Chapter 35 Interventions for Critically Ill Clients With Respiratory Problems

Chapter 35: Interventions for Critically Ill Clients with Respiratory Problems Elsevier Inc.items and derived items © 2006, 2002 by Elsevier Inc. MULTIPLE CHOICE 1. Which client is at greatest risk for the development of a pulmonary embolism? A. 40-year-old woman who has used oral contraceptives for the past 15 years and who had abdominal surgery yesterday for cancer B. 60-year-old man who caught his right hand in a piece of machinery and has five broken fingers, with extensive soft tissue damage C. 30-year-old athlete who lifts weights and was diagnosed with a pneumothorax yesterday D. 50-year-old woman who has fragile capillaries and bruises very easily ANS: A This client has several risk factors. She is at risk for deep vein thrombosis because of oral contraceptive use. The abdominal surgery also increases her risk, as does a diagnosis of cancer. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 2. Which client is at greatest risk for development of fat emboli leading to pulmonary embolism? A. 70-year-old man who is easily dehydrated because of drug-induced diabetes insipidus B. 70-year-old woman who has a recurrence of breast cancer C. 36-year-old man who fractured his femur 2 days ago D. 36-year-old woman who is 50 pounds overweight ANS: C The marrow of long bones, including the femur, has a large amount of fat. This fat can be released when the femur is fractured, forming a large fat embolism that can lodge in the blood vessels of the lungs. Unfortunately, there is no way to prevent such an event. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 3. Which diagnostic test most specifically confirms the presence of a pulmonary embolism? A. Chest x-ray B. Arterial blood gases Copyright © 2006, 2002 by Elsevier Inc. HCO3– 23 mEq/L. pH 7.” ANS: C It is possible that massaging the feet and legs could promote venous return.” C.47. Pulmonary angiography D.” D. the feet and legs of a client should never be massaged. which would allow it to move.” B. however. Which statement made by a client’s spouse indicates the need for more teaching about prevention of a pulmonary embolism at home after major abdominal surgery? A. pH 7. Which set of arterial blood gases would the nurse expect to find in a client who developed a pulmonary embolism 15 minutes ago? A.C. PCO2 25 mm Hg. so I will increase the amount of fiber in his meals every day. “He is prone to constipation. HCO3– 28 mEq/L.38. PCO2 60 mm Hg. “While he is awake. “I will check his breathing rate and level twice a day. PO2 75 mm Hg ANS: C . DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category Health Promotion and Maintenance 5. pH 7. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 4. “I will massage his feet and legs twice a day to help blood return. PO2 96 mm Hg C. The other tests provide inferential data that are not specific for only pulmonary embolism. after surgery. PO2 66 mm Hg B. HCO3– 22 mEq/L. Thus. PO2 82 mm Hg D. I will make sure he gets up and walks for at least 5 minutes every 2 hours. Ventilation-perfusion lung scan ANS: C Pulmonary angiography actually determines the presence of a substance within the pulmonary vasculature. PCO2 65 mm Hg. there is a greater danger of loosening a clot that may have formed in the deep veins of the legs.30. HCO3– 22 mEq/L. PCO2 45 mm Hg.30. pH 7. ANS: B Copyright © 2006. Place the client in shock position. PCO2 45 mm Hg. If this condition continues further. even though the client is somewhat hypoxic at this time. . HCO3– 22 mEq/L. causing an increase in hydrogen ions and a decreased pH indicative of respiratory acidosis.30.” feels nauseated. PCO2 25 mm Hg. and anxiety. A client who is 2 days postoperative from a bowel resection tells her nurse that she is having a hard time “catching her breath. hypoxia. PO2 82 mm Hg D. HCO3– 28 mEq/L.30.47. pH 7. What intervention should the nurse perform before notifying the physician? A. pH 7. D. blood flowing through the lungs does not receive adequate oxygenation and carbon dioxide is retained. Which set of arterial blood gases would the nurse expect to find in a client who developed a pulmonary embolism 6 hours ago? A. HCO3– 22 mEq/L. Assess the chest and axillary area for the presence of petechiae. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 7. PO2 96 mm Hg C. Such a problem results in excessive loss of carbon dioxide. 2002 by Elsevier Inc. resulting in a metabolic acidosis as well as a respiratory acidosis. B.38. HCO3– 23 mEq/L. Increase the IV flow rate. The bicarbonate level remains normal because not enough time has passed to trigger renal compensation for the acidosis. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 6. C. PCO2 60 mm Hg. and has chest pains when she inhales. pH 7. PCO2 65 mm Hg. Apply oxygen by mask or nasal cannula at 5 L/min.Early changes in blood gases reflect the respiratory alkalosis caused by the hyperventilation due to pain. with her head and neck flat and her legs elevated. the hypoxia results in greater production of carbon dioxide production. The nurse suspects that she is having a pulmonary embolism. PO2 75 mm Hg ANS: A As this condition of poor gas exchange continues in the client with a PE. pH 7. The reduced partial pressure of carbon dioxide results in a diminished hydrogen concentration and a higher than normal pH. PO2 66 mm Hg B. they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset. Applying oxygen in this situation can be helpful and is unlikely to cause any problems. Both of these actions can be performed after the physician is notified. The client's PPT is 5 times the control value. she is hypoxic and at risk for other complications and tissue damage. Increasing the IV flow rate and assessing for petechiae will not prevent problems. ANS: D Therapeutic PPT values for clients receiving heparin should range between 1. B. The client's PPT is the same as the control value. ANS: A Although both heparin and warfarin are anticoagulants. What is the nurse’s best action? A. it must be started while the client is still receiving heparin. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe. Which partial thromboplastin times indicates to the nurse that anticoagulation is adequate? A. B. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention . D. Hold the dose of warfarin until the client's partial thromboplastin time is the same as the control value. C. Placing the client in shock position will not improve the hypoxia and may increase the extent of the pulmonary vascular block. Monitor the client for clinical manifestations of internal or external bleeding at least every 2 hours.5 times the control value.5 and 2. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity 9. The client is receiving heparin therapy for a pulmonary embolism. The client's PPT is one half the control value. Effective Care Environment. Administer the medications as prescribed. A nurse discovers that a physician has prescribed that the client with a pulmonary embolism be started on oral warfarin while still receiving intravenous heparin. Remind the physician that two anticoagulants should not be administered concurrently. 8.If this client is having a pulmonary embolism. D. C. The client's PPT is twice the control value. 11. “Avoid prolonged sitting or standing. . Which intervention should the nurse suggest for the client going home after a pulmonary embolism to reduce the risk for recurrence of a pulmonary embolism? A. “At night. Effective Care Environment. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Safe. the risk for bleeding has a higher priority than this psychosocial issue.” C. “Use an incentive spirometer every 2 hours while awake. “It seems I can’t speak a complete sentence without stopping for breath. The client with a massive pulmonary embolism is receiving alteplase (Activase).” ANS: B Prolonged sitting or standing contributes to increased venous stasis in the legs.” D. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category Health Promotion and Maintenance 12. is a totally synthetic drug and does not stimulate allergic or anaphylactic reactions.” B.” Copyright © 2006. “Apply ice immediately to any site of injury. “I have to stop to catch my breath halfway up a flight of stairs. The client may be concerned about his or her family and professional roles but at this time.” B. The drug has an impact on clots outside of the pulmonary embolism and the client is at great risk for hemorrhage and shock. unlike urokinase. Potential for Anaphylaxis D. Ineffective Breathing Pattern C. The client with a PE already has an impaired breathing pattern and the alteplase will not worsen this problem. Risk for Injury (Bleeding) ANS: D Alteplase is a fibrinolytic agent that dissolves formed clots. What is the priority nursing diagnosis or collaborative problem for this client? A. I need to sleep either on three pillows or in my recliner. Risk for Impaired Adjustment B. Alteplase.” C.MSC: Client Needs Category: Physiological Integrity 10. The dose of fibrinolytic agents for PE is far higher than the dose used to treat clots in a coronary artery. Which statement made by the client who has respiratory problems indicates the presence of orthopnea? A. 2002 by Elsevier Inc. increasing the risk for formation of a thrombus or embolus. “Avoid bending over at the waist. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Physiological Integrity . one-pillow orthopnea. “Decrease your intake of sodium. I notice my heart usually starts to beat hard and fast.” C. two-pillow orthopnea). Cryoprecipitate D.” ANS: B Orthopnea is the sensation of dyspnea or breathlessness in the supine position. The client with a pulmonary embolism is receiving an intravenous heparin drip. “Avoid aspirin and aspirin-containing drugs. Aspirin inhibits platelet aggregation. “Your blood-clotting time will decrease. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category Health Promotion and Maintenance 14. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment/Analysis MSC: Client Needs Category: Physiological Integrity 13. Protamine sulfate C. Vitamin K ANS: B Protamine sulfate is an antidote for heparin. What precaution should the nurse give in preparation for self-care to a person who will be taking warfarin (Coumadin) for 6 months? A. Clients feel that they cannot catch their breath in the supine position and must rest or sleep in a semisitting position by placing pillows behind their backs or by using a reclining chair. The degree of breathlessness can be roughly measured by the number of pillows needed to make the client less dyspneic (e.” ANS: D Warfarin inhibits synthesis of vitamin K–dependent clotting factors. Fresh-frozen plasma B.D.. The nurse should make certain which agent is readily available? A. “When I am eating a meal. “Increase your intake of multiple vitamins.” B. These two mechanisms greatly increase the client's risk for uncontrollable bleeding.” D.g. ” B. Measure pulse oximetry. Which statement. “On hot days. . present in green. Ingestion of large amounts of vitamin K can counteract the therapeutic effects of warfarin and reduce the INR until it is no longer within the therapeutic range. The 78-year-old with chronic congestive heart failure and pulmonary edema D. leafy vegetables to prevent constipation. Plasma proteins from this edema start inflammatory processes in the lung tissues that lead to ARDS. The 24-year-old with asthma who has not taken any of her asthma medications for 2 weeks ANS: B Extensive trauma alone can cause an excessive release of intracellular enzymes that can damage lung cells and lead to ARDS.” C.” D. This contributes to the movement of fluid into lung tissue. with massive transfusions. “Instead of a safety razor. Warfarin is a vitamin K antagonist. made by the client who is taking warfarin (Coumadin) daily to prevent blood clots from forming in deep veins.” ANS: A Vitamin K. indicates a need for further discussion regarding this therapy? A. Copyright © 2006. The 22-year-old who received 10 units of blood after a motor vehicle crash C. “I have been eating more salads and other green. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category Health Promotion and Maintenance 16. In addition. there is redistribution of large volumes of blood into the pulmonary circulation. causing noncardiac pulmonary edema. I have been using an electric shaver to shave. leafy vegetables.15. I make sure I drink at least two quarts of water. Which client is at greatest risk for ARDS? A. The client at risk for acute respiratory distress syndrome (ARDS) has become cyanotic and is diaphoretic. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 17. The 62-year-old with COPD who has pneumonia B. This information is critical in preparing a client for self care. The 10 units of blood indicate severe trauma. which increases pulmonary capillary hydrostatic pressure. enhances blood clotting by increasing the synthesis of specific clotting factors in the liver. “I have two pairs of antiembolic stockings so that one pair can be washed each day. What assessment technique should the nurse perform next? A. 2002 by Elsevier Inc. ventilation is exceeding perfusion. What is the significance of this value? A. The ratio is high. the client with ARDS will always die of respiratory failure. The ratio is high. C. ventilation is exceeding perfusion. ANS: A In early ARDS.5. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Physiological Integrity 19. The ratio is low. perfusion is exceeding ventilation. Bronchodilators C. The ratio is low. Diuretic therapy ANS: C Although the client with ARDS may not respond to oxygen therapy to the same degree as clients who have other types of respiratory problems. oxygen is still the most important intervention. C. The client with respiratory difficulty has a V/Q ratio of 0. What is the most important intervention for the client with ARDS? A. D. Oxygen therapy D. Auscultate breath sounds bilaterally. Compare current ECG tracing with baseline measurement. Without oxygen therapy. Antibiotic therapy B. B. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Physiological Integrity 18.B. hypoxemia may be the only abnormal assessment finding and can be life threatening. ANS: B . Measure the blood pressure in both arms. perfusion is exceeding ventilation. D. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Safe. Therefore. However. Risk for Infection C. ventilation is decreased and is not matched with perfusion.8. mechanical ventilation is an invasive intervention and greatly increases the client's risk for infection and sepsis. 24-year-old with muscular dystrophy D. and pneumonia are all acute but short-term issues requiring relatively brief ventilatory support. even in healthy lungs. When this ratio is less than 1.5. Impaired Gas Exchange ANS: B Although the client cannot breathe well on his or her own. 2002 by Elsevier Inc. What is the priority nursing diagnosis for a client who is in phase 4 of the course of ARDS and is being mechanically ventilated? A. Perfusion is greater at the bases of the lungs and ventilation is greater at the apices of the lungs. Fatigue B. 65-year-old with bilateral bacterial pneumonia ANS: C Clients who have chronic. 21. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity Copyright © 2006. 27-year-old with status asthmaticus B. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Physiological Integrity 20. the ratio is or approaches 1. a common cause of death in this population. progressive neuromuscular diseases that preclude spontaneous ventilation require mechanical ventilation for life. . mechanical ventilation is maintaining adequate oxygenation. Risk for Social Isolation D. Ventilation and perfusion are not the same throughout. 45-year-old with morphine overdose C. essentially blood flow through some area is occurring. The health problems of status asthmaticus. When the V/Q ratio is 0. but the blood is not becoming oxygenated because ventilation is less than adequate. Effective Care Environment. morphine overdose.When ventilation and perfusion match. the normal V/Q ratio for the entire lung is about 0. Which of the following clients could be expected to require mechanical ventilation longterm? A. Assisting ventilation to healthy lungs by mimicking normal chest pressures D. negative pressure ceases and expiration occurs. The endotracheal tube is taped to the lower jaw. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 23. Delivering an individualized preset tidal volume to the lower respiratory tract ANS: C The negative-pressure ventilator is noninvasive and works by changing pressures in the chest cavity rather than by forcing air directly into the lungs. Because of the pressure gradient. C. The client has been intubated for four days. Effective Care Environment. Which finding requires immediate intervention? A. At a preset time. B. negative-pressure ventilators create pressure gradients that mimic normal ventilation. The client has hydrocolloid membrane on the skin of the cheeks. ANS: C The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. C. The client is talking around the endotracheal tube. Breath sounds are heard only in one lung. air moves from the atmosphere (high pressure) into the thoracic cavity (low pressure). with the expansion of the chest wall. The endotracheal tube is midline in the mouth. A nurse is starting a new shift and assessing the client who has an oral endotracheal tube in place. . 24. Wheezes are auscultated. Thus. negative pressure is generated in the chest cavity. The client is placed in an airtight tube that surrounds either the chest area or the entire body and leaves the head exposed. What is the main purpose of a negative-pressure ventilator? A. Which situation indicates that a nurse needs to perform endotracheal suctioning of the client who is being mechanically ventilated? A. Relieving hypoxemia by opening obstructed airways C. Condensation is present in the ventilator tubing. Healing diseased lung tissue B. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Safe. D. D. During inspiration. B.22. The recommended position for clients who have one lung affected by a problem more than the other lung is to place the “good lung down. Administering the prescribed muscle-paralyzing agents B. Effective Care Environment/Physiological Integrity. . DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe. Although the fact that breath sounds are heard only in one lung represents a problem. The endotracheal tube is too small for the client. ANS: A The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. What is the consequence of this situation? A. Copyright © 2006. Thus. Auscultating the lungs bilaterally every 4 hours for the presence of crackles. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Safe. Ensuring that the pilot balloon on the endotracheal tube cuff is inflated to its maximal pressure D.” keeping the healthier lung dependent to the less healthy lung. some of the air being moved into the client’s airway by the ventilator is escaping through the client's trachea before it reaches the lower airways and alveoli. Which intervention promotes a more normal V/Q match for a client receiving mechanical ventilation? A. wheezes. 26. (Mechanical ventilation does not improve pulmonary perfusion). The client's residual volume is too low. and other abnormal breath sounds ANS: B Clients who are being mechanically ventilated are experiencing a problem in which their normal ventilation is not adequate. The client's lungs may not be receiving the set tidal volume. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung. Effective Care Environment/Physiological Integrity.ANS: D The presence of wheezes (rhonchi) indicates partial obstruction by secretions. A deflated balloon means that the cuff is also deflated and there is no longer a seal around the tube to prevent air from escaping. it cannot be helped by suctioning the endotracheal tube. The client has no airway and must be reintubated. 25. The pilot balloon on the endotracheal tube of a client being mechanically ventilated is completely deflated. B. C. 2002 by Elsevier Inc. D. Positioning the client so that the healthier lung is dependent to the more diseased lung C. Effective Care Environment/Physiological Integrity. Document the observation as the only action. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Safe. Document the observation as the only action. C. Administer a dose of pain medication or sedative. ANS: D Stridor on inspiration is caused by laryngospasm or edema and heralds impending airway occlusion. The client's airway is in jeopardy and the physician must take immediate action by prescribing an aerosol vasoconstrictor or by reintubating the client. . 29. What is the nurse’s best action? A. Increased diaphragmatic excursion D. C. What is the nurse’s best next action after applying humidified oxygen? A. Notify the emergency team. Hypotension B. Suction the client's mouth and pharynx. Pulse oximetry value of 96% C. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Safe. Darken the room and ask visitors to leave. D. Check the client's oxygen saturation by pulse oximetry. Ask the client to cough and deep breathe. Which assessment finding alerts the nurse to the possibility that the intrathoracic pressure in a mechanically ventilated client is too high? A. B.DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Physiological Integrity 27. B. D. Low-pressure alarm sounds on the ventilator ANS: A Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. Two hours after the client with an endotracheal tube has been extubated. 28. a nurse hears stridor on inhalation. Effective Care Environment/Physiological Integrity. The client being mechanically ventilated has become more restless over the course of the shift. increase the flow rate setting on the ventilator. if the saturation is less than adequate.ANS: D Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen and may be air hungry. D. ANS: C A widely fluctuating pressure reading is one indication of inadequate flow and oxygenation. Bleeding may not be evident at the initial injury. Increased chest pain with movement ANS: B Interstitial hemorrhage accompanies pulmonary contusion. Which assessment finding 3 hours later alerts the nurse to a possible pulmonary contusion? A. Assess the client’s oxygen saturation to determine the adequacy of oxygenation. . Check the client’s oxygen saturation to determine the adequacy of oxygenation and. but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs. When in doubt. Dyspnea B. It can also be a manifestation of pain. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Physiological Integrity 30. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Physiological Integrity Copyright © 2006. The pressure reading on the ventilator of a client receiving mechanical ventilation is fluctuating widely. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment/Evaluation MSC: Client Needs Category: Physiological Integrity 31. Disconnect the ventilator from the client and use a manual resuscitation bag until the machine has been checked. Increase the tidal volume by at least 100 mL or by the client’s weight in kg. determining the adequacy of ventilation has the highest priority. The client may be air hungry” from hypoxia. 2002 by Elsevier Inc. Determine whether there is an air leak in the client’s endotracheal tube cuff. C. What is the correct action to take for this problem? A. Hemoptysis C. Hyperresonance on percussion D. The client sustained an injury to the chest in a motor vehicle crash. B. 32. This condition is life threatening without intervention. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Physiological Integrity 33. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Physiological Integrity 34. Impaired Gas Exchange C. increasing intrathoracic pressure on the affected side. What is the nurse’s interpretation of these findings? A. collapsing the lung on the side with the air leak. and leading to decreased cardiac output. Clients may breathe so shallow to reduce the pain that their breathing pattern becomes ineffective secondary to compensation for the pain. The primary consideration is to decrease pain so that adequate ventilatory status is maintained. Acute respiratory distress syndrome ANS: C Blunt chest trauma can cause an air leak into the thoracic cavity. Ineffective Breathing Pattern B. Which would the nurse expect to find in a client with a hemothorax? A. What is the priority nursing diagnosis for the client with an uncomplicated rib fracture? A. pulse oximetry of 86%. Pulmonary contusion C. Acute Pain ANS: D Treatment for uncomplicated rib fractures is nonspecific because the fractured ribs unite spontaneously. The nurse now finds the client to have increased dyspnea. to some extent) increases the pain. Paradoxical chest movements C. The client who has experienced blunt trauma to the chest is at risk for developing a hemothorax. Activity Intolerance D. Flail chest B. Tension pneumothorax D. and tracheal deviation to the right. More air enters the pleural space with each breath. Percussion dullness on affected side . moving the trachea to the unaffected side. which included simple fractures of three ribs. The client has experienced left-sided chest trauma 3 hours ago. Movement of the ribs during inhalation (and on exhalation. Hemoptysis B. ANS: B Copyright © 2006. Which respiratory assessment finding indicates to the nurse that the client may have a flail chest as a result of this incident? A. Hypertympanic sound on affected side B. B. 2002 by Elsevier Inc. For the client who has sustained tracheobronchial trauma. An area on the client’s left chest is sucked in during inhalation and puffs out during exhalation. D. C. Hypertympanic sound on affected side ANS: C A hemothorax involves bleeding into the thoracic cavity (not into the pulmonary tree so hemoptysis does not occur). The client is coughing copious amounts of frothy white sputum. Hypotension and decreased capillary refill D. The client in a nursing home became confused and climbed out of bed (over the siderails) without assistance. Wheezes are present and are heard more loudly when the client inhales compared with what is heard on exhalation. which assessment finding alerts the nurse to the possibility of tracheal lacerations? A. falling onto a vacuum cleaner temporarily left there by the cleaning staff. Subcutaneous emphysema over the trachea C. Deviation of the trachea to the affected side ANS: B Lacerations of the trachea cause massive air leaks. . decreasing lung inflation on the affected side. which manifest as extensive subcutaneous emphysema and air in the mediastinum. As a result of decreased lung inflation. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 35. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Physiological Integrity 36. The client cannot speak more than six words between breaths. percussion sounds become duller and less resonant.D. hypoxia develops. Ensure that emergency intubation equipment is at the bedside. Dyspnea C. Chest pain on inhalation B. with outward movement during expiration. Because the oxygen in the alveoli beyond the area of the clot is not being exchanged into the blood. The cardiac system attempts to compensate for this hypoxia by increasing the heart rate. G. Explain the entire procedure to the client. (Select all that apply. Deflate the endotracheal tube cuff. Muscle weakness on one side F. H. Rapidly remove the tube at peak inspiration. A.) A.Flail chest is the inward movement of the thorax during inspiration. the client feels short of breath. E. B. Give oxygen by face mask or nasal cannula. leaving a segment of the chest wall loose. C. Muffled heart sounds E. Tachycardia ANS: A. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 2. Indicate which manifestations are associated with a pulmonary embolism. D. ANS: . The client is alert and oriented. It occurs more commonly in older adults who experience chest trauma. As a result. F Rationale: Not every person with a PE has all manifestations. The client is to be extubated from the ventilator after having received mechanical ventilation for 4 days. F. It usually involves one side of the chest and results from multiple rib fractures caused by blunt chest trauma. B. Instruct the client to cough. Suction the endotracheal tube and oral cavity. C. The movement of this loose segment becomes paradoxical to the expansion and contraction of the rest of the chest wall. Hemoptysis D. Hemoptysis may be present if there is bleeding into the alveoli from increased pulmonary vascular pressure in front of the clot. I. Indicate in which order the following steps should be performed. Hyperoxygenate the client. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity OTHER 1. Most clients have chest pain on inhalation as a result of increased pressure in one area of the chest and possible vasospasms around the embolism. Tell the client to take a deep breath. 2002 by Elsevier Inc. Immediately instruct the client to cough. explain to the client exactly what is to be done to him or her and what will be expected of the client during the procedure. I. The fraction of inspired oxygen (FIO2) is usually prescribed at 10% higher than the level used while the ET tube was in place. Keeping reintubation equipment on hand prevents a delay should reintubation become necessary. Effective Care Environment. . Suctioning removes any secretions that have collected in or around the tube and ensures that the secretions will not move further down the airway once extubation has been accomplished. Hyperoxygenate the client and thoroughly suction both the ET tube and the oral cavity. just as exhalation begins. F.C. Copyright © 2006. It is normal for large amounts of oral secretions to collect. H. D Rationale: Extubation is the removal of the endotracheal (ET) tube. G. results in less disruption of the normal breathing cycle. A. Hyperoxygenating the client before extubation prevents hypoxia during the procedure. Removal of the tube at peak inspiration. Give oxygen by face mask or nasal cannula. Set up the prescribed oxygen delivery system at the bedside and bring in the equipment for emergency reintubation. Such explanations not only reduce anxiety. Then rapidly deflate the cuff of the ET tube and remove the tube at peak inspiration. Before removal. The tube is removed when the need for intubation has been resolved. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Safe. The cuff must be deflated to prevent injury to the airway tissue. E. The criteria for extubation are not exact and the client may not be ready for extubation. but they also help ensure the client’s cooperation. B.