ATI Respiratory

Nurse is providing preop teaching to a client who is undergo a pneumonectomy. The client states I am afraid it will hurt to cough after the surgery. Which statement by the nurse is appropriate? after the surgeon removes the lung, you will not need to cough. I'll make sure you get a cough suppressant to keep you from straining the incision when you cough. Don't worry. You will have a pump that delivers pain med as you need it, so you will have very little pain. I will show you how to splint your incision

"I will show you how to splint your incision while coughing." The client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint her incision to reduce pain when coughing.

A nurse is providing discharge teaching to a client who is post op following a rhinoplasty. Which instruction should the nurse include? Apply warm compress to the face take aspirin 650 mg by mouth for mild pain close your mouth when sneezing lie on your back with your head elevated 30° when resting

"Lie on your back with your head elevated 30° when resting." The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.

Nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include? if the test is positive , It means you have an active case of tuberculosis if the test is positive, you should have another tuberculin skin test in three weeks you must return to the clinic to have the test read in two or three days a nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance

"You must return to the clinic to have the test read in 2 or 3 days." The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hr indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hr, another tuberculin skin test is necessary.

"A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?" A room with air exhaust directly to the outdoor environment A room with another nonsurgical client A room in the ICU A room that is within view of the nurse's station

A room with air exhaust directly to the outdoor environment

Nurse in the ED is assessing a client for a closed pneumothorax and significant bruising of the chest following a motor vehicle crash. Client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? Absence of breath sounds expiratory wheezing inspiratory strider rhonchi

Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.

Nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? Orthopnea Cheyne-Stokes paradoxical Kussmaul

Cheyne-Stokes Cheyne-Stokes respiration is a breathing pattern of deep shallow breaths (Hyperventilation) followed by periods of apnea. Cheyne-Stokes respiration can be the result of a drug overdose or increased intracranial pressure and can proceed death.

Nurse prepping client for discharge following a bronchoscopy. Which of the following assessments is the nurses monitoring priority? Measuring heart rate palpitating peripheral pulses observing sputum for blood confirming gag reflex

Confirming gag reflex The greatest risk to the client safety is aspiration resulting from a depressed gag reflex. The nurses priority is to make sure the client care reflex has returned before discharge that client can maintain hydration and nutrition without risk.

"A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?" Unequal pupils Hypertension Tympany upon chest percussion Confusion

Confusion

Client admitted to ED after motorcycle crash. Nurse notes crackling sensation upon palpation on the right side of clients chest. After notifying the provider, the nurse should document is finding as which of the following? Friction rub crackles crepitus tactile fremitus

Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.

"A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?" Decreased serum calcium level Decreased level of serum lipids Decreased erythrocyte sedimentation rate (ESR) Increased platelet count

Decreased serum calcium level

Nurse in an urgent care clinical is collecting data from a client who reports exposure to anthrax. Which finding is an indication of the prodromal stage of inhalation anthrax? Dry cough rhinitis sore throat swollen lymph nodes

Dry cough A dry cough is a clinical manifestation found in the prodromal stage of having inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis.

Nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? Eat high calorie foods first increase intake of water at meal times perform active range of motion exercises before meals keep saltine crackers nearby for snacking

Eat high-calorie foods first. The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first.

Caring for a client with a positive Mantoux skin test following screening for tuberculosis. The nurse should inform the client that this positive reaction indicates which of the following findings? Client has never been exposed to TB the client had infectious TB in the past, but the infection is not active the client has active TB further evaluation is required

Further evaluation is required A positive Mantoux skin test indicates only that the client has been exposed to TB. Further evaluation will be needed through the use of sputum cultures and chest x-rays.

Nurse monitoring newly licensed nurse caring for client with active pulmonary TB. Client was placed on airborne precautions and is scheduled for a chest x-ray. Nurse should instruct newly licensed nurse to take which of the following actions? Have client wear a surgical mask wear a gown for protection from the clients infection ask the radiology staff to perform a portable chest x-ray in the clients room place an N95 respirator on the client

Have client wear a surgical mask Nurse should instruct the client to wear a surgical mask, which will protect anyone who comes into contact with a client, including the nurse.

Nurse caring for a client one day postop who has developed atelectasis. Which manifestation is an expected finding for this condition? Apnea dysphasia hypoxemia plural effusion

Hypoxemia

Nurse caring for a client who has tuberculosis and is taking rifampin. Which of the following client statements should indicate to the nurse that the client is experiencing an adverse effect of the medication? I have noticed my urine is orange in color I sleep more than I used to my tongue and mouth are sore my voice seems hoarse

I have noticed my urine is orange in color The nurse should identify that an adverse effect of rifampin can be red orange colored urine, saliva, sweat and tears as the medication is excreted from the body. The nurse should also inform the client that permanent standing of contact lenses can occur. However, this adverse effect is harmless. The client should inform the provider if urine becomes dark in color since this can be an indication of hepatotoxicity.

Nurse teaching a client with COPD about ways to facilitate eating. Which statement indicates a need for further teaching? I will rest at least 30 minutes before eating I will take my bronchodilators after meals I will eat five or six meals each day I will choose foods that are not gas forming

I will take my bronchodilators after meals

Nurse admitted client with manifestations that suggest tuberculosis. Which action is nurses priority? Initiate airborne precautions administer antimicrobial therapy tell client that infection will be communicable for 2 - 3 weeks from start of medication therapy teach client about manifestations of tuberculosis

Initiate airborne precautions Nurse should apply safety and risk reduction priority setting framework. Airborne precautions prevent transmission of pathogens that remain infectious in the air, including mycobacterium tuberculosis, which causes tuberculosis

Nurse caring for a client who has tuberculosis and new prescription for rifampin and pyrazinamide. Which lab test should nurse instruct the client will be required while on this medication regiment? Liver function test gallbladder studies thyroid function studies blood glucose levels

Liver function test

Nurse assessing client with multi drug resistant tuberculosis and takes ethambutol. The nurse should identify which of the following findings as an adverse effect of this medication? mottling of the extremities orange red urine and bodily secretions yellowing of the sclera loss of red/green color discrimination

Loss of red/green color discrimination Ethambutol is an anti-tubercular medication that impairs Ribonucleic acid synthesis. A common adverse reaction is the loss of red/green color discrimination due to optic neuritis. The nurse should notify the provider of this finding and expect to discontinue the medication.

Nurse in a providers office is assessing a client who states he was recently exposed to tuberculosis. Which is a clinical manifestation of pulmonary tuberculosis? Pericardial friction rub weight gain night sweats cyanosis of the fingertips

Night sweats Night sweats and fevers are clinical manifestations of tuberculosis.

Nurse in a providers office is assessing a client. Nurse should identify which findings as pulmonary tuberculosis? SATA night sweats low-grade fever weight gain flushed cheeks blood in the sputum

Night sweats low-grade fever blood in the sputum

Nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? Assist the client the floor perform an abdominal thrust open the airway with a head chin-tilt observe the client closely

Observe the client closely The nurse should observe the client closely at this point in time. As long as a client is able to cough strongly, the nurse does not need to intervene.

Nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. Nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which finding is a clinical manifestation of acute respiratory distress syndrome (ARDS)? Tympanic temp 100.4F PaO2 50 mmHg Rhonchi Hypopnea

PaO2 50mmHg Client has manifestations of ARDS. They have a low PaO2 level, even after the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS.

Nurse is preparing to assist provider to withdraw arterial blood from a clients radial artery for ABG measurements. Which action should the nurse take? Hyperventilate the client with 100% oxygen prior to obtaining specimen apply ice to the site after obtaining specimen perform an Allen's test prior to obtaining specimen release pressure applied to the puncture site one minute after the needle is withdrawn

Perform an Allen's test prior to obtaining the specimen. The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? Obtain a cardiology consult Suction the client less frequently Administer an antidysrhythmic medication Perform pre-oxygenation prior to suctioning

Perform pre-oxygenation prior to suctioning

"A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?" Perform the suctioning for up to four passes Apply suction to the catheter when advancing it into the trachea Preoxygenate the client with 100% oxygen for up to 3 min Limit each suction pass to 25 seconds

Preoxygenate the client with 100% oxygen for up to 3 min

Nurse is providing instructions about pursed lip breathing for a client who has COPD with emphysema. The nurse should explain that this breathing technique accomplishes which of the following? Increases oxygen intake promotes carbon dioxide elimination uses the intercostal muscles strengthens the diaphragm

Promotes carbon dioxide elimination The client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.

"A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication?" Constipation Black-colored stools Staining of teeth Red-colored urine

Red-colored urine

Nurse is caring for client w/ COPD and pneumonia. The nurse should monitor for which of the following acid base imbalances? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.

Nurse caring for a client who has been taking Isoniazid and rifampin for three weeks for the treatment of active pulmonary tuberculosis (TB). Client reports his urine is an orange color. Which of the following statements should the nurse make? Stop taking isoniazid for 3 days, and the discoloration should go away Rifampin can turn body fluids a reddish-orange I'll make an appointment for you to see the provider this afternoon isoniazid can cause bladder irritation m

Rifampin can turn body fluids a reddish-orange Rifampin can cause body fluids such as tears, sweat, saliva, and urine to turn a reddish orange color. The nurse should inform the client that this affect does not cause harm

Nurse is preparing a client for a thoracentesis. Which position should the nurse place the client? Lying flat on the affected side prone with the arms raised above the head supine with the head of the bed elevated sitting while leaning forward over the bedside

Sitting while leaning forward over the bedside table When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the client's ribs and allows for aspiration of accumulated fluid and air.

A nurse on a MedSurg unit is assessing a client. Nurse should identify which of the following findings as a manifestation of pulmonary embolism? Stabbing chest pain, respiratory distress and cyanosis calf tenderness elevated temperature bradycardia

Stabbing chest pain, respiratory distress and cyanosis Manifestation of pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and feeling of impending doom

Nurse on a MedSurg unit is caring for a client post up following a hip replacement surgery. Client reports feeling apprehensive and restless. Which findings should the nurse recognize as an indication of pulmonary embolism? Sudden onset of dyspnea tracheal deviation bradycardia difficulty swallowing

Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.

Nurse is planning care for a client following placement of a chest tube one hour ago. Which action should the nurse include in the plan of care? Clamp the chest tube if there is continuous bubbling in the water seal chamber keep the chest tube drainage system at the level of the right atrium tape all connections between the chest tube and drainage system empty the collection chamber and record the amount of drainage every 8hr

Tape all connections between the chest tube and drainage system. The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting.

Nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which point should the nurse plan to discuss first? How to eliminate environmental triggers that precipitate attacks the clients perception of the disease process and what might have triggered past attacks the clients medication regiment manifestations of respiratory infections

The client's perception of the disease process and what might have triggered past attacks The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client's current knowledge.

Nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which finding indicates nurse should suction the clients airway secretions? Client is unable to speak clients airway secretions were last section 2 hours ago client coughs and expectorates a large mucous plug nurse auscultates course crackles in the lung fields

The nurse auscultates coarse crackles in the lung fields. The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.

Nurse is preparing to administer cisplatin IV to a client with lung cancer. The nurse should identify which findings as an adverse effect of this medication? Hallucinations pruritus hand and foot syndrome tinnitus

Tinnitus An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.

Nurse is teaching about daily chest physiotherapy with a client who has cystic fibrosis. Nurse should instruct client that which of the following is the purpose of the treatment? To encourage deep breaths to mobilize secretions in the airways to dilate the bronchioles to stimulate the cough reflex

To mobilize secretions in the airways The purpose of chest physiotherapy is to loosen the client's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity.

Nurse is providing teaching to a client about pulmonary function test. Which of the following test measures the volume of air in the lungs can hold at the end of maximum inhalation? Total lung capacity vital lung capacity functional residual capacity residual volume

Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.

True or False: the nurse should administer the abdominal thrust to a choking pt

True

True or false the nurse in trauma assess airway first on a client who has multiple injuries following a motor vehicle crash.

True

Nurse caring for a client hospitalized with active pulmonary tuberculosis and it started on ethambutol therapy. Nurse should understand that which of the following should be monitored? Visual acuity skin color urine output cardiac rhythm

Visual acuity

"A nurse is planning care for a client who requires precautions. Which of the following actions should the nurse take?" Provide a positive pressure airflow room Wear an N95 respirator mask Allow the client to ambulate in the hall Stand 1.8 m (6 feet) away from the client

Wear an N95 respirator mask

Nurse is instructing a client who is newly diagnosed with TB about the use of anti-tubercular medication's. Which of the following information should the nurse include in the teaching? Medication will need to be taken for the rest of the clients life, even if the client feels better medication's will need to be taken until the Manitoux test is negative a typical course treatment involves 6 to 9 months of consistent medication use clients family will also need to take medication to prevent infection

a typical course treatment involves 6 to 9 months of consistent medication use

Which nurse receives notification of admission for a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which action should the nurse take? SATA assign client to a private room with negative pressure airflow add contact precaution to the clients plan of care wear N95 respirator when entering clients room ensure clients environment provides 4 exchanges of fresh air per minute institute protective environment precautions as soon as the client arrives on the unit

assign client to a private room with negative pressure airflow wear N95 respirator when entering clients room This clients history and present status suggest tuberculosis. Airborne precautions mandate private room with negative air pressure and require wearing N95 respirator when entering clients room

Nurse caring for a client suspected to have tuberculosis. Which finding should the nurse expect? Recent weight gain high fever rhinitis blood streaked sputum

blood streaked sputum Nurse should expect blood streaked sputum in a client with tuberculosis. Sputum cultures are used to diagnose pulmonary tuberculosis

Charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? Client with scabies client with pertussis client with streptococcal pharyngitis client with measles

client with measles

Nurse providing dietary teaching for a client with COPD. Which instruction should nurse include in the teaching? Eat at least 3 well proportioned large meals a day drink low protein low calorie nutrition formulas between meals avoid adding gravies and sauces to foods consume foods that are soft in texture and easy to chew

consume foods that are soft in texture and easy to chew

Nurse is assisting client who is eating at meal time. Suddenly the client grabs her neck with both hands and appears frightened. Which action should the nurse take first? Place an oxygen mask on the client check the clients pulse determine whether the client is able to breathe wrap arms around the client from behind

determine whether the client is able to breathe Caring for this client requires application of nursing process priority setting framework. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client status, the nurse must first collect adequate data from the client. This client is demonstrating a universal choking gesture. If the client is unable to move air in or out, severe airway obstruction is present. The client would need emergency interventions to clear a partial obstruction, as indicated by stride or minimal airway passage. As long as there is good air exchange and the client can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition.

Nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin , And pyrazinamide. Which of the following instructions should the nurse include? Take isoniazid with an antacid provide a sputum specimen every two weeks to the clinic for testing expect your sputum cultures to be negative after six months of therapy drink at least 8 ounces of water when you take pyrazinamide tablet

drink at least 8 ounces of water when you take pyrazinamide tablet

Nurse assessing a client who has developed atelectasis postoperatively. Which finding should the nurse expect? Facial flushing increasing dyspnea decreasing respiratory rate friction rub

increasing dyspnea

Nurse developing plan of care for a client with COPD. Nurse should include which intervention in the plan? Restrict clients fluid intake to less than 2 L/day provide the client with a low protein diet have the client use the early morning hours for exercise and activity instruct the client to use pursed lip breathing

instruct the client to use pursed lip breathing

Nurse assessing client who has postop atelectasis and is hypoxic. Which manifestation should the nurse expect? Bradycardia bradypnea legarthy intercostal retractions

intercostal retractions