Adult Nursing 2 - Quiz 2

A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching? - "Keep the humidity in your house low." - "Cover the stoma whenever you shower or bathe." - "Wear a tight cloth at the stoma to prevent anything from entering it." - "Swimming is good exercise after this surgery."

- "Cover the stoma whenever you shower or bathe."

A nurse enters a client's room and observes a container with sputum. Upon questioning about the specimen, which information from the client would necessitate the nurse to obtain a new specimen? - "The specimen is from a deep cough." - "I coughed that up about 8 hours ago." - "The lid is secured with tape." - "The container used is sterile."

- "I coughed that up about 8 hours ago."

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? - When secretions have mobilized - At bedtime - When bronchospasms occur - Immediately before a meal

- At bedtime

The health care provider has prescribed continuous positive airway pressure (CPAP) with the delivery of a client's high-flow oxygen therapy. The client asks the nurse what the benefit of CPAP is. What would be the nurse's best response? - CPAP allows for greater humidification of the oxygen that is given. - CPAP allows a lower percentage of oxygen to be used with a similar effect. - CPAP allows a higher percentage of oxygen to be safely used. - CPAP allows for the elimination of bacterial growth in oxygen delivery systems.

- CPAP allows a lower percentage of oxygen to be used with a similar effect.

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply. - Keep the nasal packing in place for 72 hours to help reshape the form of the nose. - Apply ice or cold compresses for 20 minutes every hour for the first 24 hours. - Check for any unusual changes in breathing during the first 48 hours. - Elevate the head of the bed for sleeping during the first week. - Observe for any clear drainage from either nostril. - Restrict from sports activities for 6 weeks.

- Check for any unusual changes in breathing during the first 48 hours. - Elevate the head of the bed for sleeping during the first week. - Observe for any clear drainage from either nostril. - Restrict from sports activities for 6 weeks.

A nurse is caring for an older adult with pneumonia. What are age-related structural and functional changes that occur in the respiratory system? Select all that apply. - Decreased pulmonary compliance - Decreased elasticity of the alveolar sacs - Increased residual volume - Increased diameter of alveolar ducts - Decreased dead space - Increased thickness of alveolar sacs

- Decreased elasticity of the alveolar sacs - Increased residual volume - Increased diameter of alveolar ducts - Increased thickness of alveolar sacs

A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample? - First thing in the morning - At bedtime - After a period of exercise - Immediately after a meal

- First thing in the morning

A nurse is caring for a client after a thoracotomy for a lung mass. What part of the client's care is the priority for the nurse? - Home care - Gas exchange - Anxiety - Impaired mobility

- Gas exchange

A medical nurse has admitted a client to the unit with a diagnosis of failure to thrive. The client has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the client's physician because these symptoms are suggestive of what? - Pneumothorax - Lung tumors - Infection - Pulmonary edema

- Infection

Which of the following are clinical manifestations associated with obstructive sleep apnea (OSA)? Select all that apply. - Insomnia - Excessive daytime sleepiness - Arrhythmias - Impotence - Loud snoring

- Insomnia - Excessive daytime sleepiness - Arrhythmias - Impotence - Loud snoring

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time? - Level of consciousness - Voice quality - Swallowing reflex - Anxiety

- Level of consciousness

A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem? - Laryngeal cancer - Chronic tonsillitis - Obstructive sleep apnea - Adenoiditis

- Obstructive sleep apnea

A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by - Maintaining a warm compress around the client's neck area - Removing the oral airway before the gag reflex has returned for client comfort - Sitting the client in the semi-Fowler's position - Placing the client prone with the head turned to the side

- Placing the client prone with the head turned to the side

The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids? - Presence of a cough and gag reflex - Ability to demonstrate deep inspiration - Oxygen saturation of ≥92% - Absence of nausea

- Presence of a cough and gag reflex

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to - Hold the breath for 5 seconds and then exhale. - Sit in an upright position only. - Initially inhale through the mouth. - Purse the lips when exhaling air from the lungs.

- Purse the lips when exhaling air from the lungs.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. - Regularly assess the client's vital signs every 2 to 4 hours. - Maintain an open airway. - Monitor and record hourly intake and output. - Monitor pulmonary status as directed and needed. - Encourage deep breathing exercises.

- Regularly assess the client's vital signs every 2 to 4 hours. - Monitor pulmonary status as directed and needed. - Encourage deep breathing exercises.

A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention? - Client dozing when left alone but awakening easily - Client stating pain level of 7 out of 10 that decreases with pain medication - Respiratory rate of 44 breaths/minute - Oxygen saturation level of 96% on 3 L of oxygen

- Respiratory rate of 44 breaths/minute

The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions.

- Semi-Fowlers

Which of the following interventions would be helpful for a client reporting nasal congestion, sneezing, sore throat, and muscle aches? Select all that apply. - Teach the client about hand-washing. - Provide warm salt-water gargles. - Recommend guaifenesin. - Refer the client to a physician for antibiotic therapy. - Administer oral ibuprofen.

- Teach the client about hand-washing. - Provide warm salt-water gargles. - Recommend guaifenesin. - Administer oral ibuprofen.

A client has had laryngeal surgery. What are the expected client outcomes? Select all that apply. - The client can swallow without difficulty. - The client's suture line remains intact. - The client can manage his or her own secretions. - The client maintains an adequate caloric intake. - The client's breathing patterns improve.

- The client's suture line remains intact. - The client can manage his or her own secretions. - The client maintains an adequate caloric intake.