RN Respiratory System EAQ

RN Respiratory System EAQ Which diagnostic test may be used to distinguish vascular from nonvascular structures? Chest X-ray Pulmonary angiogram Computed tomography Magnetic resonance imaging Which part of the respiratory system is referred to as Angle of Louis? Hilum Carina Alveoli Epiglottis The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? Increased appetite Clubbing of the nail beds Hypertension Weight gain A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? Dull sound on percussion Vocal fremitus on palpation Rales with rhonchi on auscultation Absence of breath sounds on auscultation During the first 36 hours after the insertion of chest tubes, when assessing the function of a threechamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? Take the client's vital signs. Inform the healthcare provider. Turn the client to the unaffected side. Check the tube to ensure that it is not kinked. Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? Cerebral palsy Cystic fibrosis Muscular dystrophy Multiple sclerosisWhich surgical procedure is appropriate for the removal of a vocal cord due to laryngeal cancer? Cordectomy Tracheotomy Total laryngectomy Oropharyngeal resections A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is mostsignificant to include? Purpose of bronchodilators Importance of meticulous oral hygiene Technique used in pursed-lip breathing Methods used to maintain a dust-free environment Which statement is true regarding the Hering-Breuer reflex? Increases tidal volume Decreases respiratory rate Prevents overdistension of the lungs Reduces the number of functional alveoli A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis What is the normal value of functional residual capacity? 2.5 L 3.5 L 4.5 L 6.0 L What is the normal value of inspiratory reserve volume? 0.5 L 1.0 L 1.5 L 3.0 L Which disorder would the nurse state is related to the tonsils? Rhinitis Sinusitis PharyngitisPneumonia Which would the nurse consider to be a potential respiratory system-related complication of surgery? Atelectasis Hyperthermia Wound dehiscence Hypovolemic shock Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs? Asthma Emphysema Chronic bronchitis Centrilobular emphysema Which diagnostic test would the nurse consider to be the gold standard for diagnosis of pulmonary embolism? Pulmonary angiography Helical computed tomography (CT) Ventilation-perfusion (V/Q) scans Computed tomography pulmonary angiography (CT-PA) client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care? The disease process and breathing exercises How to control or prevent respiratory infections Using aerosol therapy, especially nebulizers Priorities in carrying out everyday activities While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing? Lung biopsy Thoracentesis Mediastinoscopy Ventilation-perfusion scan Which parameter describes the maximum volume of air that the lungs can contain? Vital capacity Total lung capacity Inspiratory capacity Functional residual capacityBesides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? Administering oxygen Using an incentive spirometer Having the client breathe into a paper bag Administering an IV containing bicarbonate ions Which statement appropriately describes tidal volume? It is the volume of air inhaled and exhaled with each breath. It is the amount of air remaining in the lungs after forced expiration. It is the additional air that can be forcefully inhaled after normal inhalation. It is the additional air that can be forcefully exhaled after normal exhalation. The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO 2) . Which other parameter can be determined using this technique? Arterial oxygen saturation Partial pressure of oxygen in arterial blood Partial pressure of arterial carbon dioxide Partial pressure of oxygen in venous blood A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO 2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Which cartilage is also known as the Adam’s apple? Costal Cricoid Thyroid Arytenoid Which client would have relatively smaller tidal volumes due to limited chest wall movement? A client with asthma A client with pneumonia A client with pulmonary fibrosis A client with phrenic nerve paralysis Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. What should the nurse instruct the client about the purpose of pursed-lip breathing?Decreases chest pain Conserves energy Increases oxygen saturation Promotes elimination of CO 2 Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? Peak expiratory flow rate Forced vital capacity Forced mid-expiratory flow rate Forced expiratory volume/forced vital capacity ratio Which pulmonary function test provides a more sensitive index of obstruction in smaller airways? Forced vital capacity Functional residual capacity Forced expiratory volume in 1 second Forced expiratory flow over the 25% to 75% volume of the forced vital capacity A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments? Level of consciousness and pupil size Characteristics of pain and blood pressure Quality of respirations and presence of pulses Observation of abdominal contusions and other wounds A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention? Administer oral fluids. Encourage deep breathing. Increase the oxygen flow rate. Perform nasotracheal suctioning. During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the lungs. Which sound should the nurse document in the medical record? Dull Flat Tympany ResonanceWhich physical assessment maneuver is the nurse performing when instructing the client to breathe in slowly and a little more deeply than normal through the mouth? Palpation Inspection Percussion Auscultation A client is discharged from the hospital after receiving a lung transplant. Which medical device should the client use to monitor his or her lung function at home? Oximetry Spirometry Capnography Ventilation-perfusion A client who is homeless is hospitalized for alcohol withdrawal. When considering the type of personal protective equipment that is needed for the client's care, what condition does the nurse recall that homeless persons are at risk for? Prostatitis Tuberculosis Osteoarthritis Diverticulosis A nurse teaches a client how to perform diaphragmatic breathing. Which instruction should the nurse provide? Take rapid, deep breaths Breathe with hands on the hips Expand the abdomen on inhalation Perform exercises leaning forward while in a sitting position A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? Perform the procedure once in the morning and once at night. Move the trunk to an upright position and then exhale while bending over. Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. Place the mouthpiece between the lips and in front of the teeth before starting the procedure. A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have? CrepitusSinusitis Fracture of the nose Upper respiratory tract infection Which sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs? Vesicular Bronchial Adventitious Bronchovesicular Which assessment finding is considered the earliest sign of decreased tissue oxygenation? Cyanosis Cool, clammy skin Unexplained restlessness Retraction of interspaces on inspiration A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client? Limiting hydration Improving ventilation Decreasing exogenous oxygen Correcting the bicarbonate deficit A nurse is a preceptor for an orientee (newly hired nurse). The orientee is providing postoperative care to a client who recently returned from a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. How does the preceptor evaluate the suitability of the instructions given to the client by the orientee? Appropriate; oral intake after the procedure may result in aspiration Appropriate; it is important to limit painful swallowing Inappropriate; the client is too groggy after general anesthesia to comprehend information Inappropriate; fluid replacement should begin immediately after the procedure The nurse provides discharge instructions to a client who had a rhinoplasty. Which instructions should the nurse share with the client? Avoid items that may trigger sneezing Consume fluids at a tepid temperature Brush the teeth thoroughly after each food intakeSleep on the back using one pillow under the head A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement? Auscultate the lungs. Obtain arterial blood gases. Notify the healthcare provider. Apply pressure to the abdomen. A client is informed that he has developed a healthcare–associated upper respiratory tract infection and asks the nurse what this means. How should the nurse reply? "You developed an infection that requires antibiotics." "This is a highly contagious infection requiring isolation." "You acquired the infection after being admitted to the hospital." "An infection you had before beginning treatment has flared up." A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? An obese client with leg trauma A pregnant client with acute asthma A client with diabetes who has cholecystitis A client with pneumonia who is immunocompromised When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider? Substernal chest pain Episodes of palpitation Severe shortness of breath Dizziness when standing up A community health nurse is educating a client who is interested in discontinuing cigarette smoking. What should the teaching plan include? Helping the client set a date to stop smoking Referring the client to the American Red Cross (Canada: Canadian Red Cross) Encouraging the client to eat when the desire to smoke occurs Telephoning the client several weeks after the preset target date A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished? Assess the person's breathing. Offer the person sips of water.Cover the person with a warm blanket. Calculate the extent of the person's burns. While caring for a client with asthma, the nurse auscultates a bilateral high-pitched, continuous whistling sound in the anterior lung fields. What finding does the nurse document in the medical record? Crackles Wheezes Rhonchus Pleural friction rub A client newly diagnosed with tuberculosis has a productive cough. Which is the most appropriate nursing intervention to teach the client? Exercise daily Use disposable tissues Avoid foods high in sodium Monitor blood pressure weekly A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit? Tremors Anasarca Bradypnea Tachycardia A nurse provides smoking-cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client makes which statement? "I'll just finish the carton that I have at home." "I'll cut back to a half pack a day." "I find that smoking is the only way I can relax." "I should find this easy because I don't smoke when I drink." A client who just returned from surgery reports shortness of breath and chest pain. Which should the nurse initially administer? Supplemental oxygen Intravenous morphine Endotracheal intubation Sublingual nitroglycerinAfter abdominal surgery, a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by what method? Postural drainage Pursed-lip breathing Incentive spirometry Sustained exhalation Oxygen therapy is prescribed for a client being cared for in the coronary care unit. The nurse implements safety precautions. Which information should the nurse consider when planning care for this client? Oxygen is flammable. Oxygen supports combustion. Oxygen has unstable properties. Oxygen converts to an alternate form of matter. A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities? Remain with the client to assess responses. Allow family members to participate in the process. Permit the client more extended times alone for independence. Observe monitoring devices at the control panel of the ventilator. After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? Pink Clear Green Yellow A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO 2 60 mm Hg, PCO 2 55 mm Hg, and HCO 3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? Hypocapnia Hyperkalemia Generalized anemia Respiratory acidosis A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, what should the nurse do? Provide a means for the client to writeAllow the client more time for articulation Use visual clues, such as gestures and objects Face the client and speak slowly and distinctly Which criteria should the primary healthcare provider use for the prescription of long-term continuous oxygen therapy? PaO 2-72, SpO 2- 96 PaO 2-60, SpO 2- 90 PaO 2-55, SpO 2- 88 PaO 2-40, SpO 2- 75 A client with a history of closed-angle glaucoma is scheduled for abdominal surgery. Because the client is extremely anxious, surgery is to be performed under general anesthesia. What should the nurse teach the client to do to prevent respiratory complications postoperatively? Deep breathing techniques Performing productive coughing Turning from side to side frequently Pant breathing while gently closing the eyelids A client returns from a radical neck dissection with a tracheotomy and two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? Cloudy wound drainage Poor gag reflex Decreased urinary output Restlessness with dyspnea A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess in this client? Aphasia Dyspnea Dysphagia Hoarseness A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take? Put on a gown when entering the room Place the client with another client who has TB Wear a particulate respirator when caring for the client Don a surgical mask with a face shield when entering the room A nurse instructs a client to breathe deeply to open collapsed alveoli. What is the best explanation the nurse could offer to explain the relationship between alveoli and improved oxygenation?The alveoli need oxygen to live. The alveoli have no direct effect on oxygenation. Collapsed alveoli increase oxygen demand. Oxygen is exchanged for carbon dioxide in the alveolar membrane. Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing? Glottis Paranasal sinus Palatine tonsils Eustachian tubes A graduate nurse reminds a client who just had a laryngoscopy not to take anything by mouth until instructed to do so. Which conclusion should be made about this intervention by the nurse preceptor who is evaluating the performance of the graduate nurse? Appropriate, because such clients usually experience painful swallowing for several days Appropriate, because early eating or drinking after such a procedure may cause aspiration Inappropriate, because the client is likely to be anxious, and it is easier to remove the water pitcher Inappropriate, because the client is conscious and may be thirsty after not being allowed to drink fluids A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? Decrease in red cell formation Rupture of emphysematous bullae Depression in the respiratory center Excessive drying of the respiratory mucosa A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? Client no longer is infected. Tuberculin skin test is negative. Sputum is free of acid-fast bacteria. Client's temperature has returned to normal. A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client's response to this injury? Level of pain Quality and depth of respirationsAmount of serosanguineous drainage Blood pressure and pupillary response What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply. Polyps Gag reflex Shotty nodes Poor dentition Gum retraction Which diagnostic test is performed under general anesthesia to detect non-Hodgkin lymphoma and requires the client to sign an informed consent form? A thoracentesis A bronchoscopy A mediastinoscopy Computed tomography (CT) After assessing a client’s breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse’s suspicion? Wheezing Rhonchi Pleural friction rub Low-pitched crackles A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO 2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first? Prepare to intubate the client. Increase the oxygen flow rate per facility protocol. Decrease the tension of oxygen in the plasma. Have the arterial blood gases redone to verify accuracy. A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? Retrospective 24-hour calorie count Elimination pattern during the last 30 days Complete gynecological and sexual history Presence of a cough and pulmonary secretionsA client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information? The client's pneumonia is continually improving. Oxygen concentrations up to 44% can be obtained. Mechanical ventilation may be required next. Nasal cannula may be used while the client is eating. A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? Slow, deep respirations Normal oral temperature Dry, unproductive cough Diminished breath sounds When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? Administer sedatives around the clock Turn client every four hours Increase ventilator settings as needed Suction as needed The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement? "I will try to avoid smoking." "I will maintain complete bed rest." "I'll control the temperature in my home." "I'll need to clean my mouth several times a day. A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? Curing the condition permanently Raising mucous secretions from the chest Limiting pulmonary secretions by decreasing fluid intake Convincing the client that the condition is emotionally based The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How does the nurse describe this assessment finding? Respiratory stridor Subcutaneous emphysema Bilateral 2+ pitting edemaChest distention During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response? "You seem concerned about your diagnosis." "You are feeling guilty about your smoking." "There have been advances in lung cancer therapy." "Trust your healthcare provider, who is very competent in treating cancer." An older adult comes for an annual physical and tells the nurse, "I had three respiratory infections last year. How can I prevent this from happening again?" What is the nurse's best response? "Stay away from preschool and school-aged children." "Avoid putting your hands near your nose and mouth." "Wear a sweater under your coat when going outside in cold weather." "Take an aspirin when you think you may be coming down with a cold." A client has a closed chest drainage system in place. What should the nurse do to determine the amount of chest tube drainage? Refer to the date and time markings on the outside of the collection chamber. Aspirate the drainage from the collection chamber. Replace the existing system with a new one to access the drainage in the existing system. Clamp the chest tube and empty the fluid from the collection chamber. A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? To prevent dyspnea To prevent cyanosis To increase oxygen concentration to heart cells To increase oxygen tension in the circulating blood The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care? Careful monitoring for crepitus Bed rest with range-of-motion exercises Coughing and deep breathing every hour Covering the chest tube site with a sterile dressing A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? Ensuring sufficient rest Changing lifestyle routinesBreathing clean outdoor air Taking medications as prescribed A client presents to the emergency room with coughing and sudden wheezing. The nurse notes the client is progressing quickly into respiratory distress. The nurse identifies that the client is experiencing what problem? An acute asthma attack Acute bronchitis Left-sided heart failure Cor pulmonale A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority? Immediately contact the primary healthcare provider Document the amount of sputum Monitor vital signs every hour Increase the frequency of coughing and deep breathing While in the post anesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? Initiate oxygen via a nasal cannula Administer the prescribed morphine Prepare the client for endotracheal intubation Place a nitroglycerin tablet under the client's tongue The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. What should the nurse do? Assess for obstructions in the chest tube Increase the amount of continuous suction Add sterile water to the water-seal chamber Make preparations to remove the chest tube What are the uses of pulmonary function tests (PFT)? Select all that apply. Pulmonary function tests (PFT) can detect lung cancer. Pulmonary function tests (PFT) can measure lung volume. Pulmonary function tests (PFT) can assess responses to bronchodilators. Pulmonary function tests (PFT) are performed on the pulmonary nodules. Pulmonary function tests (PFT) can diagnose pulmonary disease. A client with the diagnosis of inhalation anthrax is admitted to the intensive care unit. It is most important for the nurse to make a focused assessment of which body system?Mental Hydration Neurologic Respiratory A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? An elevated pH, elevated PCO 2 A decreased pH, elevated PCO 2 An elevated pH, decreased PCO 2 A decreased pH, decreased PCO 2 A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level? Cannula Catheter Venturi mask Rebreather mask A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do? Raise the drainage system to bed level and check its patency Clamp the tube when moving the client from the bed to a chair Mark the time and fluid level on the side of the drainage chamber Secure the chest catheter to the wound dressing with a sterile safety pin A client appears anxious, exhibiting 40 shallow respirations per minute. The client complains of feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. What does the nurse conclude that the client's complaints probably are related to? Eupnea Hyperventilation Kussmaul respirations Carbon dioxide intoxication A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosisA client is brought to the emergency department after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. What client reaction should cause a nurse the most concern? Ischemia Asphyxia Lactic acidosis Increased blood pressure Which condition can cause a client’s partial pressure of end-tidal carbon dioxide (PETCO 2) to be 50 mmHg? Hypoventilation Tracheal extubation Pulmonary embolism Total airway obstruction What condition would a nurse suspect in a client with abnormal respirations with alternating periods of apnea and rapid breathing? Pectus carinatum Pectus excavatum Kussmaul breathing Cheyne-Stokes respirations During a follow-up visit three weeks after a laryngectomy, a client exhibits concern that the laryngectomy tube may become dislodged. What should the nurse teach the client to do if the tube becomes dislodged? Reinsert another tube immediately. Notify the healthcare provider at once. Keep calm because this is no immediate emergency. Quickly take action to prevent the tracheal stoma from closing. A nurse is notified that a victim of a gunshot wound to the right side of the chest is being transported to the emergency department. To prepare for the client, what is the priority nursing intervention? Reserving an operating room Obtaining equipment for a tracheotomy Arranging for a portable x-ray examination Obtaining equipment for chest tube insertion A client who had surgery for a laryngectomy is returned to the surgical unit from the postanesthesia care unit. In which position is it mostappropriate for the nurse to place the client at this time? Prone with the head turned to one side Supine with the knees flexed at 10 degreesLateral with the head slightly elevated and flexed Supine with the head in a hyperextended position A nurse is caring for a variety of clients. In which client is it mostessential for the nurse to implement measures to prevent pulmonary embolism? A 59-year-old who had a knee replacement A 60-year-old who has bacterial pneumonia A 68-year-old who had emergency dental surgery A 76-year-old who has a history of thrombocytopenia After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, what should the nurse do? Strip the chest tube catheter Check the system for air leaks Decrease the amount of suction pressure Recognize that the system is functioning correctly A nurse is caring for a client with a tracheostomy. Which action should the nurse implement when performing tracheal suctioning? Preoxygenate the client before suctioning. Employ gentle suctioning as the catheter is being inserted. Be sure the cuff of the tracheostomy is inflated during suctioning. Loosen the client's secretions before suctioning by instilling saline. A nurse is teaching Hands Only Basic Life Support for adults in the community. What should the rescuer do first after determining that the person is not responding and the emergency medical system has been activated? Identify the absence of pulse. Give two rescue breaths with a CPR mask. Perform the head tilt–chin lift maneuver. Perform chest compression at a rate of 100/min. What is the underlying rationale for why a nurse assesses a client with emphysema for clinical indicators of hypoxia? Pleural effusion Infectious obstructions Loss of aerating surface Respiratory muscle paralysis A client is admitted to the hospital with a diagnosis of emphysema. What should the nurse include when teaching the client breathing exercises? Spend more time inhaling than exhaling to blow off carbon dioxidePerform diaphragmatic exercises to improve contraction of the diaphragm Perform sit-ups to strengthen abdominal muscles to improve breathing Use abdominal exercises to limit the use of accessory muscles of respiration A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding does the nurse expect when performing the admission assessment? Weak, rapid pulse Decreased blood pressure Radiating anterior chest pain Crackles at bases of the lungs What nursing action will most help a client obtain maximum benefits after postural drainage? Administer oxygen as needed. Encourage coughing deeply. Place the client in a sitting position. Encourage the client to rest for a half hour. A client who has a history of emphysema is transported back to the nursing unit after a radical neck dissection for cancer of the tongue. The client is receiving oxygen and an intravenous infusion. Within the first hour, the client has 50 mL of sanguineous drainage in the portable wound drainage system. Which initial action should the nurse take? Inspect the dressing Increase the oxygen flow rate Notify the healthcare provider Place the client in the supine position The nurse obtains a laboratory report that shows acid-fast rods in a client's sputum. Which disorder should the nurse consider may be related to these results? Influenza virus Diphtheria bacillus Bordetella pertussis Mycobacterium tuberculosis Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurse's first intervention? Treat the victim for shock. Start rescue breathing immediately. Apply surface pressure to the foot wound. Safely remove the victim from the immediate vicinity. While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)?Barrel chest Cyanosis Hyperventilation Lordosis A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? Bradycardia Flushed face Unilateral chest pain Decreased blood pressure A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do? Keep collection device attached to mechanical suction Keep chest tube clamped distal to the water-seal chamber Keep collection device below the level of the client's chest Keep chest tube end covered with sterile gauze pads taped to the client A nurse identifies 12 mm of induration at the site of a Mantoux test when a client returns to the health office to have it read. Which explanation of this result should the nurse give to the client? Result is negative, and follow-up is not needed. The disease is active, and medication is required. Additional tests are needed, such as a chest x-ray. Outcome is inconclusive, and the test will be repeated in six weeks. A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? Tetany Hypercapnia Metabolic acidosis Respiratory alkalosis A client returns to the unit fully awake after a bronchoscopy and biopsy. Which action is priority? Assess the presence of a gag reflex Provide ice chips as a comfort measure Encourage the client to cough frequently Advise the client to stay flat for several hours The nurse is caring for a client who is hyperventilating. The nurse recalls that the client is at risk for what?Respiratory acidosis Respiratory alkalosis Respiratory compensation Respiratory decompensation A client has been admitted for an upper respiratory tract infection secondary to chronic obstructive pulmonary disease (COPD). The nurse should expect which findings when auscultating the client's breath sounds? Coarse crackles Prolonged inspiration Short, rapid inspiration Normal breath sounds A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. What should the nurse's first action be? Hold the tracheostomy open with a tracheal dilator and call for assistance Insert an obturator into the tracheostomy and gently reinsert the tracheostomy tube Pick up the tracheostomy tube from the bed and replace it until a new tube is available Obtain a new tracheostomy tube, prepare the new holder, and insert the tube using the obturator A healthcare provider prescribes oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning? Gurgling sounds with each breath Fine crackles at the base of the lungs Cyanosis in the nail beds of the fingers Dry cough at increasingly frequent intervals An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? Assess the client’s mobility. Monitor respirations and breathing effort. Teach coughing and deep-breathing exercises. Determine normal activity levels and note when the client tires. Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq/L (25 mmol/L). Which action should the nurse take? Obtain a prescription for a diuretic.Have the client breathe into a rebreather bag. Encourage the client to take deep, cleansing breaths. Request a prescription for the administration of sodium bicarbonate. A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? Productive cough Clubbing of the fingertips Crackles at the height of inhalation Diminished breath sounds on auscultation A client sustains a stab wound to the chest, and a chest tube is inserted. Later the client's chest tube appears to be obstructed. Which is the mostappropriate nursing action? Instruct the client to cough Clamp the tube immediately Prepare for chest tube removal Arrange for a stat chest x-ray film After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement? Postural drainage Turning and positioning Administration of an expectorant Percussion and vibration techniques During the assessment of a client who was admitted to the hospital because of a productive cough, fever, and chills, the nurse percusses an area of dullness over the right posterior lower lobe of the lung. Which medical diagnosis will the nurse most likely observe documented in the client’s electronic records? Pleurisy Bronchitis Pneumonia Emphysema What should the nurse include in the plan of care for a client who just had a total laryngectomy? Instructing the client to whisper Removing the outer tracheostomy tube as needed Placing the client in the orthopneic position Suctioning the tracheostomy tube whenever necessary A client who had a total laryngectomy is using a pad and pencil to communicate. The client becomes frustrated and writes, "When can I learn how to speak again?" Which is the best response by the nurse?"Every client with a laryngectomy is different. It's difficult to say." "It must be difficult for you, but be patient. These things take time." "Perhaps I can have someone from the Laryngectomy Club come speak with you." "I can provide you with more information after your incision has had time to heal." Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? Select all that apply. Elevated levels of partial arterial oxygen Elevated levels of eosinophils Elevated levels of neutrophils Elevated levels of red blood cells Elevated levels of peripheral capillary oxygen saturation A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. When caring for this client, what should the nurse do? Administer opioids frequently Assess for signs of pneumonia Give medication to suppress coughing Limit fluid intake to prevent pulmonary edema The nurse is monitoring a client who is receiving peritoneal dialysis. After the dialysate has infused, the client reports severe respiratory difficulty. Which immediate action should the nurse take? Weigh the client Auscultate breath sounds Obtain arterial blood gases Turn the client on the right side Before signing a consent form for a total laryngectomy, a client asks, "Because part of my throat will be taken out and I will breathe through a hole in my neck, will I be able to talk like I did before I had the surgery?" Which is the nurse's best response? "There are many clients who have had this operation. You'll talk again." "That's a good question. I'll have the healthcare provider talk with you." "You seem very concerned. Tell me what you know about your surgery." "Not like before but there is nothing to worry about. We do a lot of these surgeries." A client with chronic bronchitis smokes one or two cigarettes a day and has not been performing the prescribed pulmonary physiotherapy exercises because they are too tiring. Which is the best response by the nurse? "Tell me about your typical day before the exercises were prescribed." "Smoking is probably the cause of the severity of your disease at this time.""I can't make you stop doing what you are doing, and it's your choice to be sick or well." "Your being so sick is probably because of your smoking and your choosing not to exercise." What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath? Scoliosis Kyphosis Clubbing Kyphoscoliosis A client is to continue oxygen therapy at home when discharged. Which client statement indicates the need for further instruction by the nurse? "I will use only grounded electrical equipment." "I have a new woolen blanket to keep me warm." "I have told my family they cannot smoke in the house." "I will keep a pitcher of water near me so I drink enough." During a client's immediate postoperative period after a laryngectomy, what is a nursing priority? Provide emotional support Observe for signs of infection Keep the trachea free of secretions Promote a means of communication A client has a bronchoscopy in the ambulatory surgery unit. Which action should the nurse take to prevent laryngeal edema? Place ice chips in the client's mouth Offer liberal amounts of fluid to the client Keep the client in the semi-Fowler position Tell the client to suck on medicated lozenges After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client demonstrates cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. What should the nurse do first? Obtain vital signs. Administer oxygen. Call the healthcare provider. Place the client in the high-Fowler position. A nurse gave a client naloxone. To evaluate the effectiveness of the medication, what should the nurse assess for?Change in level of consciousness Increased pain Increased respiration Decreased heart rate The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. What should the nurse do? Notify the healthcare provider immediately of the findings. Administer the prescribed oxygen. Record the observations and continue to observe the client. Administer the prescribed antianxiety medication. The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema? Palpate around the tube insertion sites for crepitus Auscultate the breath sounds for crackles and atelectasis Observe the client for the presence of a barrel-shaped chest Compare the length of inspiration with the length of expiration When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern? Rupture of the pericardium Infection of the subpleural lining Decreased filling of the right side of the heart Increased volume of the unaffected lung A chest tube with an attached closed-drainage system is inserted into a client who was stabbed in the chest. Which is an important nursing intervention when caring for this client? Observe for fluid fluctuations in the water-seal chamber. Obtain a prescription for morphine to minimize agitation. Apply a thoracic binder to prevent excessive tension on the tube. Clamp the tubing securely to prevent a rapid decline in pressure. When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How should the nurse document this finding? Adventitious sounds Fine crackling sounds Vesicular breath sounds Diminished breath soundsA client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client has which response? "I may have an elevated temperature." "I may have paroxysmal hiccoughs." "I may have transient headaches." "I may have a sore throat." In which positions should the nurse place a client who has just had a right pneumonectomy? Right or left side-lying High-Fowler or supine Supine or right side-lying Left side-lying or low-Fowler When assessing a client with pleural effusion, what does the nurse expect to identify? Moist crackles at the posterior of the lungs Deviation of the trachea toward the involved side Reduced or absent breath sounds at the base of the lung Increased resonance with percussion of the involved area A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect? Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased carbon dioxide level A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test? Check the client’s blood glucose levels. Obtain informed consent from the client. Assess if the client is allergic to shellfish. Instruct the client to remove his or her dentures. What emergency equipment should the nurse ensure is readily available at the bedside after a client has surgery for a malignant lesion on a vocal cord? Crash cart with bed board Airway and rebreathing mask Tracheostomy set and oxygen Ampule of sodium bicarbonateA client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse explain the function of the water? Promotes pleural drainage via gravity Measures the pressures in the chest wall Prevents reflux of air back into the chest Ensures bubbling in the water-seal chamber A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? Supine Orthopneic Low-Fowler Semi-Fowler Histoplasmosis is suspected in a client. Which risk factor is the nurse likely to find in the history? The client is a chain smoker. The client works in a cement factory. The client has a history of a minor hand fracture. The client has a history of travel to central parts of North America. A client is diagnosed with emphysema. What long-term problem should the nurse monitor in this client? Localized tissue necrosis Carbon dioxide retention Increased respiratory rate Saturated hemoglobin molecules What should the nurse expect when assessing a client with pleural effusion? Crackles or rhonchi at the posterior of the lungs Deviation of the trachea toward the affected side Increased resonance on percussion of the affected area Reduced or absent breath sounds at the base of the lung A registered nurse is examining the medical reports of different clients. Which client may need immediate assessment? A client who is scheduled for a bronchoscopy A client who is scheduled for a thoracentesis A client with pleural effusion and decreased breath sounds A client with acute asthma and 85% oxygen saturationWhat intervention should a nurse perform during a chest examination of a female client with a suspected lung disorder? Perform the test in a dark room Examine only the anterior chest Observe for any evidence of respiratory distress Begin the chest examination on the posterior chest A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information should the nurse provide about the purpose of the chest tube? It checks for bleeding in the lung. It monitors the function of the lung. It drains fluid from the pleural space. It removes air from the pleural space. The son of a 65-year-old client said, "My father is suffering from chronic lung disease. He wakes suddenly from sleep and is unable to breathe." What condition does the nurse suspect in the client? Orthopnea Hemoptysis Histoplasmosis Paroxysmal nocturnal dyspnea A nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. What does the nurse conclude is the probable cause of the severe dyspnea? Abdominal distention or pressure Bronchial obstruction or pleural effusion Fluid retention as a result of renal failure Anxiety associated with pain on inspiration A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's mostimmediate intervention at this time? Prepare the client for emergency surgery. Facilitate the client's verbal communication. Assess the client's response to the interventions. Maintain sterility of the ventilation system that is being used. A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care? Lessens the client's chest discomfort Restores negative pressure in the pleural space Drains accumulated fluid from the pleural cavityPrevents subcutaneous emphysema in the chest wall A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. What assessment by the nurse most readily detects this complication? Palpating the neck or face Evaluating the blood gases Auscultating the lung fields Reviewing the chest x-ray film A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? Clamp the chest tubes when suctioning. Palpate the surrounding area for crepitus. Change the dressing daily using aseptic technique. Empty the drainage chamber at the end of the shift. The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding? Productive coughing Return of breath sounds Increased pleural drainage in the chamber Constant bubbling in the water-seal chamber A client has a laryngectomy and radical neck dissection for cancer of the larynx. Two tubes from the area of the incision are connected to portable wound drainage systems. Inspection of the neck reveals moderate edema even though the drainage systems are functioning. Which clinical indicator should the nurse assess in the client? Crackles Restlessness Loss of the gag reflex Cloudy wound drainage The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take? Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. Assist the client in assuming a position of comfort and perform postural drainage.A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client? The client may need up to 60% oxygen flow via Venturi mask. The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula. The client should receive humidified oxygen delivered by a face mask. The client's respiratory treatment plan should have oxygen eliminated from it. What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly? Contains many small air bubbles Bubbles vigorously on inspiration Rises with inspiration and falls with expiration Remains at a consistent level during the respiratory cycle The nurse is caring for a client who has a lesion in the right upper lobe. A diagnosis of tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis? Frothy sputum and fever Dry cough and pulmonary congestion Night sweats and blood-tinged sputum Productive cough and engorged neck veins A nurse is caring for a client who had a bronchoscopy one hour ago. Which nursing action is most appropriate for assessing the return of the client's gag reflex? Ask the client to say several words. Give the client a small swallow of water. Stroke the anterior third of the client's tongue. Touch the client's pharynx with a tongue depressor. A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply. Sharp chest pain Acute onset of dyspnea Pain in the residual limb Absence of the popliteal pulse Blanching of the affected extremity While caring for a client with a nasal injury, the nurse also suspects a skull fracture. Which manifestation might have led the nurse to conclude this? Positive dipstick testCrackling of the skin on palpation Clearly visible fracture in the X-ray report Clear yellow halo ring structure on a filter paper While assessing the medical reports of a client with upper respiratory tract infections, the nurse notices that there are alterations in the platelet count. The client has a history of recent nasal surgery. Which clinical condition does the nurse suspect? Epistaxis Rhinosinusitis Allergic rhinitis Acute pharyngitis on a client's admission to a rehabilitation unit, the nurse gives the client, who is not immunocompromised, a purified protein derivative (PPD) of tuberculin to test for tuberculosis. Which client reaction indicates a positive response? 5-mm erythema with no induration No erythema with 3-mm induration 7-mm erythema with 5-mm induration 5-mm erythema with 10-mm induration The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. What type of respirations does the nurse expect the client to exhibit? Dyspnea Hyperpnea Kussmaul breathing Cheyne-Stokes breathing following surgery in the inguinal area, the client reports pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. Which is the priority nursing action? Auscultate the chest Obtain the vital signs Elevate the head of the bed Position the client on the right side The nurse provides preoperative education to a client with extensive cancer of the upper right lobe of the lung who is scheduled for a lobectomy. The nurse concludes that the teaching was effective when the client makes which statement? "The healthcare provider is going to use a laser to destroy all of the cancer cells. I will have oxygen in place to help me breathe after the surgery." "I don't even need the lobe they are taking out. I still have three lobes in my left lung to help me breathe after the surgery.""I know that my entire right lung will be removed. I will have chest tubes to help with drainage after surgery." "The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery." A nurse is providing education to a coworker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which information will be appropriate for the nurse to include? The thoracentesis procedure uses the principle of positive pressure. It is common for a sclerosing agent to be instilled at the end of the procedure. Clients will have temporary increased dyspnea immediately after the procedure. Rapid removal of large amounts of fluid may precipitate cardiovascular collapse. in addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? Chest tube insertion Aggressive diuretic therapy Administration of beta-blockers Positive end-expiratory pressure (PEEP) The client with emphysema complains of increased shortness of breath and becomes anxious. The healthcare provider prescribes oxygen at 1 L/min via nasal cannula. The nurse understands that this prescription is appropriate for what reason? High concentrations of oxygen cause alveoli to rupture. High concentrations of oxygen eliminate the respiratory drive. The client does not need any more than 1 L/min. The oxygen at 1 L/min should be enough to diminish the anxiety. An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which condition may the client have? Laryngeal trauma Vocal cord paralysis Obstructive sleep apnea Subcutaneous emphysema Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation? Late cyanosis Early tachypnea Late use of accessory muscles Early unexplained restlessnessThe nurse is providing postoperative care for an obese adult who had major abdominal surgery. The client has a history of smoking three packs of cigarettes daily. Which lab/diagnostic finding will the nurse check for the most accurate measurement of the client's respiratory status? PaO 2 PaCO 2 Hemoglobin Oxygen saturation A client has a leaking thoracic duct following a radical neck surgery. What does the nurse expect the postoperative plan of care to include? A gastrostomy tube, a high-fat diet, and bed rest A chest tube, total parenteral nutrition (TPN), and bed rest A rectal tube, a low-fat diet, and increased activity A nasogastric tube, a moderate-fat diet, and increased activity Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly? Remains constant in the chest drainage chamber. Is bubbling gently in the chest drainage chamber. Is bubbling vigorously in the suction control chamber. Rises in the tube of the water-seal chamber during inspiration. A client with a 10-year history of emphysema is admitted in acute respiratory distress. During assessment, what does the nurse expect to identify? Chest pain on inspiration Prolonged expiration with use of accessory muscles Signs and symptoms of respiratory alkalosis Decreased respiratory rate Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? Face tent Venturi mask Nasal cannula Nonrebreather mask On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? Muscle twitching Mental instabilityDeep and rapid respirations Tachycardia and cardiac dysrhythmias A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency while the client is in the postanesthesia care unit, what should the nurse do? Suction as needed Apply an ice collar Maintain a high-Fowler position Encourage expectoration of secretions What is the major factor a nurse considers when anticipating the method of oxygen administration to be prescribed by the healthcare provider for a client? Activity level Facial anatomy Mental capacity Pathologic condition Which pulmonary risk may be increased in a postoperative client due to anesthesia? Rhonchi Fremitus Dyspnea Atelectasis A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? Hypertension Tenacious sputum Altered mental status Slowed rate of breathing A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Remove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment Permit the development of positive pressure between the layers of the pleura Provide access for the instillation of medication into the pleural space A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is for which reason?Spasm of the bronchi that traps the air Increase in the vital capacity of the lungs Too rapid expulsion of air from the bronchioles Difficulty in expelling the air trapped in the alveoli A client who works in the leather industry complains of a bloody discharge and persistent pain after the treatment of sinusitis. The client has a history of smoking. The nurse suggests the client consult a primary healthcare provider immediately. Which risk does the nurse suspect in the client? Epistaxis Facial trauma Fracture of the nose Tumor of the nasal cavity Endotracheal intubation and positive-pressure ventilation are instituted because of a client’s deteriorating respiratory status. What is the priority nursing intervention? Facilitate verbal communication Prepare the client for emergency s