Which statement by the client indicates a need for further education regarding the home care instructions for acute sinusitis?
"I will need surgery to drain my sinuses."
A nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which of the following is noted in the client?
Abdominal distention
A nurse is assisting in caring for a client with an endotracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause?
Accumulation of secretions in the client's lungs
A nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further instruction about its use if the client says she must:
After maximal inspiration, hold the breath for 10 seconds and then exhale
The nurse is assessing a client who has frequent episodes of asthma. Which assessment finding is most closely associated with asthma?
Bilateral wheezing
A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage and expects to note that it is:
Bloody
A nurse positions a client for a surgical procedure. Which position can likely lead to the potential for decreased lung expansion in the client?
Lithotomy
A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse would:
Notify the registered nurse.
A client with pneumonia is admitted to the hospital, and the health care provider writes prescriptions for the client. Which of the following prescriptions written by the health care provider would the nurse complete first?
Obtain a culture and sensitivity of sputum.
A nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. What equipment would the nurse plan to have at the bedside when the client returns from surgery?
Obturator
A nurse is assigned to care for a client after a left pneumonectomy. Which one of the follow positions would be contraindicated for this client?
On the side
A nurse is caring for the restless client who keeps biting down on an orotracheal tube. The nurse uses which of the following to prevent the client from obstructing the airway with the teeth?
Oral airway
A client with a respiratory disorder has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if the client:
Planned to eat the largest meal of the day at a time when hungry
A nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse tells the client that the primary purpose of pursed lip breathing is to:
Promote carbon dioxide elimination.
A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply.
Protect the stoma from water. Soaps should be avoided near the stoma. Wash the stoma daily using a washcloth. Apply a thin layer of petroleum jelly to the skin surrounding the stoma.
Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. Which of the following would the nurse suggest to include in the client teaching plan regarding this medication?
Return to the clinic weekly for serum drug levels.
A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position?
Right lateral
A nurse determines that which of the following clients is at greatest risk for development of acute respiratory distress syndrome (ARDS)?
A client with pancreatitis and gram-negative sepsis
A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which of the following signs and symptoms?
Dyspnea
A nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?
A man who is an inspector for the U.S. Postal Service
A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which of the following as the best action to ensure accurate readings on the oximeter?
Ask the client to limit motion in the hand attached to the pulse oximeter.
A nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection?
Chills and night sweats
A nurse is collecting subjective and objective assessment data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which of the findings?
Complaints of night sweats
A client experiencing a pleural effusion had a thoracentesis. Analysis of the extracted fluid revealed a high red blood cell count. The nurse interprets that this result is consistent with:
Trauma
A nurse is collecting respiratory data from an adult client and is auscultating for normal breath sounds. The nurse would expect to hear bronchial breath sounds in which anatomical area? Refer to figure.
1
A nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the client's bed in which position to effectively perform this procedure? Refer to figure.
1
A nurse is suctioning a client through a tracheostomy tube. The nurse plans to apply suction during the withdrawal of the catheter for a period of time no greater than:
10 seconds
A nurse is caring for a client with emphysema who is receiving oxygen. The nurse checks the oxygen flow rate to ensure that it does not exceed:
2 L/min
A nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate?
Continue to monitor, because this is an expected finding.
A nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations are made?
Coughing occurs with suctioning.
A nurse is discussing signs of severe airway obstruction with a group of nursing students. Which one of the following signs would the nurse emphasize is one that indicates severe airway obstruction?
Cyanosis
A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in this client? Select all that apply.
Dyspnea on exertion Presence of a productive cough Difficulty breathing while talking
A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when:
Aspiration of gastric contents occurs when suctioning.
A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The immediate nursing action is to:
Assess the client.
A client arrives in the emergency department with a bloody nose. What is the initial nursing action?
Assist the client to a sitting position with the head tilted slightly forward
A nurse in the emergency department is listening to the breath sounds of a client with respiratory distress and hears this sound. (Click on the sound icon.) The nurse determines that this finding is characteristic of which disorder?
Bronchitis
A nurse evaluates the client following treatment for carbon monoxide poisoning. The nurse would document that the treatment has been successful when the:
Carboxyhemoglobin levels are less than 5%.
A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. The nurse would first:
Check the client for spontaneous breathing.
The nurse is collecting data on a client with chronic airflow limitation (CAL) and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of CAL?
Emphysema
A client has the following laboratory values: pH of 7.55, HCO3 of 22 mm Hg, and a Pco2 of 30 mm Hg. What should the nurse do?
Encourage the client to slow down his breathing.
A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse plans to tell the client that this is:
Expected and the client should very gradually increase activity as tolerated
A nurse reads a client's Mantoux skin test as positive. The nurse notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse's response is based on the understanding that the client has:
Exposure to tuberculosis
A nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which of the following adverse signs and symptoms, indicating acute pulmonary edema?
Frothy sputum
A client presents to the urgent care center with epistaxis but no obvious facial injury. The nurse should take which action first?
Have the client sit down, lean forward, and apply pressure to the nose.
A client who has laryngeal nodules is scheduled for outpatient surgery to have them removed. The nurse collects data on the client and expects the client to complain of which typical symptom associated with this condition?
Hoarseness
A male client with chronic obstructive pulmonary disease (COPD) on bedrest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, what is the priority client activity for the nurse to incorporate in the plan of care?
Instruct the client to reposition himself.
The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope:
Just under the left clavicle
A nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which of the following items during periods of exposure to silica particles?
Mask
A nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. What should the nurse do?
Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.
A nurse is reading the results of a Mantoux skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that the result is:
Negative
A nurse is reading the results of the Mantoux skin test for a client who has no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that the result is:
Negative
A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which of the following results, which are consistent with this disorder?
Pao2 49 mm Hg, Paco2 52 mm Hg
A nurse is preparing to assist a health care provider with the insertion of a chest tube. The nurse anticipates that which of the following supplies will be required for the chest tube insertion site?
Petrolatum (Vaseline) gauze
A nurse is assisting in caring for a client with a chest tube. The nurse understands that which of the following is an incorrect action for the care of the client?
Pin the tubing to the bed linens.
A nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure?
Places the stethoscope on the client's gown
Arterial blood gases (ABG) are obtained on a client with pneumonia. The ABG results are pH, 7.50; PCO2, 30 mm Hg; HCO, 20 mEq/L; PO2, 75 mm Hg. The nurse interprets these results and determines that which of the following acid-base conditions exists?
Respiratory alkalosis
A nurse is collecting data on a client with chronic sinusitis. The nurse interprets that which of the following client manifestations is unrelated to this problem?
Severe evening headache
A nurse is providing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation?
Shortness of breath
An emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign, if noted in the client, would indicate the presence of a pneumothorax?
Shortness of breath
A nurse is monitoring a client following a motor vehicle accident. The nurse determines the need to prepare for chest tube insertion when the client exhibits:
Shortness of breath and tracheal deviation
A client with arthritis of the hands and fingers is having difficulty using a metered-dose inhaler (MDI). The nurse suggests to ask the health care provider for a prescription to use a(n):
Spacer
Which of the following identifies the route of transmission of tuberculosis (TB)?
The airborne route
A nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse interprets that:
The behavior is likely the result of hypoxia.
A nurse is assessing the chest tube drainage system of a postoperative client who had a right upper lobectomy. The closed drainage system has 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water-seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water-seal chamber is now constant and the client appears dyspneic. Based on these findings, the nurse should first check:
The chest tube connections
A nurse teaches a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client?
The client is breathing through the nose.
A client with tuberculosis (TB) asks a nurse about precautions to take after discharge from the hospital to prevent transmitting infection of others. The nurse develops a response to the client's question, based on the understanding that:
The disease is transmitted by droplet nuclei.
A nurse is preparing to perform chest physiotherapy (CPT) on a client. Before determining the correct position in which to place the client, the nurse must ascertain:
The lung areas involved
A client reports the chronic use of nasal sprays. The nurse provides instructions to this client about which piece of information related to chronic use of nasal sprays?
The protective mechanism of the nose may be damaged.
The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene?
The student suctions the client's tracheotomy tube for 15 seconds.
A nurse is assisting a health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan to ensure that which of the following is done as a final measure to determine correct tube placement?
Verify placement by a chest x-ray.
A nursing student is caring for a hospitalized client with a diagnosis of lung cancer. The health care provider has prescribed a partial rebreathing face mask for the client, and the nursing instructor asks the student about its purpose. The student correctly responds by stating that:
"The device conserves oxygen by having the client rebreathe her own exhaled air."
A nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which of the following data will not be needed by the laboratory for adequate evaluation of the specimen?
A list of client allergies
A client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. The nurse determines that which of the following accurately indicates effectiveness of the treatments prescribed for this problem?
Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, Pco2 of 40 mm Hg.
A nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator of the effectiveness of suctioning?
Breath sounds are now clear.
A nurse is collecting data from a client with pneumonia. Chest auscultation over areas of consolidation reveals this breath sound. (Click on the sound icon.) The nurse would interpret this breath sound to be which of the following?
Bronchial breath sounds
A nurse has finished suctioning a client. The nurse would use which of the following parameters to best determine the effectiveness of suctioning?
Clear breath sounds
A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on the understanding that:
Discomfort may occur with needle insertion, and there is minimal exposure to radiation.
A nurse is assisting a health care provider with the insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse plans to take which appropriate action?
Document the accurate functioning of the tube.
A client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which of the following should be instituted immediately by the nurse?
Droplet precautions
A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.
Early onset cough Purulent mucus production Mild episodes of dyspnea
A nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which of the following coexisting problems?
Hypotension
A nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which action first?
Immerse the end of the tube in sterile saline.
A client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. In addition to respiratory failure, the nurse plans to monitor the client for which of the following complications of this disorder?
Increased intracranial pressure
A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which of the following medications to the client in the last hour?
Lorazepam (Ativan)
A client is being prepared for a thoracentesis. The nurse assigned to care for the client assists the client to which of the following positions for the procedure?
Lying in bed on the unaffected side with the head of the bed elevated 45 degrees
A client has a chest tube that is attached to a chest drainage system. The client asks the nurse, "Can the tube come out faster if you turn the wall suction up higher?" The nurse's response is based on the understanding that turning up the wall suction would
Not increase the actual suction in the system but would cause more air to be pulled through the air vent and suction chamber to the suction source
A nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse would incorporate which of the following as the best strategy to assist the client in coping with the disease?
Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.
A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse should do which of the following after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour?
Refrigerate the specimen.
A nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention should be included? Select all that apply.
Rest Local heat Analgesics
A nurse is providing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic periods. Which position will the nurse instruct the client to assume?
Sitting on the side of the bed, leaning on an overbed table
A nurse is assisting in admitting a client to the emergency department with suspected carbon monoxide poisoning. The nurse understands that which of the following manifestations is least reliable for determining the oxygenation status of this client?
Skin color
A nurse is suctioning a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. The nurse should:
Stop the procedure and oxygenate the client
A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, what interpretation should the nurse make
The client should be repeating the sequence 10 to 20 times in each session.
A client has a closed-chest tube drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets that:
The tube is patent.
A nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. The nurse determines that which of the following is occurring?
There is an air leak somewhere in the system.
A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which of the following signs or symptoms observed by the nurse clearly indicates that the pneumothorax is rapidly worsening?
Tracheal deviation to the right
The low-exhaled volume (low-pressure) alarm sounds on a ventilator. A nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. The immediate nursing action is to:
Ventilate the client with a resuscitation bag.
A client receiving parenteral nutrition through a central intravenous line is exhibiting signs and symptoms of an air embolism. The nurse immediately places the client in which position?
Left side in Trendelenburg's
A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which of the following positions for the procedure?
Left side-lying with the head of the bed elevated 45 degrees
A client being discharged from the hospital to home with a diagnosis of tuberculosis (TB) is worried about the possibility of infecting the family and others. The nurse determines that the client would get the most reassurance from the knowledge that:
The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.
