Assessment of the Respiratory System, Noninfectious Upper Respiratory Problems, & Pulmonary Embolism Flashcards
A nurse assesses a client’s respiratory status. Which information is of highest priority for the nurse to obtain?
a. Average daily fluid intake
b. Neck circumference
c. Height and weight
d. Occupation and hobbies
ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a clients occupation and hobbies. Although it will be important for the nurse to assess the clients fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the clients neck circumference will not be an important part of a respiratory assessment.
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
a. Encourage the client to increase fluid intake.
b. Assess the clients level of consciousness.
c. Raise the head of the bed to at least 45 degrees.
d. Provide the client with humidified oxygen.
ANS: B
Assessing the clients level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.
A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention?
a. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
b. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
c. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
d. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
ANS: C
Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention.
. A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
a. Are you taking any medications or herbal supplements?
b. Do you have any chronic breathing problems?
c. How often do you perform aerobic exercise?
d. What is your occupation and what are your hobbies?
ANS: B
The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and should be asked first.
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?
a. Call the physician and request a prescription for food and water.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the clients gag reflex before giving any food or water.
d. Let the client have a small sip to see whether he or she can swallow.
ANS: C
The topical anesthetic used during the procedure will have affected the clients gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client’s plan of care?
a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 liters per nasal cannula
d. Complete bed-rest with frequent repositioning
ANS: A
A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bed-rest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.
A nurse auscultates a harsh hollow sound over a client’s trachea and larynx. Which action should the nurse take first?
a. Document the findings.
b. Administer oxygen therapy.
c. Position the client in high-Fowler’s position.
d. Administer prescribed albuterol.
ANS: A
Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the clients position because the finding is normal.
A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
a. Encourage deep breathing and coughing.
b. Implement an air mattress overlay.
c. Ambulate the client three times each day.
d. Provide a diet high in protein and vitamins.
e. Administer acetaminophen (Tylenol) twice daily.
ANS: A, C, D
Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.
After teaching a client how to perform diaphragmatic breathing, the nurse assesses the clients understanding. Which action demonstrates that the client correctly understands the teaching?
a. The client lays on his or her side with his or her knees bent.
b. The client places his or her hands on his or her abdomen.
c. The client lays in a prone position with his or her legs straight.
d. The client places his or her hands above his or her head.
ANS: B
To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the clients lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
ANS: B
This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found.
ANS: C
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?
a. Breathing so rapidly interferes with oxygenation.
b. Maybe the client has respiratory distress syndrome. c. The blood clot interferes with perfusion in the lungs.
d. The client needs immediate intubation and mechanical ventilation.
ANS: C
A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin (Coumadin).
ANS: B
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L
c. Red blood cell count: 4.8/mm3
d. White blood cell count: 8.7/mm3
ANS: B
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
d. Tell the client to take slow, deep breaths.
ANS: A
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.
