Which action would the nurse take first when caring for a client with a possible pulmonary embolus

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client?

Tachychardia
The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.

Wrong
Candidiasis
The nurse should monitor a client who is taking an inhaled glucocorticoid, such as beclomethasone, for candidiasis.
Hyperkalemia
The nurse should monitor the client for hypokalemia, which is a potential adverse effect of albuterol.
Dyspnea
The nurse should monitor the client for a decrease in dyspnea. A decrease in dyspnea is a therapeutic effect of albuterol, not an adverse effect.

A nurse in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect?

PaO2 58 mm Hg
The nurse should expect the client to have lower partial pressures of oxygen.
Wrong
Arterial pH 7.50
The nurse should expect the client's pH level to decrease because respiratory failure can cause respiratory acidosis.
PaCO2 25 mm HgThe nurse should expect the client's carbon dioxide level to rise with acute respiratory failure.
SaO2 92%The nurse should expect the client to have a decrease in oxygen saturation.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack?

Albuterol
The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.
Wrong
Cromolyn sodium
The nurse should administer cromolyn sodium, an anti-inflammatory agent, for maintenance therapy of asthma, rather than for treatment during an acute asthma attack.
Prednisone
The nurse should administer prednisone following an acute attack to promote anti-inflammatory effects.
Fluticasone/salmeterol
The nurse should administer fluticasone/salmeterol for maintenance therapy of asthma because it combines a glucocorticoid and a long-acting beta2-adrenergic agonist.

A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider?

"I will notify the provider if there is continuous bubbling in the water seal chamber."
Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.

Wrong

"I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration."Fluctuation of drainage in the tubing with inspiration is an expected finding for a client who has a chest tube. The nurse should continue to monitor the client. However, this finding does not require notification of the provider.

"I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery."Drainage of 60 mL in the first hour after surgery is an expected finding for a client who has a chest tube. The nurse should continue to monitor the client, but notification of the provider is not required at this time.
"I will notify the provider if there are several small, dark-red blood clots in the tubing."Small, dark-red blood clots are an expected finding for a client who is postoperative after chest surgery. The nurse should continue to monitor the client, but notification of the provider is not required at this time.

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen?

Arterial blood gases
When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

Wrong
Blood pressure
The nurse should monitor the client's blood pressure, which provides important information regarding the client's circulatory status. However, another assessment is the priority.
Capillary refill
The nurse should monitor the client's capillary refill, which provides information about peripheral circulation. However, another assessment is the priority.
Heart rate
The nurse should monitor the client's heart rate, which provides important information regarding the client's circulatory status. However, another assessment is the priority.

A nurse is assisting The provider who is performing a thoracentesis at the bedside of a client. Which of the following action should the nurse take? (Select all that apply.)

Wear goggles and a mask during the procedure is correct. The nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid.

Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure.

Instruct the client to take deep breaths during the procedure is incorrect. The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung.

Position the client laterally on the affected side before the procedure is incorrect. The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid.

Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk for bleeding at the procedure site.

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen?

Nonrebreather mask
The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.

Wrong
Simple face mask
A simple face mask delivers oxygen concentrations between 40% and 60% and has open exhalation ports that allow room air in and exhaled air out. It does not provide the highest level of oxygen for a client who is in respiratory distress.

Partial rebreather maskThe partial rebreather mask delivers oxygen concentrations of 60% to 75%. The exhalation ports are open, which will allow room air in and exhaled air out. It does not provide the highest level of oxygen for a client who is in respiratory distress.

Nasal cannula
The oxygen flow rate via nasal cannula is 1 to 6 L/min and provides oxygen at a concentration of 24% to 44%. It does not provide the highest level of oxygen for a client who is in respiratory distress.

A nurse is caring for a client who is in respiratory distress and requires endotracheal suction. Which of the following actions should the nurse take?

"I will use a rotating motion when removing the suction catheter."

The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.

Wrong
"I will use clean technique when suctioning a client's endotracheal tube."
The nurse should use sterile technique when performing endotracheal suctioning to avoid the introduction of pathogens into the sterile respiratory system.

"I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube."The nurse should suction the endotracheal tube prior to suctioning the nonsterile oropharyngeal cavity to prevent cross contamination.

"I will suction a client's endotracheal tube every 2 hours."The nurse should suction the endotracheal tube only when needed. Routine suctioning can result in hypoxia, tissue damage, bleeding, and bronchospasms.

A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect?

Blood-tinged sputum

The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.

Wrong
Decreased tactile fremitusThe nurse should expect an increase, rather than a decrease, in tactile fremitus because of tumor tissue or fluid replacing airspaces.

Resonance with percussion
The nurse should expect a dullness or flat sound, rather than resonance, upon percussion because of the presence of masses in the lungs.

Peripheral edema
The nurse should expect cyanosis of the lips and fingertips. However, peripheral edema is not an expected finding for a client who has lung cancer.

A nurse is assessing a client who is 4 he postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider?

Decreased oxygen saturation
When using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia because of airway obstruction.

Bleeding at the surgical site
Bleeding at the surgical site requires intervention by the nurse because hemorrhage is a complication of the procedure. However, there is another finding that is the priority for the nurse to report to the provider.

Urinary retention
Urinary retention is a complication following a surgical procedure using general anesthesia and requires assessment by the nurse. However, there is another finding that is the priority for the nurse to report to the provider.

Increased pain level An increased pain level is a complication following a surgical procedure and requires intervention by the nurse to promote comfort. However, there is another finding that is the priority for the nurse to report to the provider.

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments?

Presence of gag reflex

The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

Pain level rating using a 0 to 10 scale
The client is at risk for increased pain because of the introduction of the scope into the trachea. However, another assessment is the priority.

Hydration status
A client who is postoperative following a bronchoscopy has been NPO for 4 to 8 hr, which increases the client's risk for dehydration. The nurse should assess the client's hydration status. However, another assessment is the priority.

Appearance of the IV insertion site
IV medication given for moderate sedation places the client at risk for phlebitis. Although the nurse should assess for redness, warmth, and drainage at the IV insertion site, another assessment is the priority.

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?

"I should remove the old twill ties after the new ties are in place."
As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

Wrong
"I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma."
The client should use gauze squares moistened in 0.9% sodium chloride to cleanse around the stoma or, if prescribed, half-strength hydrogen peroxide can be used on the skin to clean crusty areas. Using a cotton-tipped applicator places the client at risk for aspiration of cotton fibers. Also, the client should be careful not to get hydrogen peroxide into the tracheal stoma.

"I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage."Cutting a 4-inch square gauze dressing places the client at risk for aspiration of gauze fibers. The client should apply a commercially-prepared split gauze tracheostomy dressing under the flange of the tracheostomy tube.

"I should apply suction while inserting the catheter into my tracheostomy tube."
The client should apply suction only when withdrawing the catheter to prevent tracheal tissue trauma.

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include?

"Expect your urine and other secretions to be orange while taking this medication."

The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.

Wrong
"Ringing in the ears is an adverse effect of this medication."Tinnitus is not an adverse effect of rifampin. However, the nurse should inform the client that rifampin can cause gastrointestinal disturbances.

"Have your skin test repeated in 4 months to show a positive result."The nurse should inform the client that the purified protein derivative skin test results will continue to show positive, even after the disease is no longer active.

"Remember to take this medication with a sip of water just before your first bite of each meal."
The nurse should instruct the client to take rifampin 1 hr before or 2 hr after a meal.

A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing?

High-Fowler's position with the arms supported on the overbed table

The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.

Lateral position with a pillow at the back and over the chest to support the arm
A lateral position promotes alignment of the back and can be a good position for sleeping. However, this position does not promote maximum chest expansion to facilitate breathing.

Semi-Fowler's position with pillows supporting both armsThe semi-Fowler's position, which has the head and trunk elevated to a 30° to 45° angle, does not promote maximum chest expansion to facilitate breathing.

Supine position with the head of the bed elevated to 15°Supine position allows the diaphragm and abdominal organs to place pressure on the thoracic cavity and compromise chest expansion. This position does not promote maximum chest expansion to facilitate breathing.

A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement?

Airborne
The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask.

Wrong

Neutropenic
The nurse should initiate protective environment precautions for clients who need protection from outside infections, such as clients who are receiving bone marrow transplants.

Contact
The nurse should initiate contact precautions for clients who have infections that are transmitted by direct contact, such as scabies and methicillin-resistant Staphylococcus aureus (MRSA).

Droplet
The nurse should initiate droplet precautions for clients who have infections that are transmitted by large droplets in the air and by being within 3 feet of a client, such as influenza. Staff and visitors should wear a surgical mask when within 3 feet of the client, and the nurse should assign dedicated equipment to the client.

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider.

Productive cough with green sputum

When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.

Wrong
Increased anterior-posterior chest diameter
An increased anterior-posterior chest diameter, or barrel chest, is nonurgent because it is an expected finding for a client who has COPD. Therefore, there is another finding that is the nurse's priority to report.

Clubbing of the fingers
Clubbing of the fingers is nonurgent because it is an expected finding for a client who has COPD with chronic low arterial oxygen levels. Therefore, there is another finding that is the nurse's priority to report.

Pursed-lip breathing with exertion
Pursed-lip breathing is nonurgent because it is an expected finding for a client who has COPD. Clients who have COPD use pursed-lip breathing to improve oxygenation when performing physical activity. Therefore, there is another finding that is the nurse's priority to report.

A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first?

Apply supplemental oxygen.
When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

Wrong

Increase the rate of IV fluids.The nurse should increase the rate of the IV fluids to increase cardiac output. However, another action is the nurse's priority.

Administer pain medication.The nurse should administer pain medication to decrease discomfort and anxiety. However, another action is the nurse's priority.

Initiate cardiac monitoring.
The nurse should initiate cardiac monitoring because the client is at risk for dysrhythmias and right ventricular failure. However, another action is the nurse's priority.

A nurse is providing teaching to a client who has chronic asthma and a new prescription of montelukast. Which of the following client statements indicates an understanding of the teaching?

"I will take this medication every night even if I don't have symptoms."
Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.

"I will monitor my heart rate every day while taking this medication."
Clients who take short-acting beta2 agonists should monitor their heart rate because tachycardia is an adverse effect of these medications. However, tachycardia is not an adverse effect of montelukast.

"I will make sure I have this medication with me at all times."Clients who take short-acting beta2 agonists should have their medication with them at all times because these medications are used to relieve bronchoconstriction during an asthma attack.

"I will need to carefully rinse my mouth after I take this medication."Clients who take inhaled glucocorticoids should rinse their mouths and gargle after use because oral candidiasis is an adverse effect of these medications.

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription?

A client who has epistaxis
The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.

Wrong

A client who has amyotrophic lateral sclerosisThe nurse should identify that a client who has amyotrophic lateral sclerosis can receive nasopharyngeal suctioning.

A client who has pneumonia The nurse should identify that a client who has pneumonia can receive nasopharyngeal suctioning.

A client who has emphysema The nurse should identify that a client who has emphysema can receive nasopharyngeal suctioning

A nurse is caring for a client who is post operative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis?

pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client?

Container of sterile water

The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.

Wrong

Extra drainage system
The nurse should empty the collection chamber in the drainage system or replace it before the drainage reaches the bottom of the tube. Therefore, it is not necessary to have an extra drainage system easily accessible for the client.

Suture removal set
The nurse should retrieve a suture removal set when the chest tube is removed. However, it is not necessary to have a suture removal set easily accessible for the client.

Nonadherent pads
The nurse should provide nonadherent, airtight, sterile petrolatum gauze when the chest tube is removed. However, it is not necessary to have to have nonadherent pads easily accessible for the client. If the chest tube is accidentally removed, the nurse should cover the wound with dry, sterile gauze.

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding?

Persistent cough

When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.

Wrong
Pallor
Pallor is an important finding because it can indicate blood loss. However, another assessment finding is the nurse's priority.

Insertion site pain
Insertion site pain is an important finding because untreated pain can result in shallow respirations. However, another assessment finding is the nurse's priority

Temperature 37.3° C (99.1° F)
A temperature of 37.3° C (99.1° F) is an important finding because it can indicate infection. However, another assessment finding is the nurse's priority.

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider?

Intercostal retractions

The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

Wrong

Decreased bowel sounds
The nurse should identify that decreased bowel sounds is an expected finding for a client who has ARDS.

Oxygen saturation 92%
The nurse should identify that an oxygen saturation of 92% is within the expected reference range for a client who has ARDS.

CO2 24 mEq/L
The nurse should identify that a CO2 of 24 mEq/L is within the expected reference range for a client who has ARDS.

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?

Provide a diet that is high in calories and protein.
The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

Wrong
Schedule respiratory treatments following meals.The nurse should schedule respiratory treatments before meals.

Have the client sit up in a chair for 2-hr periods three times per day.The nurse should provide short periods of activity frequently throughout the day.

Combine activities to allow for longer rest periods between activities.
The nurse should schedule activities that are short in duration with adequate rest periods in between to prevent fatigue.

A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect?

Temperature 38.8° C (101.8° F)

An elevated temperature is an expected finding for a client who has bacterial pneumonia.

Wrong

Bradypnea
Tachypnea is an expected finding for a client who has bacterial pneumonia.

Decreased fremitusIncreased fremitus is an expected finding for a client who has bacterial pneumonia.

SaO2 95% on room airAn oxygen saturation level of lower than 95% is an expected finding for a client who has bacterial pneumonia.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority?

Administer heparin via continuous IV infusion.

When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

Wrong

Provide a quiet environment.The nurse should provide a client who has a pulmonary embolism with a quiet environment to promote rest and conserve oxygen. However, another intervention is the nurse's priority.

Encourage use of incentive spirometry every 1 to 2 hr.The nurse should encourage a client who has a pulmonary embolism to use an incentive spirometer to improve oxygenation and ventilation. However, another intervention is the nurse's priority.

Obtain a blood sample for electrolyte study.The nurse should obtain a blood sample from a client who has a pulmonary embolism to send to the laboratory for coagulation studies, electrolyte levels, and a CBC. However, another intervention is the nurse's priority.

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism?

A client who is 48 hr postoperative following a total hip arthroplasty The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications.

Wrong

A client who is 8 hr postoperative following an open surgical appendectomyA client who is postoperative following an open surgical appendectomy is at a low risk for developing a pulmonary embolism. The greatest risk to this client is peritonitis. There is another client who is at greater risk for developing a pulmonary embolism.

A client who is 2 hr postoperative following an open reduction external fixation of the right radius A client who is postoperative following an open reduction external fixation of the right radius is at a low risk for pulmonary embolism. The greatest risk to this client is neurovascular compromise. There is another client who is at greater risk for developing a pulmonary embolism.

A client who is 4 hr postoperative following a laparoscopic cholecystectomyA client who is 4 hr postoperative following a laparoscopic cholecystectomy is at a low risk for pulmonary embolism. Some clients develop pain from carbon dioxide retention in the abdomen following a laparoscopic cholecystectomy. There is another client who is at greater risk for developing a pulmonary embolism.

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm?

Artificial airway cuff leak

An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound.

Wrong

Excess secretionsAn excess of secretions in the airway causes the high-pressure alarm to sound.

Kinks in the tubing
Kinks in the tubing can cause an obstruction, which causes the high-pressure alarm to sound.

Biting on the endotracheal tube
Biting on the endotracheal tube causes the high-pressure alarm to sound.

A nurse is working in the emergency department is caring for a client following an acute chest trauma. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax?

Tracheal deviation to the unaffected side

The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

Wrong

Collapsed neck veins on the affected sideA client who has a tension pneumothorax will not have collapsed neck veins on the affected side. Distended neck veins are an expected finding.

Collapsed neck veins on the unaffected side
A client who has a tension pneumothorax will not have collapsed neck veins on the unaffected side secondary to a tension pneumothorax.
Distended neck veins are an expected finding.

Tracheal deviation to the affected sideThe trachea of a client who has a tension pneumothorax does not deviate to the affected side.

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider?

Elevated temperature
The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.

Wrong
Barrel-shaped chest
Chronic overinflation of the lungs and flattening of the diaphragm lead to the appearance of a barrel-shaped chest, which is an expected finding of emphysema.

Diminished breath soundsDiminished breath sounds are an expected finding for clients who have emphysema due to limited chest excursion and air trapping.

Rhonchi on inspiration
Rhonchi on inspiration is an expected finding for clients who have emphysema.

Which actions will the nurse take when preparing a client before thoracentesis?

Which action would the nurse include when performing tracheostomy care on a client receiving mechanical ventilation?

Which physical assessment findings should the nurse identify as signs of acute respiratory distress?

How is a pulmonary assessment performed?