A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective
airway clearance related to thick, secretions. Which action is a priority for the nurse to
include in the plan of care?
a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation >93%.
Give this one a try later!
ANS: B
Because the reason for the poor airway clearance is the thick secretions,
the best action will be to encourage the patient to improve oral fluid intake.
Patients should be instructed to use the incentive spirometer on a regular
basis (e.g., every hour) in order to facilitate the clearance of the secretions.
The other actions may also be helpful in improving the patients gas
, exchange, but they do not address the thick secretions that are causing the
poor airway clearance.
A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an
oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which
intervention will the nurse anticipate?
a. Administration of 100% oxygen by non-rebreather mask
b. Endotracheal intubation and positive pressure ventilation
c. Insertion of a minitracheostomy with frequent suctioning
d. Initiation of continuous positive pressure ventilation (CPAP)
Give this one a try later!
ANS: B
The patients lethargy, low respiratory rate, and SpO2 indicate the need for
mechanical ventilation with ventilator-controlled respiratory rate.
Administration of high flow oxygen will not be helpful because the patients
respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate
removal of secretions, but it will not improve the patients respiratory rate or
oxygenation. CPAP requires that the patient initiate an adequate respiratory
rate to allow adequate gas exchange.
The nurse palpates the posterior chest while the patient says 99 and notes absent
fremitus. Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
, c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
Give this one a try later!
ANS: D
To assess for tactile fremitus, the nurse should use the palms of the hands
to assess for vibration when the patient repeats a word or phrase such as
99. After noting absent fremitus, the nurse should then auscultate the lungs
to assess for the presence or absence of breath sounds. Absent fremitus
may be noted with pneumothorax or atelectasis. The vibration is increased
in conditions such as pneumonia, lung tumors, thick bronchial secretions,
and pleural effusion. Turning, coughing, and deep breathing is an
appropriate intervention for atelectasis, but the nurse needs to first assess
breath sounds. Fremitus is decreased if the hand is farther from the lung or
the lung is hyperinflated (barrel chest).The anterior of the chest is more
difficult to palpate for fremitus because of the presence of large muscles
and breast tissue.
The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with
community-acquired pneumonia. Which assessment information is most important to
communicate to the health care provider?
a. Scattered crackles bilaterally in the posterior lung bases.
b. Persistent cough that is productive of blood-tinged sputum.
c. Temperature of 101.5 F (38.6 C) after 2 days of IV antibiotic therapy.
d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.
Give this one a try later!
airway clearance related to thick, secretions. Which action is a priority for the nurse to
include in the plan of care?
a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation >93%.
Give this one a try later!
ANS: B
Because the reason for the poor airway clearance is the thick secretions,
the best action will be to encourage the patient to improve oral fluid intake.
Patients should be instructed to use the incentive spirometer on a regular
basis (e.g., every hour) in order to facilitate the clearance of the secretions.
The other actions may also be helpful in improving the patients gas
, exchange, but they do not address the thick secretions that are causing the
poor airway clearance.
A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an
oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which
intervention will the nurse anticipate?
a. Administration of 100% oxygen by non-rebreather mask
b. Endotracheal intubation and positive pressure ventilation
c. Insertion of a minitracheostomy with frequent suctioning
d. Initiation of continuous positive pressure ventilation (CPAP)
Give this one a try later!
ANS: B
The patients lethargy, low respiratory rate, and SpO2 indicate the need for
mechanical ventilation with ventilator-controlled respiratory rate.
Administration of high flow oxygen will not be helpful because the patients
respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate
removal of secretions, but it will not improve the patients respiratory rate or
oxygenation. CPAP requires that the patient initiate an adequate respiratory
rate to allow adequate gas exchange.
The nurse palpates the posterior chest while the patient says 99 and notes absent
fremitus. Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
, c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
Give this one a try later!
ANS: D
To assess for tactile fremitus, the nurse should use the palms of the hands
to assess for vibration when the patient repeats a word or phrase such as
99. After noting absent fremitus, the nurse should then auscultate the lungs
to assess for the presence or absence of breath sounds. Absent fremitus
may be noted with pneumothorax or atelectasis. The vibration is increased
in conditions such as pneumonia, lung tumors, thick bronchial secretions,
and pleural effusion. Turning, coughing, and deep breathing is an
appropriate intervention for atelectasis, but the nurse needs to first assess
breath sounds. Fremitus is decreased if the hand is farther from the lung or
the lung is hyperinflated (barrel chest).The anterior of the chest is more
difficult to palpate for fremitus because of the presence of large muscles
and breast tissue.
The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with
community-acquired pneumonia. Which assessment information is most important to
communicate to the health care provider?
a. Scattered crackles bilaterally in the posterior lung bases.
b. Persistent cough that is productive of blood-tinged sputum.
c. Temperature of 101.5 F (38.6 C) after 2 days of IV antibiotic therapy.
d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.
Give this one a try later!
