NUR 2243 Respiratory EAQs

NUR 2243 Respiratory EAQs
1. A client arrivesin the emergency department with multiple crushing wounds of the chest,
abdomen,and legs. Which are the priority nursing assessments?-
Answer
Quality of respirations and presence of pulses
2. A client is extubated in the postanesthesia care unit aftersurgery.For which common response
should the nurse be alert when monitoring the client for acute respiratory distress?
Answer
Restlessness
3. What order would the nurse follow for the assessment of the pharynx in a client with a
respiratory disorder?
Answer
1.
Inspect the mouth.
Observe the rise and fall of the soft palate.
Assess the symmetry of enlarged tonsils, if present. Inspect the neck symmetry.
Palpate the lymph nodes.
4. The nurse is providing postoperative care to a client with lung cancer
who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes
puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels
spongy and crackles can be felt. How does the nurse describe this assessment finding?
Answer
Subcutaneous emphysema