Correct answer—B. Rationales: The client’s multiple rib fractures caused a flail chest. Signs include:

Flail chest can also cause tension pneumothorax, a condition in which air enters the chest but can’t be ejected during exhalation. Classic signs are tracheal deviation (away from the affected side), cyanosis, severe dyspnea, absent breath sounds on the affected side, distended jugular veins, and shock. The client with a ruptured diaphragm presents with hyperresonance on percussion, hypotension, dyspnea, dysphagia, shifted heart sounds, and bowel sounds in the lower to middle chest. A client with massive hemothorax shows signs of shock (tachycardia, hypotension), dullness on percussion on the injured side, decreased breath sounds on the injured side, respiratory distress and, possibly, mediastinal shift.

Nursing process step: Assessment

Correct answer—D. Rationales: Flail chest is a fracture of two or more ribs in two or more places, resulting in a free-floating segment of the chest wall. Paradoxical chest movement is commonly a sign of flail chest; however, until the chest muscles relax or pain relief is achieved, para-doxical movements are unlikely to be seen. Flail chest is usually a closed injury. Bilateral injury isn’t required in flail chest. If bilateral injury is present, the risk of mortality increases drastically.

Nursing process step: Assessment

Correct answer—B. Rationales: A sucking chest wound is indicative of an open pneumothorax. All other findings are associated with flail chest.

Nursing process step: Assessment

Correct answer—B. Rationales: Hypoxemia is a universal finding in ARDS. The PaCO₂ is low early in the disease because of hyperventilation, and it rises later in the disease because of fatigue and worsening clinical status. The bicarbonate level may be low in ARDS and is related to reduced tissue oxygenation. Reduced oxygenation leads to anaerobic metabolism and accumulating lactate. HCO₃˜ in the serum combines with the lactate, reducing circulating HCO₃– levels. The carboxyhemoglobin level is increased in a client with an inhalation injury, which commonly progresses to ARDS; however, this isn’t a common cause of ARDS.

Nursing process step: Assessment

Correct answer—B. Rationales: The client with COPD has abnormal ABG levels, which may predispose him to respiratory distress. The client is hypoxemic with hypercapnia. Oxygen should be administered at low concentrations to maintain hypoxic drive. If the PaO₂ remains inadequate at low dose, the nurse should increase the oxygen while continuously monitoring the client’s respiratory status. A client with COPD usually benefits from adequate hydration to liquefy secretions. Allow the client to assume a position that facilitates ventilation, usually a forward-leaning high Fowler’s position.

Nursing process step: Intervention

Correct answer—D. Rationales: Acute respiratory distress syndrome (ARDS) is an acute physiologic syndrome characterized by noncardiac pulmonary edema caused by increased pulmonary capillary permeability, high PEEP, and low oxygen saturation despite the use of supplemental oxygen. Emphysema is a permanent condition that’s caused by alveolar destruction. Pulmonary effusion is caused by excessive fluid accumulation in the pleura, and chronic bronchitis is a narrowing of the airway passages and an increase in mucus production.

Nursing process step: Assessment

Correct answer—C. Rationales: The client with COPD has a markedly increased need for protein and calories to maintain an adequate nutritional status. The client’s diet should be high in both protein and calories and should be divided into five or six small meals per day. Fluid intake should be maintained at 3 L/day unless contraindicated. Fluids should be taken between meals to reduce gastric distention and pressure on the diaphragm. The client with COPD should rest for 30 minutes before each meal to conserve energy and decrease dyspnea. The client should also avoid exercise and breathing treatments for at least 1 hour before and after eating.

Nursing process step: Evaluation

Correct answer—B. Rationales: Elevated pulmonary pressures resulting from pulmonary emboli can lead to dysfunction of the right heart, which in turn can lead to an increase in right atrial volume, showing an altered P wave on the ECG. The lead to monitor for this finding is lead II. In this lead, the P wave is taller and more peaked than a normal P wave. A physiologic S₂ split is normal. When pulmonary pressures become severely elevated, the split becomes pathologic. Breath sounds are generally clear in a client with pulmonary emboli, although a pleural friction rub may be heard.

Nursing process step: Assessment

Correct answer—B. Rationales: Inflammation of smooth muscle leading to constriction and mucus production results in air trapping, respiratory acidosis, and hypoxemia, the classic definition of asthma. Pulmonary effusion is caused by excessive fluid accumulation in the pleura. Chronic bronchitis is a narrowing of the airway passages and an increase in mucus production, but it doesn’t produce air trapping. ARDS is an acute physiologic syndrome characterized by noncardiac pulmonary edema caused by increased pulmonary capillary permeability, high PEEP, and low oxygen saturation despite the use of supplemental oxygen.

Nursing process step: Assessment

Correct answer—D. Rationales: Although riskier than a [V with dot above]/[Q with dot above] scan, pulmonary angiography confirms the presence of a pulmonary embolus. Bronchoscopy is typically used in differential diagnosis of pneumonia. A chest X-ray is usually done to rule out other pulmonary problems, such as pneumonia and atelectasis. A [V with dot above]/[Q with dot above] scan is used to locate the inadequately perfused area; however, results aren’t definitive.

Nursing process step: Assessment

Correct answer—B. Rationales: Beta₂-agonists are the first-line drugs of choice for the client with asthma. They relax bronchial smooth muscle and enhance mucociliary clearance. Beta-adrenergic blockers, aspirin, and NSAIDs all worsen asthma.

Nursing process step: Analysis

Correct answer—A. Rationales: A mediastinal shift, systolic blood pressure less than 80 mm Hg, and a capillary refill greater than 4 seconds can all be associated with a hemothorax greater than 1,500 mL. The client with a massive hemothorax has mediastinal shift, blood pressure depicting decompensation, diminished peripheral blood flow, decreased urine output, and respiratory distress.

Nursing process step: Assessment

Correct answer—D. Rationales: If the client states “I should hold my head back and forcefully exhale,” further teaching is necessary. The correct technique for using an inhaler is as follows: The inhaler must be mixed thoroughly before administration. The client should hold his breath for 5 to 10 seconds to allow the medication to reach as far as possible into the lungs. If the client has difficulty with this technique, a spacer device may be added to the inhaler. A forced exhalation isn’t recommended because coughing, small-airway closure, and air trapping may result.

Nursing process step: Evaluation

Correct answer—A. Rationales: The priority is always airway, breathing, and circulation. Provide oxygen by face mask. If hypocapnia is present on admission, arterial blood gas (ABG) analysis should be repeated within 15 to 20 minutes. Worsening hypocapnia with progressive obtundation is an indication for emergency intubation. A loading dose of heparin should be administered, followed by a continuous drip. The heparin should be titrated to an activated partial thromboplastin time 11/2 to 2 times the control. Heparin therapy is sufficient treatment for most clients with pulmonary emboli. For clients who present with significant hemodynamic compromise, streptokinase (Streptase) and tissue plasminogen activator (alteplase [Activase]) have been approved for use in pulmonary emboli. Pain increases oxygen demand and anxiety, and it should be treated with morphine or meperidine (Demerol). The nurse should monitor ABG levels carefully to prevent carbon dioxide retention.

Nursing process step: Analysis

Correct answer—A. Rationales: The optimal PEFR is greater than 80% of predicted or personal best with a variability of less than 20%. Monitoring PEFR helps assess the severity of obstruction. The nurse should evaluate the client’s response to treatment and detect changes in airflow. If PEFR is increasing and subjective symptoms are decreasing, medication or dosage needn’t be changed. If PEFR is decreasing and symptoms are increasing, the client can better judge his status and adjust medications appropriately.

Nursing process step: Evaluation

Correct answer—C. Rationales: X-ray assessment of the lateral neck assists in diagnosing common respiratory emergencies in children. The lateral neck X-ray of a child with epiglottiditis shows a thickened mass. The steeple sign is found in the client with viral croup syndrome. Subglottic narrowing with membranous tracheal exudate is found in bacterial tracheitis. Supraglottic narrowing isn’t a diagnostic indicator.

Nursing process step: Assessment

Correct answer—D. Rationales: If the client is effectively removing secretions, suctioning can be harmful. Suctioning can cause mucosal trauma, hypoxemia, and even pulmonary infection. Incentive spirometry every 2 hours, sitting in a chair at bedside three times per day, and splinting the abdomen to facilitate coughing are all measures to prevent pneumonia.

Nursing process step: Evaluation

Correct answer—A. Rationales: A CBC is helpful in determining the presence of infection and identifying the microbial (viral, bacterial, fungal) agent. A chest X-ray can identify the location of the pneumonia. Sedimentation rate, electrolytes, and lumbar puncture don’t assist in the differential diagnosis of pneumonia.

Nursing process step: Assessment

Correct answer—C. Rationales: Because children are at high risk for developing abrupt airway obstruction, the most important intervention for a child with epiglottiditis is airway management. Intubation should be performed as soon as possible in a controlled environment. Children need supplemental oxygen, but most are so anxious that they won’t allow a mask to stay in place. Provide humidified “blow-by” oxygen administered by the parent, if possible. The child needs parenteral antibiotics; however, the priority is airway management. The most common rhythm in this client is sinus tachycardia related to compensation.

Nursing process step: Analysis

Correct answer—A. Rationales: Tension pneumothorax presents with severe respiratory distress, hypotension, diminished breath sounds over the affected area, hyperresonance, jugular vein distention and, eventually, tracheal shift. A finding of multiple rib fractures in a client with respiratory distress verifies a diagnosis of flail chest. A client with a ruptured diaphragm presents with hyperresonance on percussion, hypotension, dyspnea, dysphagia, shifted heart sounds, and bowel sounds in the lower to middle chest. A client with massive hemothorax shows signs of shock (tachycardia, hypotension), dullness on percussion on the injured side, decreased breath sounds on the injured side, respiratory distress, and possibly, mediastinal shift.

Nursing process step: Assessment

Correct answer—A. Rationales: The most common cause of traumatic pneumothorax is broken ribs. Other common causes include penetrating trauma (gunshot or knife wound), insertion of a central venous pressure catheter, barotrauma in mechanically ventilated clients, and closed pleural biopsy.

Nursing process step: Assessment