Questions and Answers
What do arterial blood gases evaluate?
Which finding should the nurse report to the provider for a client with emphysema?
What is the nurse's priority intervention for a client with pulmonary embolism?
Expect your urine and other secretions to be ______ while taking rifampin.
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Which situation should the nurse recognize as a possible cause of the low-pressure alarm in a client receiving mechanical ventilation?
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Which of the following clients is at greatest risk for a pulmonary embolism?
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In which position should the nurse place a client with emphysema to promote effective breathing?
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For which of the following adverse effects should the nurse monitor a client receiving albuterol?
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Which assessment should the nurse identify as the priority after a client undergoes bronchoscopy with moderate sedation?
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Which manifestation should the nurse expect in a client who has lung cancer?
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Which finding indicates that the client may be experiencing a tension pneumothorax following acute chest trauma?
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Which isolation precautions should the nurse include in the plan of care for a client with active TB?
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What lab finding should the nurse expect in a client experiencing acute respiratory failure?
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Which of the following actions should the nurse take first for a client experiencing a pulmonary embolism?
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Which statement by a staff nurse shows understanding of endotracheal suctioning?
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What finding should the nurse prioritize reporting for a client who is 4 hr postoperative following a total laryngectomy?
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Which actions should the nurse take when assisting with a thoracentesis?
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What is the priority assessment finding for a client who is 1 hr postoperative following a thoracentesis?
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Which manifestation should the nurse expect in a client with bacterial pneumonia?
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For which client should the nurse clarify the provider's prescription for nasopharyngeal suctioning?
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What item should the nurse keep easily accessible for a client with a chest tube following a lobectomy?
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Which intervention should be included in the care plan for a client with COPD?
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Which statement indicates a client understands teaching about montelukast for chronic asthma?
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Which ABG values indicate that a client is experiencing respiratory acidosis?
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Which finding should the nurse report for a client with acute respiratory distress syndrome (ARDS)?
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Which finding is the priority for the nurse to report for a client with COPD?
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Which statement by a newly licensed nurse indicates understanding of when to notify the provider for a client with a chest tube?
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Which low-flow delivery device should the nurse use to provide the highest level of oxygen for a client in respiratory distress?
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Which medication should the nurse plan to administer during an acute asthma attack?
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Study Notes
Mechanical Ventilation and Alarms
- A low-pressure alarm in mechanical ventilation typically indicates potential issues, including an artificial airway cuff leak, which affects oxygen delivery.
Tracheostomy Care
- When managing a temporary tracheostomy, instruct clients to remove old twill ties only after securing new ones to prevent accidental decannulation.
Risk for Pulmonary Embolism
- Clients who have undergone total hip arthroplasty are at the highest risk for pulmonary embolism due to immobility, particularly within 48-72 hours post-surgery.
Breathing Position for Emphysema
- Position clients with emphysema in High-Fowler's position to facilitate optimal lung expansion and ease of breathing.
Asthma and Albuterol
- Monitor clients using albuterol for tachycardia, a common side effect, especially with frequent use.
Post-Bronchoscopy Care
- Post moderate sedation after bronchoscopy, the presence of a gag reflex is the top priority to prevent aspiration.
Symptoms of Lung Cancer
- Blood-tinged sputum is a significant expected symptom in clients with lung cancer, indicating potential bleeding from the tumor.
Tension Pneumothorax Indicators
- Tracheal deviation to the unaffected side suggests a tension pneumothorax, due to free air in the chest cavity causing the lung to collapse.
Tuberculosis Isolation Protocol
- Implement airborne precautions for clients with tuberculosis to minimize the risk of transmission through the air.
Acute Respiratory Failure Labs
- Anticipate a PaO2 of 58 mm Hg in clients experiencing acute respiratory failure, indicating significantly low oxygen levels.
First Response to Pulmonary Embolism
- The immediate action for clients with a pulmonary embolism should be to apply supplemental oxygen to address severe hypoxemia.
Endotracheal Suctioning Technique
- Appropriate suction technique includes using a rotating motion while withdrawing the catheter to maximize secretion removal.
Postoperative Laryngectomy Monitoring
- Following a total laryngectomy, decreased oxygen saturation is critical to monitor due to the high risk of airway obstruction.
Thoracentesis Nursing Care
- Use goggles and a mask, cleanse the procedure site, and apply pressure post-thoracentesis to minimize complications.
Priority After Thoracentesis
- Report a persistent cough in clients post-thoracentesis as it may indicate a tension pneumothorax—an emergency.
Bacterial Pneumonia Indicators
- An elevated temperature of 38.8° C (101.8° F) is a common symptom of bacterial pneumonia, reflecting infection.
Contraindications for Nasopharyngeal Suctioning
- Avoid nasopharyngeal suctioning in clients with epistaxis due to the risk of exacerbating bleeding.
Chest Tube Maintenance
- Keep a container of sterile water accessible for patients with chest tubes to use in the event of accidental disconnection.
COPD Dietary Considerations
- For clients with COPD, recommend a diet that is high in calories and protein, while low in carbohydrates.
Montelukast Education
- Clients prescribed montelukast for chronic asthma should understand the importance of taking the medication every night, regardless of symptoms.
Detecting Respiratory Acidosis
- ABG values showing pH 7.30 and PaCO2 55 mm Hg indicate respiratory acidosis, necessitating urgent clinical attention.
ARDS Assessment Alerts
- Report findings of intercostal retractions in ARDS clients as they signify worsening respiratory distress.
Productivity of Cough in COPD
- A productive cough with green sputum in COPD clients is a priority finding indicating potential infection that must be reported.
Chest Tube Monitoring
- Continuous bubbling in the water seal chamber of a chest tube indicates an air leak and should prompt immediate provider notification.
Oxygen Delivery Devices
- A nonrebreather mask provides the highest oxygen concentration for clients in respiratory distress, delivering over 90% FiO2.
Medication for Acute Asthma Attack
- Albuterol is the first-line treatment for acute asthma attacks due to its rapid bronchodilation properties.
Monitoring Effectiveness in Acute Respiratory Failure
- Use arterial blood gases (ABGs) to assess the efficacy of treatments in clients with acute respiratory failure.
Emphysema Symptoms
- An elevated temperature in clients with emphysema should be reported as it may suggest a respiratory infection.
Management of Pulmonary Embolism
- Administering heparin via continuous IV infusion is prioritized for clients with pulmonary embolism to prevent further clot development.
Rifampin Patient Education
- Inform clients taking rifampin that it will turn their urine and other secretions orange, a harmless but notable effect.
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Description
Test your knowledge on respiratory care in mechanical ventilation scenarios with this ATI RN flashcard quiz. Focus on identifying causes of low-pressure alarms and understanding their implications in clinical settings. Perfect for nursing students preparing for medical-surgical nursing exams.
