Learning System: Respiratory

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of the medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome D. Tinnitus

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

A nurse in the emergency department is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Ronchi

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

A nurse in an urgent care clinical is collecting data from a patient who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes

A. 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.

A nurse is planning care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat high-calorie foods first B. Increase intake of water at meal times C. Perform active range-of-motion exercises before meals D. Keep saltine crackers nearby for snacking

A. Eat high-calorie foods first - Although it is important for a client who has COPD to maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the client should limit intake of water at mealtimes to reduce the feeling of early satiety.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the follow findings should the nurse recognize as an indication of a pulmonary embolism (PE)? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

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

A nurse is providing teaching to a patient about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

A. 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.

A nurse on a medical unit is caring for a patient who apirated gastric contents prior to admission. The nurse administers 100% oxygen by nonbreather mask after the patient reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. Tympanic temperature of 38 C (100.4 F) B. PaO2 50 mm Hg C. Rhonchi D. Hypopnea

B. PaO2 50 mm Hg - The patient who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS. -The client who has ARDS will have clear breath sounds because edema occurs in the interstitial spaces and not in the airway. -The client who has ARDS will manifest hyperpnea

A nurse is providing instructions about pursed-lip breathing for a patient who has COPD with emphysema. The nurse should explain that this breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphram

B. Promotes carbon dioxide elimination - A patient 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 patient'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 an older adult client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

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

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. How to eliminate environmental triggers that precipitate attacks B. The client's perception of the disease process and what might have triggered past attacks C. The client's medication regimen D. Manifestations of respiratory infections

B. 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 the knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client's current knowledge.

A nurse is teaching about daily chest physiotherapy with a client who has cystic fibrosis. The nurse should instruct the client that which of the following is the purpose of the treatments? A. To encourage deep breaths B. To mobilize secretions in the airways C. To dilate the bronchioles D. To stimulate the cough reflex

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

A 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? A."If the test is positive, it means you have an active case of tuberculosis." B. "If the test is positive, you should have another tuberculin skin test in 3 weeks." C. "You must return to the clinic to have the test read in 2 or 3 days." D. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."

C. "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 patient is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the patient's chest. After notifying the provider, the nurse should document the finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

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

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips

C. Night sweats - Night sweats, fevers, anorexia and weight loss are clinical manifestations of tuberculosis. -A pericardial friction rub is a clinical manifestation of rheumatic carditis. -Cyanosis of the fingertips is a clinical manifestation of Raynaud's disease.

A nurse is preparing to assist a provider to withdraw arterial blood from a patient's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? A. Hyperventilate the patient with 100% oxygen prior to obtaining the specimen. B. Apply ice to the site after obtaining the specimen. C. Perform an Allen's test prior to obtaining the specimen. D. Release pressure applied to the puncture site 1 minute after the needle is withdrawn.

C. 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 planning care for a patient following placement of a chest tube 1 hour ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuously bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all of the connections between the chest tube and the drainage system D. Empty the collection chamber and record the amount of drainage every 8 hours

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

The nurse is providing teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? A. "Apply warm compresses to the face." B. "Take aspirin 650 milligrams by mouth for mild pain." C. "Close your mouth when sneezing." D. "Lie on your back with your head elevated 30° when resting."

D. "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.

A nurse is providing preoperative teaching to a patient who is to undergo a pneumonectomy. The patient states "I am afraid it will hurt to cough after surgery." Which of the following statements by the nurse is appropriate? A. After the surgeon removes your lung you will not need to cough. B. I'll make sure you get a cough suppressant to keep you from straining the incision when you cough. C. Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain. D. I will show you how to splint your incision while you cough.

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

A nurse is caring for a patient who is scheduled for a thoracentesis. In which of the following positions should the nurse place the client? A. Lying flat on the affected side B. Prone with the arms raised over the head C. Supine with the head of the bed elevated D. Sitting while leaning forward over the bedside table

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

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following indicates that the nurse should suction the client's airway secretions? A. The client is unable to speak B. The client's airway secretions were last suctioned 2 hr ago C. The client coughs and expectorates a large mucous plug D. The nurse auscultates coarse crackles in the lung fields

D. 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.