d. Have you tried to stop smoking?

a. Do you smoke or inhale marijuana or other herbal products?

After inspecting a client’s thorax, the nurse writes “AP:T 1:2, bilateral symmetrical movements, sternum midline, respiratory rate 16 and regular.” What do these findings suggest?

a. Nothing. These findings are normal.
b. The client has pneumonia.
c. The client has a respiratory illness.
d. The client has allergies.

a. Nothing. These findings are normal.

While palpating the posterior thorax of a client, the nurse notes increased fremitus. What does this finding suggest to the nurse?

a. The client needs to speak up.
b. The client has a thick chest wall.
c. The client could either have fluid in the lungs or have an infection.
d. Nothing. This is a normal finding.

c. The client could either have fluid in the lungs or have an infection.

The nurse sees that the client will breathe deeply and then stop breathing for a short while. Which of the following does this observation suggest?

a. This client is hyperventilating.
b. This client is in a diabetic coma.
c. This client has pneumonia.
d. This is seen in aging people, people with heart failure, and people who have suffered brain damage.

d. This is seen in aging people, people with heart failure, and people who have suffered brain damage.

In planning a patient education session, the nurse sees one area of focus for Healthy People 2010 is chronic obstructive pulmonary disease (COPD). Which of the following information should the nurse include in the education session to address this focus area?

a. Screening for environmental triggers
b. Smoking cessation
c. Develop action plans
d. Identify those at risk

b. Smoking cessation
B
besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present?
A) Unexplained pain and hyperactivity
B) Headache, flushing of the face, and nosebleed
C) Dizziness, mental confusion, and mottled extremities
D) Restlessness and dusky or cyanotic skin that is cool to the touch
D
Which of the following vlues for vital signs would the nurse address first?
A) Heart rate = 72 beats per minute
B) Respiration rate = 28 breaths per minute
C) Blood pressure = 160/86
D) Oxygen saturation by pulse oximetry = 89%
E) Temperature = 37.2° C (99° F), tympanic
D
An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of
breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his “high blood.” Which vital sign value would take priority in initiating care?
A) Respiration rate = 20 breaths per minute
B) Oxygen saturation by pulse oximetry = 92%
C) Blood pressure = 138/84
D) Temperature = 39° C (102° F), tympanic
C
The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for “up ad lib.” What action should the nurse take?
A) Give him some slippers and tell him where the bathroom is located.
B) Ask the nursing assistant to assist him to the bathroom.
C) Obtain orthostatic blood pressure measurements.
D) Tell him it is not a good idea and provide a urinal.
A
Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client’s temperature is 36.1° C (97° F). The client’s remaining vital signs are in the normally acceptable range. What should the nurse do next?
A) Check the client’s temperature history.
B) Document the results; temperature is normal.
C) Recheck the temperature every 15 minutes until it is normal.
D) Get another thermometer; the temperature is obviously an error.
B
The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse’s decision?
A) The client is in shock.
B) The client has an arrhythmia.
C) The client underwent surgery 18 hours earlier.
D) The client showed a response to orthostatic changes.
D
The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration?
A) Count respirations during the time the client is not talking to the visitor.
B) Wait at the client’s bedside until the visit is over and then count respirations.
C) Tell the client it is very important to end the conversation so the nurse can count respirations.
D) Document the respiration rate as “deferred” and measure the rate later, since the talking client is obviously not in respiratory distress.
D
The nurse observes that a client’s breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern?
A) Respirations cease for several seconds.
B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea.
C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise.
D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.
C
52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. SHe smoked for 35 years and recently lost over 10 pounds. What vital sign should not be delegated to a nursing assistant:
a) temperature
b) radial pulse
c) respiratory rate
d) oxygen saturation
1, 5, 2, 4, 3
Place the vital signs in order of priority for your nursing interventions:
1) SpO2= 89%
2) BP= 160/86 mmHG
3) Temperature= 37.3 (99.4)
4) HR= 72 BPM
5) RR= 28 BrPM
1, 2, 4, 7
82 yr old admitted via ambulance to ER with shortness of breath, anorexia, and malaise. He recently visited the health care center and is on antibiotic for pneumonia. He is also on a diuretic, beta-adrergic blocker, which helps his “high blood”.
He has a temperature of 38.2 (100.8) via temporal artery. What additional assessment data is needed in planning intervention for the patients infection ? (choose all that apply)
1. HR
2. Skin turgor
3. Smoking history
4. Allergies to antibiotics
5. Recent BM’s
6. BP in right arm
7. Client’s normal temperature
8. BP in distal extremity
The nurse should assist the client to a sitting position to provide the best position to examine which of the following?
A) Heart
B) Lungs
C) Abdomen
D) Pulse sites
B Lungs
In assessing the client’s lungs, the nurse notes that the lungs are normal upon percussion. This means that the nurse detected:
A) Dullness
B) Tympany
C) Resonance
D) Hyperresonance
C Resonance
In assessing the client’s lungs the nurse hears adventitious breath sounds that are high-pitched, continuous musical sounds, such as a squeak heard continuously during inspiration or expiration, usually louder on expiration. These adventitious breath sounds are known as:
A) Crackles
B) Rhonchi
C) Wheezes
D) Pleural friction rub
C Wheezes
_________________ is the high-pitched, drumlike sound heard over a gastric air bubble
Tympany
___________________ are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration.
Rhonchi
________________ are moist sounds heard during inspiration that are not cleared with coughing.
crackles
________________ are high-pitched continuous muscles sounds such as a squeak heard continuously during inspiration and expiration.
Wheezes
An inflamed pleura is called?
Pleuritis or pleuracy
Pleural space creates certain kinds of what pressure that keep the lungs inflated?
Negative
What occurs in alveoli?
Gas exchange
What is the process called?
Diffusion
What is the purpose of macrophages in the area?
To keep down infection
High concentrations of O2 can result in?
Severe pulmonary edema, shunting of blood, and hypoxemia
Also absorption atelectasis ( I also remember her talking about blindness something about retinal ???)
The most common infecting organism present in deliver of O2 administration is?
Pseudomonas aeruginosa
How often should a patient receiving supplemental o2 be reevaluated?
Every 30-90 days during the first year of therapy, and annually after that, as long as the patient remains stable.
The primary purpose of the respiratory system is?
Gas Exchange
The area before the respiratory bronchioles that serve only as a conducting pathway is termed?
Anatomic dead space (Vd)
Normal tidal wave volume for adults is?
500 ml
*For every 500 ml inhaled, about 150 is(Vd: dead space)
What is the lipoprotein that lowers the surface tension in the alveoli called?
Surfactant
The space between the pleural layers is called?
Intrapleural
The tendency for the lungs to relax after being stretched or expanded is called?
Elastic recoil
The measure of the ease of expansion of the lungs?
Compliance
Compliance is increased when there is destruction of alveolar walls and loss of tissue as in what disease?
COPD
BLOOD PICKS UP OXYGEN EASIER IN LUNGS, BUT DELIVERS OXYGEN LESS TO THE TISSUES
SHIFT TO THE LEFT
What are some conditions that can cause a shift to the left?
Alkalosis, hypothermia, decrease in PACO2.
What can you do when patients experience a shift to the left?
Higher concentrations of O2
BLOOD PICKS UP OXYGEN LESS RAPIDLY IN LUNGS, BUT DELIVERS OXYGEN MORE READILY IN TISSUES
SHIFT TO THE RIGHT
What are some conditions seen in shift to the right?
Acidosis, hyperthermia, PACO2 is increased
Adequate values for PACO2 are:
80-100 mmhg
Effects of aging on respiratory systems
Stiffening of the chest wall
Decrease in elastic recoil of the lung
decrease in chest wall compliance
costal cartilages calcify with aging
*Many older adults lose subcutaneous fat, and bony prominences are pronounced.
Mucous membranes tend to be drier
FROM EVOLVE

When assessing a patient’s sleep-rest pattern related to respiratory health, the nurse would ask if the patient (select all that apply)

A.Has trouble falling asleep.

B.Needs to urinate during the night.

C.Awakens abruptly during the night.

D.Sleeps more than 8 hours per night.

E.Has to sleep with the head elevated.

A.Has trouble falling asleep.

C.Awakens abruptly during the night.

E. Has to sleep with the head elevated.

The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health

After assisting at the bedside with thoracentesis, the nurse should continue to assess the patient for signs and symptoms of

A. Pneumothorax.
B. Bronchospasm.
C. Pulmonary edema.
D. Respiratory acidosis.

A. Pneumothorax

Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing pulmonary edema, respiratory acidosis, or bronchospasm.

The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting

A. Chest excursion.
B. Spinal curvatures.
C. The respiratory pattern. Incorrect
D. The fingernails and their base Correct

D. The fingernails and their base Correct

Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases to be drawn. Which of the following is the minimum length of time the nurse should plan to hold pressure on the puncture site?

A. 2 Minutes
B. 5 Minutes
C. 10 Minutes
D. 15 Minutes

B. 5 Minutes Correct

After obtaining an arterial blood gas, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, the primary care provider is likely to order a

A. Thoracentesis.
B. Pulmonary angiogram.
C. CT scan of the patient’s chest.
D. Positron emission tomography (PET).

D. Positron emission tomography (PET). Correct

PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan, which uses an IV radioactive glucose preparation, can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.

A patient with recurrent shortness of breath has just had a bronchoscopy. Which of the following is a priority nursing action immediately following the procedure?

A. Monitoring the patient for laryngeal edema
B. Assessing the patient’s level of consciousness
C. Monitoring and controlling the patient’s pain
D. Assessing the patient’s heart rate and blood pressure Incorrect

A. Monitoring the patient for laryngeal edema

Priorities for assessment are the patient’s airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.

To promote airway clearance in a patient with pneumonia, the nurse
instructs the patient to do which of the following (select all that apply)?A.Maintain adequate fluid intake

B.Splint the chest when coughing

C.Maintain a high Fowler’s position

D.Maintain a semi-Fowler’s position

E. Instruct patient to cough at end of exhalation

A. Maintain adequate fluid intake
B. Splint the chest when coughing
C. Maintain a high fowler’s position
E. Instruct patient to cough at end of exhalationThe nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler’s) with head slightly flexed

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment?

A. Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions

A. Hyperthermia related to infectious illness

Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/min. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.

Which of the following physical assessment findings in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?

A. Basilar crackles
B. Respiratory rate of 28
C. Oxygen saturation of 85%
D. Presence of greenish sputum

A. Basilar Crackles
The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions.

Which of the following clinical manifestations would the nurse expect to find during assessment of a patient admitted with pneumococcal pneumonia?

A. Hyperresonance on percussion
B. Vesicular breath sounds in all lobes
C. Increased vocal fremitus on palpation
D. Fine crackles in all lobes on auscultation

C. Increased vocal fremitus on palpation

A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial breath sounds, and crackles in the affected area.

When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which of the following risk factors (select all that apply)?

A. Obesity

B.
Pneumonia

C. Hypertension

D. Cigarette smoking

E. Recent long distance travel

A. Obesity
C. Hypertension
D. Cigarette Smoking
E. Recent long travelResearch has demonstrated an increased risk of pulmonary embolism in women associated with obesity, heavy cigarette smoking, and hypertension. Other risk factors include immobilization, surgery within the last 3 months, stroke, history of DVT, and malignancy

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that “something is wrong.” Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the following should the nurse first suspect as the etiology of this episode?

A. New onset of angina pectoris
B. Septic embolus from the knee joint
C. Pulmonary embolus from deep vein thrombosis
D. Pleural effusion related to positioning in the operating room

In the case scenario in question 15 above, which of the following actions should the nurse take first?

A. Notify the physician.
B. Administer a nitroglycerine tablet sublingually.
C. Conduct a thorough assessment of the chest pain.
D. Sit the patient up in bed as tolerated and apply oxygen.

C. Pulmonary embolus from deep vein thrombosis
The patient presents the classic symptoms of pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain.2nd Answer
D. Sit the patient up in bed as tolerated and apply oxygen.

The patient’s clinical picture is consistent with pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician.

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these findings?

A. Continue with ambulation since this is a normal response to activity.
B. Obtain a physician’s order for arterial blood gas determinations to verify the oxygen saturation.
C. Obtain a physician’s order for supplemental oxygen to be used during ambulation and other activity.
D. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.

C. Obtain a physician’s order for supplemental oxygen to be used during ambulation and other activity.

An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen.

When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient’s underlying respiratory defenses because of impairment of which of the following?

A. Cough reflex
B. Mucociliary clearance
C. Reflex bronchoconstriction
D. Ability to filter particles from the air

B. Mucociliary clearance

Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.

A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this patient?

A. Perform a comprehensive health history with the patient to review prior respiratory problems.
B. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Incorrect
C. Delay any physical assessment of the patient and review with the family the patient’s history of respiratory problems.
D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient’s acute respiratory distress is being managed.

Which of the following nursing interventions is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease?

A. Positioning patient on right side
B. Maintaining adequate fluid intake
C. Positioning patient with “good lung down”
D. Performing postural drainage every 4 hours

C. Positioning patient with “good lung down”

Therapeutic positioning identifies the best position for the patient assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation is patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

Which of the following clinical manifestations would the nurse expect to find during assessment of a patient admitted with pneumococcal pneumonia?

A. Hyperresonance on percussion
B. Vesicular breath sounds in all lobes
C. Increased vocal fremitus on palpation
D. Fine crackles in all lobes on auscultation

C. Increased vocal fremitus on palpation

A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial breath sounds, and crackles in the affected area.

Which of the following is the priority nursing intervention in helping a patient expectorate thick lung secretions?

A. Humidify the oxygen as able
B. Administer cough suppressant q4hr
C. Teach patient to splint the affected area
D. Increase fluid intake to 3 L/day if tolerated

D. Increase fluid intake to 3 L/day if tolerated

Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful, but does not liquefy the secretions so that they can be removed.

During discharge teaching for a 65-year-old patient with COPD and pneumonia, which of the following vaccines should the nurse recommend that this patient receive?

A. a. Staphylococcus aureus
B. Haemophilus influenzae
C. Pneumococcal
D. Bacille-Calmette-Guérin (BCG)

C. Pneumococcal

The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility.

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been most effective when the patient states which of the following measures to prevent a relapse?

A. “I will seek immediate medical treatment for any upper respiratory infections.”
B. “I will increase my food intake to 2400 calories a day to keep my immune system well.”
C. “I should continue to do deep-breathing and coughing exercises for at least 6 weeks.”
D. “I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate.”

C. “I should continue to do deep-breathing and coughing exercises for at least 6 weeks.”

It is important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of the infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is required to liquefy secretions. Home O2 is not a requirement unless the patient’s oxygenation saturation is below normal.

After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that which of the following physician orders have been completed before administering a dose of cefotetan (Cefotan) to the patient?

A. Orthostatic blood pressures
B. Sputum culture and sensitivity
C. Pulmonary function evaluation
D. Serum laboratory studies ordered for am

B. Sputum culture and sensitivity

The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefotetan. It is important that the organisms are correctly identified (by the culture) before their numbers are affected by the antibiotic; the test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, all of the other options will not be affected by the administration of antibiotics.

During admission of a patient diagnosed with non-small cell carcinoma of the lung, the nurse questions the patient related to a history of which of the following risk factors for this type of cancer (select all that apply)?

A. Asbestos exposure

B. Cigarette smoking

C. Exposure to uranium

D.Chronic interstitial fibrosis

E.Geographic area in which he was born

A. Asbestos exposure
B. Cigarette Smoking
C. Exposure to uraniumNon-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung

Which of the following nursing interventions is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease?

A. Positioning patient on right side
B. Maintaining adequate fluid intake
C. Positioning patient with “good lung down”
D. Performing postural drainage every 4 hours

C. Positioning patient with “good lung down”

Therapeutic positioning identifies the best position for the patient assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation is patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to which of the following pathophysiologic changes?

A. Laryngospasm
B. Pulmonary edema
C. Narrowing of the airway
D. Overdistention of the alveoli

C. Narrowing of the airway

Narrowing of the airway leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing.

A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which of the following clinical manifestations might be present as an early symptom during an exacerbation of asthma?

A. Anxiety
B. Cyanosis
C. Bradycardia
D. Hypercapnia

A. Anxiety

An early symptom during an asthma attack is anxiety because he is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating.

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. Which of the following is the primary reason for the nurse to carefully inspect the chest wall of this patient?

A. Allow time to calm the patient.
B. Observe for signs of diaphoresis.
C. Evaluate the use of intercostal muscles.
D. Monitor the patient for bilateral chest expansion.

C. Evaluate the use of intercostal muscles.

Which of the following positions is most appropriate for the nurse to place a patient experiencing an asthma exacerbation?

A. Supine
B. Lithotomy
C. High Fowler’s
D. Reverse Trendelenburg

C. High Fowler’s

The patient experiencing an asthma attack should be placed in high Fowler’s position to allow for optimal chest expansion and enlist the aid of gravity during inspiration.

The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, which of the following findings indicates to the nurse that the patient’s respiratory status is improving?

A. Wheezing becomes louder
B. Vesicular breath sounds decrease
C. The cough remains nonproductive
D. Aerosol bronchodilators stimulate coughing

A. Wheezing becomes louder

The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange.

The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. The nurse assesses for which of the following etiologic factor for this nursing diagnosis in patients with asthma?

A. Work of breathing
B. Fear of suffocation
C. Effects of medications
D. Anxiety and restlessness

A. Work of breathing

When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity.

The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient’s condition does not improve, the nurse should anticipate which of the following is likely to be the next step in treatment?

A. Intravenous fluids
B. Biofeedback therapy
C. Systemic corticosteroids
D. Pulmonary function testing

C. Systemic corticosteroids

Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient.

A patient with acute exacerbation of COPD needs to receive precise amounts of oxygen. Which of the following types of equipment should the nurse prepare to use?

A. Oxygen tent
B. Venturi mask
C. Nasal cannula
D. Partial nonrebreather mask

B. Venturi mask

The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered.

While teaching a patient with asthma about the appropriate use of a peak flow meter, the nurse instructs the patient to do which of the following?

A. Use the flow meter each morning after taking medications to evaluate their effectiveness.
B. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse.
C. Increase the doses of the long-term control medication if the peak flow numbers decrease.
D. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.

B. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse.

It is important to keep track of peak flow readings daily, especially when the patient’s symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the flow meter, and should be assessed before and after medications to evaluate their effectiveness.

The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, the nurse should provide which of the following instructions?

A. “Close lips tightly around the mouthpiece and breathe in deeply and quickly.”
B. “To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it.”
C. “You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs.”
D. “Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible.”

A. “Close lips tightly around the mouthpiece and breathe in deeply and quickly.”

The patient should be instructed to breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after noting which of the following?

A. Hypertension and pulmonary edema
B. Oropharyngeal candidiasis and hoarseness
C. Elevation of blood glucose and calcium levels
D. Adrenocortical dysfunction and hyperglycemia

B. Oropharyngeal candidiasis and hoarseness

Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state which of the following as the primary benefit?

A. “I will pay less for medication because it will last longer.”
B. “More of the medication will get down into my lungs to help my breathing.”
C. “Now I will not need to breathe in as deeply when taking the inhaler medications.”
D. “This device will make it so much easier and faster to take my inhaled medications.”

B. “More of the medication will get down into my lungs to help my breathing.”

A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat.

Which of the following test results identifies that a patient with an asthma attack is responding to treatment?

A. An increase in CO2 levels
B. A decreased exhaled nitric oxide
C. A decrease in white blood cell count
D. An increase in serum bicarbonate levels

B. A decreased exhaled nitric oxide

Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma.

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which of the following patient vital signs?

A. Pulse rate of 76
B. Respiratory rate of 18
C. Temperature of 98.4° F
D. Oxygen saturation 96%

A. Pulse rate of 76

Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 76 indicates that the patient did not experience tachycardia as an adverse effect.

The patient has an order for each of the following inhalers. Which of the following should the nurse offer to the patient at the onset of an asthma attack?

A. Albuterol (Proventil)
B. Salmeterol (Serevent)
C. Beclomethasone (Beclovent)
D. Ipratropium bromide (Atrovent)

A. Albuterol (Proventil)

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring which of the following patient parameters?

A. Apical pulse
B. Bowel sounds
C. Intake and output
D. Deep tendon reflexes

C. Intake and output

Corticosteroids such as prednisone can lead to fluid retention. For this reason, it is important to monitor the patient’s intake and output.

When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for which of the following potential triggers (select all that apply)?

A. Exercise

B. Allergies

C. Emotional stress

D.Decreased humidity

E. Upper respiratory infections

A, B, C, and E

Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, psychologic factors, and gastroesophageal reflux disease

The nurse is assisting a patient to learn self-administration of beclomethasone two puffs inhalation every 6 hours. The nurse explains that the best way to prevent oral infection while taking this medication is to do which of the following as part of the self-administration techniques?

A. Chew a hard candy before the first puff of medication.
B. Rinse the mouth with water before each puff of medication.
C. Ask for a breath mint following the second puff of medication.
D. Rinse the mouth with water following the second puff of medication.

D. Rinse the mouth with water following the second puff of medication.
The patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection.

The nurse is scheduled to give a dose of salmeterol by metered dose inhaler (MDI). The nurse would administer the right drug by selecting the inhaler with which of the following trade names?

A. Vanceril
B. Serevent
C. AeroBid
D. Atrovent

B. Serevent

The nurse is evaluating whether a patient understands how to safely determine whether a metered dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler?

A. Place it in water to see if it floats.
B. Keep track of the number of inhalations used.
C. Shake the canister while holding it next to the ear.
D. Check the indicator line on the side of the canister.

B. Keep track of the number of inhalations used.

It is no longer appropriate to see if a canister floats in water or not since this is not accurate. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing when those inhalations have been used.

The nurse is scheduled to give a dose of ipratropium bromide by metered dose inhaler. The nurse would administer the right drug by selecting the inhaler with which of the following trade names?

A. Vanceril
B. AeroBid
C. Atrovent
D. Pulmicort

C. Atrovent

The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 2 mg/ml. How many milliliters should the nurse use to prepare the patient’s dose?

A. 0.2
B. 2.5 Correct
C. 3.75
D. 5.0

B. 2.5 Correct

5 mg ÷ 2 mg/ml = 2.5 ml

When planning patient teaching about COPD, the nurse understands that the symptoms are caused by which of the following?

A. An overproduction of the antiprotease a1-antitrypsin
B. Hyperinflation of alveoli and destruction of alveolar walls
C. Hypertrophy and hyperplasia of goblet cells in the bronchi
D. Collapse and hypoventilation of the terminal respiratory unit

B. Hyperinflation of alveoli and destruction of alveolar walls

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with COPD are successful based on which of the following findings?

A. Absence of dyspnea
B. Improved mental status
C. Effective and productive coughing
D. PaO2 within normal range for the patient
.

C. Effective and productive coughing

Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing

When caring for a patient with COPD, the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which of the following would be an appropriate intervention to add to the plan of care for this patient?

A. Order fruits and fruit juices to be offered between meals. Incorrect
B. Order a high-calorie, high-protein diet with six small meals a day.
C. Teach the patient to use frozen meals at home that can be microwaved.
D. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.

B. Order a high-calorie, high-protein diet with six small meals a day.

Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, interfering with the work of breathing. Finally, the metabolism of a high carbohydrate diet yields large amounts of CO2, which may lead to acidosis in patients with pulmonary disease. For these reasons, the patient with COPD should take in a high-calorie, high-protein diet, eating six small meals per day.

The nurse reviews pursed lip breathing with a patient newly diagnosed with COPD. The nurse reinforces that this technique will assist respiration by which of the following mechanisms?

A. Loosening secretions so that they may be coughed up more easily
B. Promoting maximal inhalation for better oxygenation of the lungs
C. Preventing bronchial collapse and air trapping in the lungs during exhalation
D. Increasing the respiratory rate and giving the patient control of respiratory patterns

C. Preventing bronchial collapse and air trapping in the lungs during exhalation

The focus of pursed lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation.

Nursing assessment findings of jugular vein distention and pedal edema would be indicative of which of the following complications of emphysema?

A. Acute respiratory failure I
B. Secondary respiratory infection
C. Pulmonary edema caused by left-sided heart failure
D. Fluid volume excess resulting from cor pulmonale

D. Fluid volume excess resulting from cor pulmonale

Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.

A patient has been receiving oxygen per nasal cannula while hospitalized for COPD. The patient asks the nurse whether oxygen use will be needed at home. Which of the following would be the most appropriate response by the nurse?

A. “Long-term home oxygen therapy should be used to prevent respiratory failure.”
B. “Oxygen will not be needed until or unless you are in the terminal stages of this disease.”
C. “Long-term home oxygen therapy should be used to prevent heart problems related to COPD.”
D. “Oxygen will be needed when your oxygen saturation drops to 88% and you have symptoms of hypoxia.”

D. “Oxygen will be needed when your oxygen saturation drops to 88% and you have symptoms of hypoxia.”

Long-term oxygen therapy in the home should be considered when the oxygen saturation is ≤88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status.

Before discharge, the nurse discusses activity levels with a 61-year-old patient with COPD and pneumonia. Which of the following exercise goals is most appropriate once the patient is fully recovered from this episode of illness?

A. Slightly increase activity over the current level.
B. Swim for 10 min/day, gradually increasing to 30 min/day.
C. Limit exercise to activities of daily living to conserve energy.
D. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

D. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate <75% to 80% of maximum heart rate (220 – patient’s age).

The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium (Atrovent) after noting which of the following assessment findings?

A. Decreased respiratory rate
B. Increased respiratory rate
C. Increased peak flow readings
D. Decreased sputum production

C. Increased peak flow readings

Ipratropium is a bronchodilator that should lead to increased peak expiratory flow rates (PEFRs).

The nurse is teaching a patient how to self-administer ipratropium (Atrovent) via a metered dose inhaler. Which of the following instructions given by the nurse is most appropriate to help the patient learn proper inhalation technique?

A. “Avoid shaking the inhaler before use.”
B. “Breathe out slowly before positioning the inhaler.”
C. “After taking a puff, hold the breath for 30 seconds before exhaling.” Incorrect
D. “Using a spacer should be avoided for this type of medication.”

B. “Breathe out slowly before positioning the inhaler.”

It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication, thus enhancing the effectiveness of the dose

Which of the following statements made by a patient with COPD indicates a need for further teaching regarding the use of an ipratropium inhaler?

A. “I should rinse my mouth following the two puffs to get rid of the bad taste.”
B. “I should wait at least 1 to 2 minutes between each puff of the inhaler.”
C. “Because this medication is not fast acting, I cannot use it in an emergency if my breathing gets worse.”
D. “If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily.”

D. “If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily.”

The patient should not take extra puffs of the inhaler at will to make breathing easier. Excessive treatment could trigger paradoxical bronchospasm, which would worsen the patient’s respiratory status.

Which statement explains why it can be difficult to assess a child’s dietary intake?

A. No systematic assessment tool has been developed for this purpose.
B. Biochemical analysis for assessing nutrition is expensive.
C. Families usually do not understand much about nutrition. Incorrect
D. Recall of children’s food consumption is frequently unreliable.

D. Recall of children’s food consumption is frequently unreliable.

It is difficult for parents to recall exactly what their child has eaten. Concurrent food diaries are somewhat more reliable.
Systematic tools have been developed and are available.
Nutrients for different foods are known; the quantity and type of food consumed are the facts that are difficult to ascertain.
The family does not need nutritional knowledge to describe what the child has eaten.

The nurse is ready to begin a physical examination on an 8-month-old infant. The child is sitting contentedly on the mother’s lap, chewing on a toy. What should the nurse do first?

A. Elicit reflexes.
B. Auscultate the heart and lungs.
C. Examine the eyes, ears, and mouth.
D. Examine the head, systematically moving toward the feet.

B. Auscultate the heart and lungs.

While the child is quiet, auscultation should be performed.
It may disturb or upset the child to elicit reflexes first, making auscultation and the remainder of the physical examination difficult.
It may disturb or upset the child to examine the eyes, ears, and mouth first, making auscultation and the remainder of the physical examination difficult.
Although most physical examinations proceed from the head to the feet, the nurse should perform the assessment for a child in an order that moves from least disturbing to most disturbing from the child’s perspective.

The nurse is assessing a 3-year-old African-American child who is being seen in the clinic for the first time. The child’s height and weight are in the 20th percentile on the commonly used growth chart from the National Center for Health Statistics. When interpreting the data, the nurse recognizes

A. child’s growth is within normal limits.
B. child’s growth is not within normal limits.
C. growth chart is not accurate for African-American children.
D. growth chart is not useful until several measurements are plotted over time.

A. child’s growth is within normal limits.

The growth charts are population based and include all children without regard to race or ethnicity.
A child’s growth within the 20th percentile is within the normal range.
Children from different ethnic and racial groups are included, making the growth chart representative for all groups.
The growth chart is useful both for screening and for assessment over time.

What is the most accurate method of determining the length of a child younger than 12 months of age?

A. Standing height
B. Estimation of length to the nearest centimeter or 1/2 inch
C. Recumbent length measured in the prone position
D. Recumbent length measured in the supine position

D. Recumbent length measured in the supine position

The crown-heel length measurement is the most accurate measurement in infants.
Infants are generally unable to stand for obtaining a height measurement.
Measurement should not be estimated, because an accurate measurement is required to determine growth.
The infant should be measured in the supine position, not the prone position.

The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is to

A. use the small cuff.
B. use the large cuff.
C. use either cuff, using palpation method.
D. locate the proper-sized cuff before taking the blood pressure

D. locate the proper-sized cuff before taking the blood pressure

To obtain an accurate blood pressure reading, it is preferable to use the proper-sized cuff. Therefore, locating one before taking the blood pressure is the best nursing action.
The smaller cuff gives a falsely increased blood pressure and is not the method of choice.
The larger cuff, which may give a falsely lowered blood pressure, is preferable to the smaller cuff, which gives a falsely increased blood pressure, but neither is the method of choice.
Auscultation is preferred to palpation.

The nurse is assessing skin turgor in a child. The nurse grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended, or tented, for a few seconds, and then slowly falls back on the abdomen. Based on the nurse’s knowledge of assessing skin turgor, the assessment finding is that the

A. tissue shows normal elasticity.
B. child is properly hydrated.
C. assessment is done incorrectly.
D. child has poor skin turgor

D. child has poor skin turgor

Tenting is the term for poor skin turgor.
In normal elasticity, the skin would return immediately to its original position.
If the child is properly hydrated, skin turgor would be elastic.
The correct way to assess turgor is to grasp the skin on the abdomen between the thumb and index finger, pull it taut, and quickly release it.

The nurse needs to take the blood pressure of a preschooler for the first time. What action would be best for gaining the child’s cooperation?

A. Take the blood pressure when a parent is there to comfort the child.
B. Tell the child that this procedure will help the child to get well faster.
C. Explain to the child how blood flows through the arm and why taking the blood pressure is important.
D. Permit the child to handle equipment and see the dial move before putting the cuff in place

D. Permit the child to handle equipment and see the dial move before putting the cuff in place

The best approach for a preschooler is to allow the child to play out the experience ahead of time, thereby decreasing the child’s anxiety.
The parent’s presence will be helpful, but it will not alleviate fear of the unknown.
Telling a child that the procedure will help the child to get well faster is not a true statement, and the child will not be able to understand the relationship between the blood pressure and feeling better.
The explanation of how blood pressure is determined physiologically is too complex an explanation for this age group.

It is time to give a 3-year-old medication. What approach is most likely to receive a positive response from the child?

A. “It’s time for your medication now. Would you like water or apple juice afterward?”
B. “Wouldn’t you like to take your medicine now?”
C. “You must take your medicine because the doctor says it will make you better.”
D. “See how nicely your roommate took medicine? Now take yours.”

A. “It’s time for your medication now. Would you like water or apple juice afterward?”

The best explanation for using pulse oximetry on young children is that it

A. is noninvasive.
B. is better than capnography.
C. is more accurate than arterial blood gas measurements.
D. provides intermittent measurements of oxygen.

A. is noninvasive.

Pulse oximetry is a noninvasive method for determining oxygen saturation.
Capnography measures carbon dioxide exhalation. It does not reflect oxygen perfusion.
Pulse oximetry is less invasive and easier to test than arterial blood gases.
Pulse oximetry provides continuous or intermittent measurements of oxygen saturation.

The nurse is caring for an infant with a tracheostomy when accidental decannulation occurs. The nurse is unable to reinsert the tube. What action should the nurse take next?

A. Notify the surgeon.
B. Perform oral intubation.
C. Try inserting a larger tracheostomy tube.
D. Try inserting a smaller tracheostomy tube.

D. Try inserting a smaller tracheostomy tube.

A smaller tracheostomy tube should be available at the bedside at all times. Insertion of the smaller tube will keep the stoma open until further action can be taken.
Notification of the surgeon should be done after the emergent situation is handled.
Oral intubation is done if a tracheostomy tube cannot be inserted.
A larger tracheostomy tube would cause trauma to the trachea and, therefore, is not used.

A neonate had corrective surgery 3 days ago for esophageal atresia. The nurse notices that after gastrostomy feedings, there is often a backup of feeding into the tube. The most appropriate intervention by the nurse is to

A. position the child in a supine position after feedings. Incorrect
B. position the child on the left side after feedings.
C. leave the gastrostomy tube open and suspended after feedings.
D. leave the gastrostomy tube clamped after feedings.

C. leave the gastrostomy tube open and suspended after feedings

The formula is backing up into the tube because of delayed emptying. By keeping the tube open to air, it will prevent the buildup of pressure on the operative site and the subsequent backup of feeding into the tube.
The child should be positioned on the right side with the head elevated approximately 30 degrees after feeding.
The child should be positioned on the right side with the head elevated approximately 30 degrees after feeding.
Leaving the gastrostomy tube clamped after feedings will create pressure on the operative site and increase the risk of backup of the feedings.

What clinical manifestation would the nurse expect when a pneumothorax occurs in a neonate who is undergoing mechanical ventilation?

A. Barrel chest
B. Wheezing
C. Thermal instability
D. Nasal flaring and retractions

D. Nasal flaring and retractions

Nasal flaring, retractions, and grunting are signs of respiratory distress in a neonate.
Barrel chest develops with chronic obstructive pulmonary disease, not with acute pneumothorax.
Wheezing has a greater association with bronchopulmonary dysplasia or an obstruction in the airways than with an acute pneumothorax.
An acute pneumothorax would not affect the neonate’s thermal stability.

The nurse is interviewing the parents of a 4-month-old infant brought to the hospital emergency department. The infant is dead on arrival, and no attempt at resuscitation is made. The parents state that the baby was found in the crib with a blanket over the head, lying face down in bloody fluid from the nose and mouth. The parents indicate no problems when the infant was placed in the crib asleep. Which of the following causes of death does the nurse suspect?

A. Suffocation
B. Child abuse
C. Infantile apnea
D. Sudden infant death syndrome (SIDS)

D. Sudden infant death syndrome (SIDS)

Death is consistent with the appearance of SIDS. The infant is usually found in a disheveled bed; with blankets over the head; huddled into a corner and clutching the sheets; with frothy, blood-tinged fluid in the mouth and nose; and lying face down. The diaper is also usually full of stool, indicating a cataclysmic type of death.
Although the child was found under the blanket, the other findings are consistent with SIDS.
The findings as reported are consistent with SIDS, not child abuse.
The history and physical findings are consistent with SIDS, not infantile apnea.

Apnea of infancy has been diagnosed in an infant scheduled for discharge with home monitoring. Part of the infant’s discharge teaching plan should include?

A. Cardiopulmonary resuscitation (CPR)
B. Administration of intravenous (IV) fluids
C. Foreign airway obstruction removal using the Heimlich maneuver
D. Advice that the infant not be left with caretakers other than the parents

A. Cardiopulmonary resuscitation (CPR)

CPR is essential for all parents and caregivers to know, especially when an infant has a history of apnea of infancy that is being monitored at home.
Most likely, the child will not be receiving home IV therapy as part of the discharge care.
The Heimlich maneuver is used to intervene when a child or an adult is experiencing a choking episode. It would not be necessary for the parents to learn the maneuver at this time. (Back slaps and chest thrusts are used on the responsive infant for choking.)
The parents should arrange for other caregivers to help when possible. There is no reason that the infant cannot be left with capable and trained individuals. Anyone caring for the infant will need to be taught to use equipment and how to perform CPR.

The most appropriate time to perform bronchial postural drainage is

A. immediately before all aerosol therapy.
B. before meals and at bedtime.
C. immediately on arising and at bedtime.
D. thirty minutes after meals and at bedtime

B. before meals and at bedtime.

The most effective time for bronchial drainage is before meals and before bedtime to prevent the interaction of excessive amounts of mucus and food intake, thereby increasing the risk of vomiting.
Bronchial drainage is more effective after other respiratory therapies such as bronchodilator or nebulizer treatments. These treatments open the airways, facilitating the movement of mucus with the positioning of bronchial drainage.
Bronchial drainage should be done three or four times each day to be effective.
When bronchial drainage is completed after meals, it may cause the child to vomit.

A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because it

A. liquefies secretions.
B. improves oxygenation.
C. promotes ventilation.
D. soothes inflamed mucous membrane.

D. soothes inflamed mucous membrane.

Humidified inspired air soothes the membranes inflamed by the infection and dry air.
The size of the droplets in humidified air is too large to liquefy secretions.
No additional oxygen is provided with humidified air.
The humidity has no effect on ventilation.

A 4-year-old child is brought to the emergency department. The child has a “froglike” croaking sound on inspiration, is agitated, and is drooling. The child insists on sitting upright. The priority action by the nurse is to

A. examine the child’s oropharynx and report the assessment to the healthcare provider.
B. make the child lie down and rest quietly.
C. auscultate the child’s lungs and make preparations for placement in a mist tent.
D. notify the healthcare provider immediately and be prepared to assist with a tracheostomy or intubation.

D. notify the healthcare provider immediately and be prepared to assist with a tracheostomy or intubation.

Sitting upright, drooling, agitation, and a froglike cough are indicative of epiglottitis. This is a medical emergency, and tracheostomy or intubation may be necessary.
Examination of the oropharynx may cause total obstruction and should not be done when a child manifests signs indicating potential epiglottitis.
The child assumes a tripod position to facilitate breathing. Forcing the child to lie down will increase the respiratory distress and anxiety.
Interventions should be planned once the diagnosis of epiglottitis has been made or ruled out.

The mother of a 20-month-old tells the nurse that the child has a barking cough at night. The child’s temperature is 37ºC (98.6ºF). The mother states the child is not having difficulty breathing. The nurse suspects croup and should recommend

A. controlling the fever with acetaminophen (Tylenol) and call the primary care provider if the cough gets worse tonight.
B. trying a cool-mist vaporizer at night and watching for signs of difficulty breathing.
C. trying over-the-counter cough medicine and coming to the clinic tomorrow if there is no improvement.
D. bringing the child to the hospital to be admitted and to be observed for impending epiglottitis.

B. trying a cool-mist vaporizer at night and watching for signs of difficulty breathing.

Because the child is not having difficulty breathing, the nurse should teach the parents the signs of respiratory distress and tell them to come to the emergency department if they develop. Cool mist is recommended to provide relief because this therapy will assist in opening up the child’s airways.
The child does not have a temperature and, therefore, does not need management with acetaminophen.
Cough suppressants are not indicated by symptom, and the American Pediatrics Association no longer recommends over-the-counter cough medicines for children under the age of 2 years.
A barking cough is characteristic of laryngotracheobronchitis, not epiglottitis.

An infant with a congenital heart defect is receiving palivizumab (Synagis). Based on the nurse’s knowledge of medication, the purpose of this medication is to

A. prevent respiratory syncytial virus (RSV) infection.
B. make isolation of the infant with RSV unnecessary.
C. prevent secondary bacterial infection.
D. decrease toxicity of antiviral agents.

A. prevent respiratory syncytial virus (RSV) infection.

Palivizumab is a monoclonal antibody specifically used in the prevention of RSV. Monthly administration is expected to prevent infection with RSV.
The goal of this drug is prevention of RSV. It will not affect the need to isolate the child if RSV develops.
Palivizumab is specific to RSV, not bacterial infections.
Palivizumab will have no effect on antiviral agents.

A child with asthma is having pulmonary function tests. What explains the purpose of the peak expiratory flow rate (PEFR)?

A. Confirms the diagnosis of asthma
B. Determines the cause of asthma
C. Identifies the “triggers” of asthma
D. Assesses the severity of asthma

D. Assesses the severity of asthma

The PEFR measures the maximum amount of air that can be forcefully exhaled in 1 minute. This can provide an objective measure of pulmonary function when compared with the child’s baseline.
The diagnosis of asthma is made on the basis of clinical manifestations, history, and physical examination, not pulmonary function tests such as the PEFR.
The cause of asthma is inflammation, bronchospasm, and obstruction, which are not identified by the PEFR.
Some of the triggers of asthma are identified with allergy testing, not with the PEFR.

A 4-year-old boy needs to use a metered-dose inhaler to treat asthma. He cannot coordinate the breathing to use it effectively. The nurse should suggest that he use a

A. spacer.
B. nebulizer.
C. peak expiratory flow meter.
D. trial of chest physiotherapy.

A. spacer.

The medication in a metered-dose inhaler is sprayed into the spacer. The child can then inhale the medication without having to coordinate the spraying and breathing.
A nebulizer is a mechanism to administer medications, but it cannot be used with metered-dose inhalers.
Peak expiratory flow meters measure pulmonary function but are not related to medication administration.
Chest physiotherapy is unrelated to medication administration.

One of the goals for children with asthma is to prevent respiratory tract infection because infections

A. lessen effectiveness of medications.
B. encourage exercise-induced asthma.
C. increase sensitivity to allergens.
D. can trigger an episode or aggravate asthmatic state.

D. can trigger an episode or aggravate asthmatic state.

Respiratory tract infections can trigger an asthmatic attack. An annual influenza vaccine is recommended. All respiratory equipment should be kept clean.
Respiratory tract infection affects the asthma, not the medications.
Exercise-induced asthma is caused by vigorous activity, not a respiratory tract infection.
Sensitivity to allergens is independent of respiratory tract infection.

Cystic fibrosis may affect one system or multiple systems of the body. What is the primary factor responsible for possible multiple clinical manifestations?

A. Atrophic changes in the mucosal wall of the intestines
B. Hypoactivity of the autonomic nervous system
C. Hyperactivity of the apocrine glands
D. Mechanical obstruction caused by increased viscosity of exocrine gland secretions

D. Mechanical obstruction caused by increased viscosity of exocrine gland secretions Correct

Children with cystic fibrosis have thick exocrine gland secretions. The viscous secretions obstruct small passages in organs such as the lungs and pancreas.
Thick mucous secretions are the probable cause of the multiple body system involvement, not atrophic changes in the intestinal mucosal walls.
There is an identified autonomic nervous system anomaly, but it is not hypoactivity.
The apocrine, or sweat, glands are not hyperactive. The child loses a greater amount of salt due to abnormal chloride movement.

The parent of a child with cystic fibrosis calls the clinic nurse to report that the child has developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic because these symptoms are suggestive of

A. pneumothorax.
B. bronchodilation.
C. carbon dioxide retention.
D. increased viscosity of sputum.

A. pneumothorax.

The child is exhibiting signs of increasing respiratory distress suggestive of a pneumothorax. The child needs to be seen as soon as possible.
Bronchodilation would not produce the described symptoms.
Carbon dioxide retention would not produce the described symptoms.
The increased viscosity of sputum is characteristic of cystic fibrosis. The change in respiratory status is potentially due to a pneumothorax.

Because the absorption of fat-soluble vitamins is decreased in cystic fibrosis, which vitamin supplementation is necessary?

A. C, D
B. A, E, K
C. A, D, E, K
D. C, folic acid

C. A, D, E, K
A, D, E, and K are the fat-soluble vitamins, which need to be supplemented in higher doses for the child with cystic fibrosis.
C is not one of the fat-soluble vitamins.
D also needs to be supplemented in children with cystic fibrosis.
C and folic acid are not fat-soluble vitamins.

An immediate intervention to teach parents for when an infant chokes on a piece of food would be to

A. have infant lie quietly while a call is placed for emergency help. Incorrect
B. position infant in a head-down, face-down position and administer five quick back slaps.
C. administer mouth-to-mouth resuscitation.
D. give some water by a cup to relieve the obstruction.

B. position infant in a head-down, face-down position and administer five quick back slaps.

Positioning the infant head and face down while administering five quick blows between the shoulder blades is the correct initial sequence of actions for an infant with an obstructed airway.
The infant needs to receive treatment immediately. Emergency help is called after attempting to remove the obstruction.
Mouth-to-mouth resuscitation should not be used. This may push the object further into the child’s respiratory system.
If the child is obstructed, the water will not be able to pass. This will increase the risk of aspiration.

The school nurse is called to the cafeteria because a child “has eaten something he is allergic to.” The child is in severe respiratory distress. The first action by the nurse is to

A. determine what the child has eaten.
B. administer diphenhydramine (Benadryl) PO stat.
C. move the child to the nurse’s office or hallway.
D. have someone call for an ambulance and paramedic rescue squad or 9-1-1.

D. have someone call for an ambulance and paramedic rescue squad or 9-1-1.

Because the child is in severe respiratory distress, the nurse should have someone call for a rescue squad or 9-1-1.
Because severe respiratory distress is occurring, treatment of the response is indicated. What the child has eaten can be determined later.
Diphenhydramine by mouth will not be effective for this type of emergency allergic reaction.
The child should not be moved, unless the child is currently in a place that puts him or her at greater hazard.

Asthma is classified into four categories: mild intermittent, mild persistent, moderate persistent, and severe persistent. Clinical features used to determine these categories include (Select all that apply)

A. lung function.

B.associated allergies.

C. frequency of symptoms.

D. frequency and severity of exacerbations.

Lung Function, Frequency of symptoms, Frequency and severity of exacerbations,

The peak expiratory flow rate is one of the diagnostic criteria for classifying severity.
The frequency of symptoms is one of the diagnostic criteria for classifying severity.
The frequency and severity of exacerbations are two of the diagnostic criteria for classifying severity.
The clinical features that distinguish the categories of asthma do not include other allergies

A 5-year-old child is brought the Emergency Department with abrupt onset of sore throat, pain with swallowing, fever, and sitting upright and forward. Acute epiglottitis is suspected. What are the most appropriate nursing interventions? (Select all that apply.)

A. Vital signs

B.
Throat culture

C Medical history

D. Assessment of breath sounds

E. Emergency airway equipment readily available

Vital Signs
Medical History
Assessment of breath sounds
Emergency airway equipment readily available

Vital signs should always be taken as a part of the assessment.
Medical history is important in assisting with the diagnosis in addition to knowing immunization status.
Assessment of breath sounds is important in assisting with the diagnosis. Suprasternal and substernal retractions may be noted.
Emergency airway equipment must be readily available in case the airway becomes obstructed.
Throat culture should never be done when diagnosis of epiglottis is suspected. Manipulation of the throat can stimulate the gag reflex in an already inflamed airway and cause laryngeal spasm that will cause occlusion of the airway

The nurse is planning care for the a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority? A. Administer Prescribed stool softner B. Administer …

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A) Tinnitus, vertigo, and hearing difficulties. B) Sudden, stabbing, severe pain over the lip and chin. C) Facial weakness and paralysis. D) Difficulty in chewing, …

Which symptoms should the nurse anticipate when caring for a client with acute cholecystitis? Select all that apply: 1. Chills 2. Fever 3. Nausea and vomiting 4. Increased appetite 5. Rigidity of upper right abdomen. 1., 2., 3. & 5. …

The primary function of the respiratory system is _____. gas exchange Functionally, the respiratory system can be divided into two parts: the ____ airways through which air moves as it passes between the atmosphere and the lungs, and the ____ …

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