CAQs medsurg assn #3
A client has a closed chest drainage system in place. What should the nurse do to determine the amount of chest tube drainage? 1 Refer to the date and time markings on the outside of the collection chamber. 2 Aspirate the drainage from the collection chamber. 3 Replace the existing system with a new one to access the drainage in the existing system. 4 Clamp the chest tube and empty the fluid from the collection chamber.
1
A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement? 1 Auscultate the lungs. 2 Obtain arterial blood gases. 3 Notify the healthcare provider. 4 Apply pressure to the abdomen.
1
A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, what should the nurse do? 1 Provide a means for the client to write 2 Allow the client more time for articulation 3 Use visual clues, such as gestures and objects 4 Face the client and speak slowly and distinctly
1
Which diagnostic test would the nurse consider to be the gold standard for diagnosis of pulmonary embolism? 1 Pulmonary angiography 2 Helical computed tomography (CT) 3 Ventilation-perfusion (V/Q) scans 4 Computed tomography pulmonary angiography (CT-PA)
1
Which would the nurse consider to be a potential respiratory system-related complication of surgery? 1 Atelectasis 2 Hyperthermia 3 Wound dehiscence 4 Hypovolemic shock
1
While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? 1 Initiate oxygen via a nasal cannula 2 Administer the prescribed morphine 3 Prepare the client for endotracheal intubation 4 Place a nitroglycerin tablet under the client's tongue
1
A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? 1 Bradycardia 2 Restlessness 3 Constricted pupils 4 Clubbing of the fingers
2
A nurse provides smoking-cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client makes which statement? 1 "I'll just finish the carton that I have at home." 2 "I'll cut back to a half pack a day." 3 "I find that smoking is the only way I can relax." 4 "I should find this easy because I don't smoke when I drink."
2
Which parameter describes the maximum volume of air that the lungs can contain? 1 Vital capacity 2 Total lung capacity 3 Inspiratory capacity 4 Functional residual capacity
2
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? 1 Decrease in red cell formation 2 Rupture of emphysematous bullae 3 Depression in the respiratory center 4 Excessive drying of the respiratory mucosa
3
A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take? 1 Put on a gown when entering the room 2 Place the client with another client who has TB 3 Wear a particulate respirator when caring for the client 4 Don a surgical mask with a face shield when entering the room
3
Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? 1 Administering oxygen 2 Using an incentive spirometer 3 Having the client breathe into a paper bag 4 Administering an IV containing bicarbonate ions
3
Which criteria should the primary healthcare provider use for the prescription of long-term continuous oxygen therapy? 1 PaO2-72, SpO2- 96 2 PaO2-60, SpO2- 90 3 PaO2-55, SpO2- 88 4 PaO2-40, SpO2- 75
3
Which sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs? 1 Vesicular 2 Bronchial 3 Adventitious 4 Bronchovesicular
3
A client is transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection. In what position should the nurse place the client to facilitate respirations and promote comfort? 1 Sims 2 Lateral 3 Orthopneic 4 Semi-Fowler
4
A nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli and improved oxygenation? 1 "The alveoli need oxygen to live." 2 "The alveoli have no direct effect on oxygenation." 3 "Collapsed alveoli increase oxygen demands." 4 "Oxygen is exchanged for carbon dioxide in the alveolar membrane."
4
Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. What should the nurse instruct the client about the purpose of pursed-lip breathing? 1 Decreases chest pain 2 Conserves energy 3 Increases oxygen saturation 4 Promotes elimination of CO2
4
During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the lungs. Which sound should the nurse document in the medical record? 1 Dull 2 Flat 3 Tympany 4 Resonance
4
Which client would have relatively smaller tidal volumes due to limited chest wall movement? 1 A client with asthma 2 A client with pneumonia 3 A client with pulmonary fibrosis 4 A client with phrenic nerve paralysis
4
Which diagnostic test may be used to distinguish vascular from nonvascular structures? 1 Chest X-ray 2 Pulmonary angiogram 3 Computed tomography 4 Magnetic resonance imaging
4
Which pulmonary function test provides a more sensitive index of obstruction in smaller airways? 1 Forced vital capacity 2 Functional residual capacity 3 Forced expiratory volume in 1 second 4 Forced expiratory flow over the 25% to 75% volume of the forced vital capacity
4
Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? 1 Peak expiratory flow rate 2 Forced vital capacity 3 Forced mid-expiratory flow rate 4 Forced expiratory volume/forced vital capacity ratio
4
A client comes to the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response? 1 "Cover your cough with your forearm." 2 "Dispose of used paper tissues in a paper bag." 3 "Encourage your roommate to get the flu vaccine." 4 "Move out of your apartment until you are over the cold."
1
The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique? 1 Arterial oxygen saturation 2 Partial pressure of oxygen in arterial blood 3 Partial pressure of arterial carbon dioxide 4 Partial pressure of oxygen in venous blood
1
A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? 1 Curing the condition permanently 2 Raising mucous secretions from the chest 3 Limiting pulmonary secretions by decreasing fluid intake 4 Convincing the client that the condition is emotionally based
2
After abdominal surgery, a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by what method? 1 Postural drainage 2 Pursed-lip breathing 3 Incentive spirometry 4 Sustained exhalation
3
The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care? 1 Careful monitoring for crepitus 2 Bed rest with range-of-motion exercises 3 Coughing and deep breathing every hour 4 Covering the chest tube site with a sterile dressing
3
Which statement is true regarding the Hering-Breuer reflex? 1 Increases tidal volume 2 Decreases respiratory rate 3 Prevents overdistension of the lungs 4 Reduces the number of functional alveoli
3
A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? 1 Distended neck veins 2 Paradoxical respirations 3 Increasing amounts of purulent sputum 4 Absence of breath sounds over the affected area
4
A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? 1 Slow, deep respirations 2 Normal oral temperature 3 Dry, unproductive cough 4 Diminished breath sounds
4
A client returns from a radical neck dissection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? 1 Cloudy wound drainage 2 Absence of the gag reflex 3 Decreased urinary output 4 Restlessness with dyspnea
4
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? 1 Hypocapnia 2 Hyperkalemia 3 Generalized anemia 4 Respiratory acidosis
4
A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? 1 Retrospective 24-hour calorie count 2 Elimination pattern during the last 30 days 3 Complete gynecological and sexual history 4 Presence of a cough and pulmonary secretions
4
What order would the nurse follow for the assessment of the pharynx in a client with a respiratory disorder?
The assessment of the pharynx begins with an inspection of the mouth. By using a tongue depressor, the posterior pharynx and the rise and fall of the soft palate are observed. The next step is to assess for edema or ulceration and the symmetry of the enlarged tonsils. The neck is inspected for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. The last step is to palpate the lymph nodes for size, shape, mobility with palpation, consistency, and tenderness.
