Question 1

A client admitted for difficulty breathing becomes worse.Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)?

Accepted Answer

A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen.Increased dyspnea goes along with the increased hypoxemia,as does anxiety.Chest pain is not specific to ARDS; although chest pain can occur with ARDS,it occurs with many other conditions as well.Pitting edema would not be an assessment factor that confirms ARDS.Clubbing occurs in chronic,not acute,respiratory conditions.

Question 2

Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply)

Accepted Answer

Older adults,especially those with chronic lung problems,are at higher risk for pulmonary embolism.Prolonged bedrest is also a risk factor,as are abdominal surgery and smoking.Because platelets are involved in the clotting process,elevated platelets may contribute to increased clotting.Diabetes and waiting for surgery are not known risk factors.

Question 3

The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation.The client's oxygen saturation has dropped from 94% to 86%.What is the priority action by the nurse?

Accepted Answer

This client has a flail chest characterized by paradoxical chest wall motion.With the oxygen saturation dropping,the client is at high risk for respiratory failure and needs to be intubated.Deep-breathing exercises are not enough at this point.Rib binders are not used anymore because they limit chest wall expansion and were used only for simple rib fractures.

Question 4

The nurse assesses a client admitted for chest trauma who reports dyspnea.The nurse finds tracheal deviation and a pulse oximetry reading of 86%.What is the nurse's priority intervention?

Accepted Answer

Blunt chest trauma can cause an air leak into the thoracic cavity,collapsing the lung on the side with the air leak (pneumothorax).More air enters the pleural space with each breath,increasing intrathoracic pressure on the affected side,moving the trachea to the unaffected side,and leading to decreased cardiac output.This condition (tension pneumothorax)is life threatening without intervention.The client will need oxygen administration right away and a chest tube inserted.

Question 5

The nurse is caring for a client on a ventilator when the high-pressure alarm sounds.What actions are most appropriate?

Accepted Answer

Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway.The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs.The nurse also should assess the tubing for kinks.The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team.If the tubing became disconnected,the low-pressure alarm would sound.

Question 6

A client with severe respiratory insufficiency becomes short of breath during activities of daily living.Which nursing intervention is best?

Accepted Answer

Clients with shortness of breath and decreased oxygen saturation must be monitored closely.Minimal involvement in activities is required if the client is severely short of breath.The nurse should continue to assess the client and can increase involvement in activities if shortness of breath subsides.The Rapid Response Team is not required.Clustering or spacing of activities does nothing to decrease the client's involvement,which is the cause of shortness of breath.

Question 7

The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP).What intervention is most appropriate for this client?

Accepted Answer

A requirement for using CPAP is that the client will be able to breathe spontaneously.Antianxiety and sleep medications should not be administered to the client during weaning.Telling the client to relax may be helpful in some cases but does not take priority over ensuring the client's ability to breathe spontaneously.

Question 8

The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest.What is the nurse's best action?

Accepted Answer

The endotracheal tube is more likely to slip into the right mainstem bronchus,leading to the breath sounds described.The nurse should assess placement of the ET tube by assessing where the markings are,making sure it is taped,and confirming equal breath sounds bilaterally.If it is believed that the tube has slipped into the right mainstem bronchus,the health care provider should order a chest x-ray and reposition the tube.

Question 9

A nurse is making initial rounds on assigned clients at the beginning of the shift.One client is receiving a heparin infusion at 5 mL/hr.The nurse notes that 25,000 units of heparin are mixed in 250 mL of solution.How many units per hour is the client receiving? __________ units/hr

Accepted Answer

The answer of A nurse is making initial rounds on...

Question 10

The nurse is assessing arterial blood gases (ABGs).The client with which ABG reading requires the nurse's immediate attention?

Accepted Answer

This client has the most severe hypoxia and respiratory alkalosis,indicated by low partial pressure of arterial carbon dioxide (PaCO₂)values on ABG analysis.

Question 11

Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)?

Accepted Answer

Hemoptysis,sharp chest pain,and hypotension all may be caused by pulmonary embolism and the pulmonary hypertension that results.Rather than wheezes,crackles usually occur along with a dry cough.

Question 12

What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation?

Accepted Answer

The nurse should have the client point to words on a board to communicate needs.The endotracheal tube is positioned and placement is maintained with tape or some other type of appliance.Asking the client to move his or her mouth and lips could result in possible extubation.Communication is limited and could be misunderstood with blinking.Teaching the client sign language,even simple,would be an involved and unrealistic goal.

Question 13

The nurse auscultates the following lung sound in a client with a respiratory disorder.What is the nurse's best action? (Click the media button to hear the audio clip.)

Accepted Answer

The sound heard is stridor.Stridor on inspiration is caused by laryngospasm or edema and heralds impending airway occlusion.The client's airway is in jeopardy and immediate intervention is necessary.Using the spirometer or coughing and deep breathing will not help the client in this situation.The nurse needs to call the Rapid Response Team.

Question 14

The nurse is caring for a client with a high risk for pulmonary embolism (PE).Which prevention measures does the nurse add to the client's care plan?

Accepted Answer

Both antiembolism stockings (or sequential pressure devices)and a turning schedule can help prevent venous thromboembolism,which can lead to PE.Massaging the calves is discouraged because this can cause a clot to break loose and travel to the lungs.Legs should be elevated when in bed,and the client should perform active range of motion (ROM)if able.If the client is unable to perform active ROM,the nurse should provide passive ROM.

Question 15

A client is ordered heparin 5000 units at 7 AM.The heparin is provided in a vial labeled 20,000 units per mL.How much does the nurse administer? ______ mL

Accepted Answer

The answer of A client is ordered heparin 5000 units...

Question 16

A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask.What action does the nurse take?

Accepted Answer

Restlessness and confusion are clinical manifestations of hypoxemia.It is important that the nurse stay with the client,ensure that the oxygen is maintained,and attempt to calm the client.Because of the client's restlessness,the nurse cannot delegate care to the spouse.Requesting a sedative might adversely affect the client's respiratory status further.Restraining the client could increase restlessness and increase oxygen demand.

Question 17

The nurse is prioritizing care for a client on a ventilator.What are essential nursing interventions for this client?

Accepted Answer

The nurse should assess the client when an alarm sounds and should intervene accordingly.The nurse should also check the settings to make sure they are correct and should evaluate the water level to make sure the humidifier does not go dry.The nurse would not be responsible for changing ventilator settings,weaning the client,or changing the ventilator tubing.

Question 18

The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side.What finding requires immediate attention?

Accepted Answer

Puffiness of the skin around the chest tube and a crackling feeling indicate subcutaneous emphysema,or air leaking into the tissue around the insertion site.This must be addressed immediately.A hemothorax involves bleeding into the thoracic cavity and decreased lung inflation on the affected side,resulting in duller and less resonant percussion notes.Pain at the insertion site,fluctuation in the water seal,and dullness to percussion are all expected.

Quiz 34: Care of Critically Ill Patients With Respiratory Problems

A client admitted for difficulty breathing becomes worse.Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS) ?

Which clients are at highest risk for pulmonary embolism (PE) ? (Select all that apply)