Few Notes for Respiratory
An independent nursing intervention that would be helpful in preventing the accumulation of secretions
in a patient who had general anesthesia for surgery is frequent changes of position.
RATIONALE: This minimizes pooling of respiratory secretions and maximizes chest expansion, which aids
in airway and is an independent nursing function.
When a spontaneous pneumothorax is suspected in a patient with a history of emphysema, the nurse
should call the physician and give o@ 2L per nasal cannula.
RATIONALE: oxygen is supplied to prevent anoxia but in high concentrations. In a patient with
emphysema a low PO2, not high PCO2, is the respiratory stimulus.
QUIZ QUESTIONS
Precautions taken to minimize the chance of the tracheostomy tube from being accidently dislodged
are: tracheostomy tie strings are not changed for at least 24 hours after insertion, first tube changed is
performed by a physician, and ensure the cuff is inflated using minimal leak technique.
Cuffless tracheostomy tube: Patient does not require mechanical ventilation and can protect airway.
Patient can swallow without aspiration but may need suctioning of secretions.
Fenestrated tracheostomy tube: Airflow around tube allows speaking when the cuff is deflated and the
plug is inserted. Tube is most likely to cause airway obstruction if exact steps are not followed to produce
speech.
Stridor: Partial airway obstruction of the trachea or larynx. Patient may need a breathing treatment to
help clear this up
Finger-clubbing: found in end-stage COPD and patient suffers from chronic hypoxemia
Fine crackles: interstitial filing f fluid in the lungs. Use Lasix (furosemide)
Atelectasis: Absent breath sounds when auscultating lungs. Use incentive spirometer to prevent this
Hyper resonance- You may find this in the following patients: COPD and lung hyperinflation,
pneumothorax or collapsed lung, asthmatic or air trapping
Wheezing: asthmatic patient experiencing bronchoconstriction of the airway
Increased tactile fremitus: Patient who has pneumonia or lung consolidation with exudate and a patient
who has pulmonary edema or lung consolidation from fluid
Pleurisy: patient with abrupt, sharp chest pain that is aggravated by inspiration. To prevent chest wall
movement, the patient’s breathing pattern is shallow and rapid. Pleural friction rub is auscultated
I CLICKER QUESTIONS
A patient is admitted to the hospital. A focused respiratory assessment of the left lower lung field reveals
the following: bronchial breath sounds, diminished breath sounds and tactile fremitus. Based on the
assessment findings, what condition does the nurse suspect?
A) Pneumonia
B) Asthma
C) Emphysema
D) Early left-sided heart failure
Supplemental low-flow oxygen therapy is prescribed for a man who has emphysema. Which is the most
essential action for the nurse to include in the plan care?
A) Anticipate the need for humidification
B) Notify the physician that the order is contraindicated
C) Place the patient in an upright position
D) Schedule frequent pulse oximeter checks
A patient who is 64 yo and has been smoking since he was 11 is admitted to the hospital because of a
respiratory infection that has not improved with outpatient therapy. Which finding would the nurse
expect to observe during the patient’s nursing assessment?
A) Electrocardiogram changes
B) Increased anterior-posterior chest diameter
C) Slow, labored respiratory pattern
D) Weight-height relationship indicating obesity
A nurse reviews the arterial blood gas(ABG) values and notes a pH of 7.50, a PaCO2 of 30mmHg and
HCO3 of 25mEq/L. Which acid-base imbalance is the patient experiencing?
A) Metabolic acidosis
B) Respiratory acidosis
C) Respiratory alkalosis
D) Metabolic alkalosis
A nurse reviews an ABG report for a patient who has COPD. The results are pH of 7.35, a PaCO2 of
62mm Hg, PaO2 of 70mm Hg and HCO3 of 28mEq/L. Which action should the nurse take?
A) Prepare for intubation
B) Assess respiratory effort
C) Reposition the patient
D) Apply oxygen 100%mask
A patient who is diagnosed with a exacerbation of COPD has a RR 30 per minute, oxygen sat is 55%,
pulse is 110 per minute and BP is 70/40. Which of these actions should a nurse initiate first?
A) Initiate CPR
B) Start bag mask ventilation
C) Notify physician of a change in patient status
D) Place resuscitation equipment at bedside
A patient who has pneumonia has the following physical assessment findings. Which finding best
supports the nursing diagnosis, Ineffective airway clearance?
A) RR 20
B) Oxygen sat 95%
C) Rhonchi that do not clear with cough
D) Bronchovesicular breath sounds over middle lung fields
Which position does the nurse suggest the patient, who reports chronic dyspnea, assume to reduce the
workload of breathing?
A) Tripod
B) Semi-fowlers position
C) Prone position
D) Trendelenburg position
Which feelings of loss are experienced most by the patient who is breathlessness and easily fatigued?
Discuss
A) Social Activity
B) Coping ability
C) Family
D) Intimacy
Which rationale does the student nurse give her instructor for limiting activity for a patient who is
recovering from pneumonia?
A) Keeps respiration below 20 per minute
B) Decrease muscles’ need for oxygen
C) Limits the trigger for coughing
D) Reduces the need for nutritional intake
Which rationale does the student nurse give her instructor for adding deep breathing and coughing to
the care plan of a patient who was admitted for pneumonia?
A) Increase the depth of respirations
B) Decreases the need for intravenous fluids
C) Facilitates the removal of secretions
D) Minimizes the need for expectorates
