Which statement by the client indicates a need for further teaching
regarding the reinforced home care instructions for acute sinusitis? - ANS
✓"I will need surgery to drain my sinuses."
Rationale:
The nurse provides instructions to the client regarding measures to
promote sinus drainage, comfort, and resolution of the infection. The nurse
instructs the client to apply heat in the form of hot wet packs over the
affected sinuses to promote comfort and help resolve the infection. Large
amounts of fluids are important to help liquefy secretions. Sleeping with
the head of the bed elevated to a 45-degree angle will assist in promoting
drainage. Surgery may be performed to improve drainage in chronic
conditions if other measures are not helpful, but it is not usually a
treatment measure for acute sinusitis.
The nurse is assisting with monitoring the functioning of a chest-tube
drainage system in a client who just returned from the recovery room after
a thoracotomy with wedge resection. Which findings should the nurse
expect to note? Select all that apply. - ANS ✓50 mL of drainage in the drainage-
collection chamber
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
1
Respiratory - Saunders
,Respiratory
Fluctuation of water in the tube of the water-seal chamber during
inhalation and exhalation
(Rationale)
The bubbling of water in the water-seal chamber indicates air drainage
from the client. This is usually seen when intrathoracic pressure is greater
than atmospheric pressure, and it may occur during exhalation, coughing,
or sneezing. Excessive bubbling in the water-seal chamber may indicate an
air leak, which is an unexpected finding. The fluctuation of water in the
tube in the water-seal chamber during inhalation and exhalation is
expected. An absence of fluctuation may indicate that the chest tube is
obstructed, the lung has re-expanded, or no more air is leaking into the
pleural space. Gentle (not vigorous) bubbling should be noted in the
suction-control chamber. A total of 50 mL of drainage is not excessive in a
client returning to the nursing unit from the recovery room; however,
drainage of more than 70 to 100 mL/hr is considered excessive and
requires health care provider notification. The chest-tube insertion site is
covered with an occlusive (airtight) dressing to prevent air from entering
the pleural space. Positioning the drainage system below the client's chest
allows gravity to drain the pleural space.
A clinic nurse is assisting in caring for a client whose chief complaint is the
presence of flulike symptoms. Which recommendation by the nurse is
therapeutic? Select all that apply. - ANS ✓Get plenty of rest.
Take antipyretics for fever.
Increase intake of liquids.
The nurse is caring for a client who is suspected of having lung cancer. The
nurse monitors the client for which most frequent early sign of lung
cancer?
Cough - ANS ✓Cough
2
Respiratory - Saunders
, Respiratory
A client arrives in the emergency department with an episode of status
asthmaticus. What is the nurse's priority action? - ANS ✓Place the client in
high-Fowler's position.
The nurse instructs a client on pursed-lip breathing and asks the client to
demonstrate the breathing technique. Which observation by the nurse
indicates that the client is performing the technique correctly? - ANS ✓The
client breathes out slowly through the mouth.
A client had thoracic surgery 2 days ago and has a chest tube in place
connected to a closed chest tube system. The nurse notes continuous
bubbling in the water seal chamber. The nurse determines which? - ANS
✓There is a leak in the system, which requires immediate investigation and
correction.
A client has undergone fluoroscopy-assisted aspiration biopsy of a lung
lesion. The nurse determines that the client is experiencing complications
from the procedure if the nurse makes which observation? - ANS ✓Absence
of breath sounds in the right upper lobe
While assessing a client who is admitted to the hospital with a diagnosis of
pleurisy, the nurse would note which characteristic symptom of this
disorder? - ANS ✓
The nurse is assessing a client who has frequent episodes of asthma. Which
assessment finding is most closely associated with asthma? - ANS ✓
A client diagnosed with tuberculosis (TB) is distressed over the loss of
physical stamina and fatigue. The nurse should provide which explanation
for these symptoms? - ANS ✓Expected and the client should very gradually
increase activity as tolerated
The nurse is assisting a client with a closed chest tube drainage system to
get out of bed to a chair. During the transfer, the chest tube gets caught in
the leg of the chair and accidentally dislodges from the insertion site. Which
3
Respiratory - Saunders
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