Question

A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)

Answer 1

Correct Answers:

Dyspnea
Barrel chest
Clubbing of the fingers
Shallow respiration

Rationale :

💨Dyspnea is a hallmark symptom of emphysema due to air trapping and reduced gas exchange, making breathing increasingly difficult, especially with exertion.

🏐Barrel chest occurs as a result of lung hyperinflation, causing the chest to become rounded and expanded over time.

☁️Clubbing of the fingers is associated with chronic hypoxia, which is common in advanced stages of emphysema.

😮‍💨Shallow respirations are often seen due to ineffective ventilation and fatigue from the increased work of breathing.

🛑Bradycardia is not expected; clients with emphysema may actually experience tachycardia as a compensatory mechanism for hypoxia.

📌Core Message

Emphysema is marked by dyspnea, barrel chest, clubbing, and shallow breathing, all resulting from chronic airflow limitation and hypoxia.

Answer 2

Correct Answers:

Verify that the suction regulator is on.

Rationale :

🔌Bubbling in the suction control chamber indicates that suction is actively being applied. If there is no bubbling, the first action should be to check whether the suction regulator is turned on and functioning properly.

🧠This step ensures that the system is receiving the ordered amount of suction, which is essential for proper lung re-expansion and drainage.

📞Notifying the provider is premature unless the issue persists after verifying the equipment, as nurses must first assess the equipment setup.

👀Continuing to monitor without action is inappropriate if bubbling is expected and absent—this may indicate ineffective suction.

🧪Milking the chest tube is not a routine action and can cause increased intrathoracic pressure or tissue damage—it should be done only if prescribed and after confirming the cause of the issue.

📌Core Message

When expected bubbling is absent in a chest tube's suction chamber, the nurse must first verify that suction is on before taking further action.

Answer 3

Correct Answers:

Respiratory acidosis

Rationale :

🧪A pH of 7.22 indicates acidemia (normal: 7.35–7.45), and a PaCO₂ of 68 mm Hg (normal: 35–45 mm Hg) indicates hypercapnia, meaning CO₂ retention is the cause of the acidosis.

💨This suggests that the primary issue is respiratory, as CO₂ buildup from hypoventilation (respiratory rate of 7/min) is leading to respiratory acidosis.

🧫The bicarbonate level of 28 mEq/L (normal: 22–26) is slightly elevated, showing renal compensation is trying to buffer the acid, but it’s not enough to normalize the pH.

🧠Metabolic acidosis would present with a low pH and low bicarbonate, not high PaCO₂.

🎈Respiratory alkalosis would involve a high pH and low PaCO₂ (e.g., from hyperventilation), which is the opposite of this case.

🧂Metabolic alkalosis would show elevated pH and bicarbonate, not acidosis.

📌Core Message

A low pH with elevated PaCO₂ and hypoventilation points to respiratory acidosis as the primary disturbance.

Answer 4

Correct Answers:

Breathe in through her nose and out through pursed lips.

Rationale :

😮‍💨Pursed-lip breathing is a key technique that helps clients with emphysema improve gas exchange by promoting longer exhalation, reducing air trapping, and maintaining positive airway pressure, which keeps alveoli open longer.

👃Breathing in through the nose warms, filters, and humidifies the air, which is also beneficial for lung function.

🛏️Resting in a supine position can impair ventilation in clients with emphysema; they breathe more effectively in high Fowler's or tripod positions.

🥩A low-protein diet is not advised—clients with COPD or emphysema need adequate protein intake to maintain muscle strength, including respiratory muscles.

💧Limiting fluid intake is not appropriate; clients should have adequate hydration to help thin secretions, aiding in their expectoration and improving ventilation.

📌Core Message

Pursed-lip breathing supports better ventilation and gas exchange in emphysema by reducing air trapping and enhancing airflow.

Answer 5

Correct Answers:

Expiratory wheeze

Rationale :

👃Wheezing is a high-pitched musical sound that occurs primarily during expiration due to narrowed airways, which is a hallmark of asthma exacerbations.

🔊This sound results from air being forced through constricted bronchioles, which is commonly seen in bronchospasm, inflammation, and mucus production associated with asthma.

🩺Pleural friction rub is a grating sound heard during both inspiration and expiration, typically seen in pleurisy, not asthma.

🌬️Fine rales are soft, crackling sounds heard on inspiration and are associated with fluid in the alveoli, such as in heart failure or pneumonia, rather than asthma.

🔊Rhonchi are low-pitched, coarse sounds often due to secretions in larger airways, seen in conditions like bronchitis, not typical of acute asthma.

📌Core message

Expiratory wheezing is the classic auscultatory finding in acute asthma due to bronchoconstriction and airway inflammation.

Answer 6

Correct Answers:

Absence of breath sounds

Rationale :

💨Pneumothorax occurs when air enters the pleural space, causing lung collapse, which prevents air from moving in and out of the affected area, leading to absent breath sounds on auscultation.

👃This absence is a critical clinical indicator and occurs because the collapsed lung is no longer ventilated, resulting in no breath sounds over the involved lung field.

🚫Inspiratory stridor is typically associated with upper airway obstruction, such as in croup or laryngeal edema, and not with pneumothorax.

🌬️Expiratory wheeze indicates lower airway narrowing, commonly found in conditions like asthma or COPD, rather than pneumothorax.

💦Coarse crackles are bubbling or rattling sounds due to fluid in the airways, often related to pulmonary edema, not pneumothorax.

📌Core message

An absence of breath sounds is a key sign of lung collapse from pneumothorax and requires immediate attention.

Answer 7

Correct Answers:

Encourage the client to drink 8 glasses of water a day.

Rationale :

💧Adequate hydration helps thin respiratory secretions, making it easier for clients with COPD to expectorate mucus and improve airway clearance.

👩‍💼Clients with COPD often experience excessive mucus production and difficulty clearing secretions; promoting fluid intake is a non-pharmacologic intervention that enhances respiratory function.

⏰Instructing the client to cough only every 4 hours is insufficient; frequent coughing and deep breathing should be encouraged to mobilize secretions more effectively.

🥩A low protein diet is inappropriate for COPD clients, who often have increased caloric and protein needs due to the energy demands of breathing and risk of muscle wasting.

🛏️Advising the client to lie down after eating can impair diaphragmatic movement and increase the risk of aspiration; clients should remain upright to support optimal lung expansion.

📌Core message

Promoting fluid intake supports airway clearance in COPD by helping to loosen thick mucus and improve respiratory efficiency.

Answer 8

Correct Answers:

Maintain the drainage container below the level of the clients chest.

Rationale :

📉Positioning the chest drainage system below chest level uses gravity to promote adequate drainage and prevent backflow of fluid or air into the pleural space, which could worsen the pneumothorax.

🩺This positioning helps maintain the negative pressure essential for effective chest tube function and promotes lung re-expansion.

🚫Adding tap water to the suction control chamber is incorrect; only sterile water should be used to ensure asepsis and proper regulation of suction.

🗑️Emptying the collection container is never done; the entire system is replaced when full to preserve sterility and system integrity.

⚠️Clamping the chest tube if disconnected can lead to tension pneumothorax, a life-threatening condition; instead, the tube should be placed in sterile water until reconnected.

📌Core message

Keeping the drainage system below chest level ensures safe and effective chest tube function by promoting gravity-assisted drainage and preventing complications.

Answer 9

Correct Answers:

Sitting, leaning forward over the bedside table.

Rationale :

🪑The sitting, leaning forward position helps to expand the intercostal spaces, allowing optimal access to the pleural cavity for fluid aspiration during thoracentesis.

📏This position stabilizes the client while gravity helps pool pleural fluid at the lung base, improving needle accuracy and safety of the procedure.

🚫A prone position is contraindicated because it limits access to the posterior thoracic space and does not facilitate proper lung expansion.

🛌Although High Fowler’s improves lung expansion, it does not offer the same pleural access or stability as sitting and leaning forward.

🧎‍♂️The side-lying position with knees to chest is appropriate for lumbar punctures, not for thoracentesis.

📌Core message

The leaning-forward seated position provides the best access to the pleural space and helps ensure safety and effectiveness during thoracentesis.

Answer 10

Correct Answers:

Liver function tests

Rationale :

🧪Pyrazinamide is an antitubercular medication that is hepatotoxic, meaning it can cause liver damage; therefore, liver function tests (LFTs) are required to monitor for potential drug-induced hepatitis.

🧫Clients taking pyrazinamide are at risk for asymptomatic liver enzyme elevations or more severe liver injury, especially when used in combination with other hepatotoxic TB drugs like isoniazid or rifampin.

🧍‍♀️Gallbladder studies are not related to pyrazinamide’s mechanism or common adverse effects and are not routinely monitored during therapy.

🧠Thyroid function studies are unnecessary because pyrazinamide does not affect thyroid hormone production or regulation.

🩸While blood glucose levels may require monitoring in diabetic clients, they are not the primary concern with this medication unless comorbid diabetes exists.

📌Core message

Liver function monitoring is essential during pyrazinamide therapy due to its hepatotoxic effects, especially in combination drug regimens for tuberculosis.

1 :
A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)

2 :
A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

4 :
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

5 :
A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the clients chest, the nurse should expect to hear which of the following sounds?

6 :
A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax?

7 :
A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

8 :
The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

10 :
A nurse is caring for a client who has tuberculosis and is about to start taking pyrazinamide. The nurse should identify that the client needs which of the following tests while taking this medication therapy?

1 : A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)

2 : A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

4 : A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

5 : A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the clients chest, the nurse should expect to hear which of the following sounds?

6 : A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax?

7 : A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

8 : The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

9 : A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

10 : A nurse is caring for a client who has tuberculosis and is about to start taking pyrazinamide. The nurse should identify that the client needs which of the following tests while taking this medication therapy?

1 :
A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)

2 :
A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

4 :
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

5 :
A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the clients chest, the nurse should expect to hear which of the following sounds?

6 :
A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax?

7 :
A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

8 :
The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

10 :
A nurse is caring for a client who has tuberculosis and is about to start taking pyrazinamide. The nurse should identify that the client needs which of the following tests while taking this medication therapy?