Med Surg RESP Ques cont.
A client diagnosed with tuberculosis is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client? 1. This is expected and will last for at least 1 year. 2. This is expected, and the client should gradually increase activity as tolerated. 3. This is an unexpected finding with tuberculosis, but it should resolve within 1 month or so. 4. This is a short-lived problem that should be gone within 1 week after beginning drug therapy.
2. This is expected, and the client should gradually increase activity as tolerated.
A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain? 1. "It hurts more when I breathe in." 2. "I have never had this pain before." 3. "It hurts on the left side of my chest." 4. "The pain is about a 6 on a scale of 1 to 10."
1. "It hurts more when I breathe in."
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1. Water or a kink in the tubing 2. Biting on the endotracheal tube 3. Increased secretions in the airway 4. Disconnection or leak in the system 5. The client stops spontaneous breathing.
1. Water or a kink in the tubing 2. Biting on the endotracheal tube 3. Increased secretions in the airway
The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client? 1. Drink hot tea throughout the day. 2. Drink hot cocoa in place of coffee. 3. Avoid foods that are highly seasoned. 4. Restrict fluid intake to 1000 mL daily.
3. Avoid foods that are highly seasoned.
The clinic nurse administers a tuberculin (Mantoux) skin test to a client. The nurse tells the client to return to the clinic for reading the results in how long? 1. 6 to 12 hours 2. 12 to 24 hours 3. 24 to 28 hours 4. 48 to 72 hours
4. 48 to 72 hours
A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1. A disconnection of the ventilator tubing 2. An exaggerated client inspiratory effort 3. Accumulation of respiratory secretions 4. Generation of extreme negative pressure by the client
3. Accumulation of respiratory secretions
A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies? 1. Administration of plasma expanders, low-flow oxygen, and suctioning 2. Administration of bronchodilators, intubation, and mechanical ventilation 3. Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure 4. Administration of antihypertensives, high-flow oxygen, and continuous positive airway pressure mask
3. Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure
The 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 which occurs? 1. Suctioning is required frequently. 2. The client's skin and mucous membranes are light pink. 3. Aspiration of gastric contents occurs during suctioning. 4. Excessive secretions are suctioned from the tube and stoma.
3. Aspiration of gastric contents occurs during suctioning.
A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action? 1. Place the client in supine position. 2. Apply an ice collar around the client's neck. 3. Assist the client to a sitting position with the head tilted forward. 4. Instruct the client to swallow the blood until the bleeding can be controlled.
3. Assist the client to a sitting position with the head tilted forward.
A nurse is caring for a client with a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action? 1. Apply an occlusive dressing. 2. Reinsert the chest tube quickly. 3. Contact the respiratory therapist. 4. Contact the health care provider (HCP).
1. Apply an occlusive dressing.
The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 700 mL and determines that the tidal volume indicates which factor? 1. The amount of air delivered with each set breath 2. A breath that has a greater volume than the preset tidal volume 3. The number of breaths that the client will receive per minute by the ventilator 4. The fraction of inspired oxygen (Fio2) that is delivered to the client through the ventilator
1. The amount of air delivered with each set breath
A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use? 1. Telfa dressing and Neosporin ointment 2. Petrolatum gauze and sterile 4 × 4 gauze 3. Benzoin spray and a hydrocolloid dressing 4. Sterile 4 × 4 gauze, Neosporin ointment, and tape
2. Petrolatum gauze and sterile 4 × 4 gauze
The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1. Excessive secretions 2. Kinks in the ventilator tubing 3. The presence of a mucous plug 4. Displacement of the endotracheal tube
4. Displacement of the endotracheal tube
A nurse is caring for a client with a chest tube drainage system. While the client is being assisted to sit up in bed in preparation for ambulation, the chest drainage system accidentally disconnects. Which is the initial nursing action? 1. Call a respiratory therapist. 2. Contact the health care provider (HCP). 3. Encourage the client to perform the Valsalva maneuver. 4. Place the end of the chest tube in a container of sterile water.
4. Place the end of the chest tube in a container of sterile water.
The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication? 1. A kink in the ventilator circuit 2. A leak in the endotracheal tube cuff 3. Displacement of the endotracheal tube 4. A disconnection of the ventilator tubing
1. A kink in the ventilator circuit
A health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by which mechanism? 1. Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance 2. Attaching a T-piece to the ventilator and providing supplemental oxygen at a concentration that is 10% higher than the ventilator setting 3. Providing pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts 4. Removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time
1. Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? 1. Inflate the cuff on the tracheostomy tube. 2.Deflate the cuff on the tracheostomy tube. 3. Maintain the head of the bed in low Fowler's position. 4. Place the tray in a comfortable position in front of the client.
1. Inflate the cuff on the tracheostomy tube.
The nurse enters a client's room with a pulse oximetry machine and tells the client that the health care provider (HCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can quickly and most effectively alleviate the client's anxiety by providing which information about pulse oximetry? 1. It is painless and safe. 2. It causes only mild discomfort at the site. 3. It requires insertion of only a very small catheter. 4. It has an alarm to signal dangerous drops in oxygen saturation levels.
1. It is painless and safe.
The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions when performing this procedure? Select all that apply. 1. Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine the need for suctioning 3. Hyperoxygenating the client before, during, and after suctioning 4. Intermittently suctioning during insertion of the suction catheter 5. Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed
1. Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine the need for suctioning 3. Hyperoxygenating the client before, during, and after suctioning
A nurse and an unlicensed assistive personnel (UAP) are assisting the respiratory therapist to position a client for postural drainage. The UAP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas? 1. Lobes 2. Alveoli 3. Trachea 4. Main bronchi
1. Lobes
The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema? 1. Lung crackles 2. Pain with deep breathing 3. Increased chest tube drainage 4. Respiratory rate of 20 breaths per minute
1. Lung crackles
A client who is intubated and receiving mechanical ventilation has a problem of risk for infection. The nurse should include which measures in the care of this client? Select all that apply. 1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts. 5. Drain water from the ventilator tubing into the humidifier bottle.
1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts.
The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply. 1. Pressure support is added to the oxygen system. 2. The T-piece is connected to the client's artificial airway. 3. The client is removed from the mechanical ventilator for a short period of time. 4. The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on his or her own. 5. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen that is 10% higher than a ventilator setting.
1. Pressure support is added to the oxygen system. 2. The T-piece is connected to the client's artificial airway. 3. The client is removed from the mechanical ventilator for a short period of time. 5. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen that is 10% higher than a ventilator setting.
A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply. 1. Suctioning the client as needed 2. Encouraging coughing every 2 hours 3. Placing the bed in low Fowler's position 4. Supporting the neck incision when the client coughs 5. Monitoring the respiratory status frequently as prescribed
1. Suctioning the client as needed 2. Encouraging coughing every 2 hours 4. Supporting the neck incision when the client coughs 5. Monitoring the respiratory status frequently as prescribed
The nurse is monitoring the function of a client's chest tube that is attached to a Pleur-Evac drainage system. The nurse notes that the fluid in the water-seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring? 1. The system is patent. 2. There is a leak in the system. 3. The client has residual pneumothorax. 4. Suction should be added to the system.
1. The system is patent.
The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures? 1. "I should restrict my fluid intake for 2 weeks." 2. "I should perform arm exercises two or three times a day." 3. "If I experience any soreness in my chest or shoulder, I should notify the health care provider." 4. "If I experience any numbness or altered sensation around the incision, I should contact the health care provider (HCP)."
2. "I should perform arm exercises two or three times a day."
The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement, if made by the client, indicates a need for further teaching? 1. "I should avoid heavy lifting for at least 4 to 6 weeks." 2. "I should remove the chest tube site dressing as soon as I get home." 3. "If I have any difficulty in breathing, I should call the health care provider." 4. "If I note any signs of infection, I should contact the health care provider (HCP)."
2. "I should remove the chest tube site dressing as soon as I get home."
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 to 4 L/min. The nurse responds that this would be harmful because a higher oxygen flow rate could lead to which physical responses? 1. Drying of nasal passages 2. Decrease in the client's oxygen-based respiratory drive 3. Increase for the risk of pneumonia from drier air passages 4. Decrease in the client's carbon dioxide-based respiratory drive
2. Decrease in the client's oxygen-based respiratory drive
The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will check for which item to detect an early sign of this disorder? 1. Edema 2. Dyspnea 3. Frothy sputum 4. Diminished breath sounds
2. Dyspnea
A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status? 1. Oxygen saturation of 89% 2. Respiratory rate of 16 breaths per minute 3. Moderate amounts of tracheobronchial secretions 4. Small to moderate amounts of frank blood suctioned from the tube
2. Respiratory rate of 16 breaths per minute
A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the health care provider. This instruction is based on the understanding that the endotracheal tube could enter which respiratory structures? 1. Left main bronchus if inserted too far 2. Right main bronchus if inserted too far 3. Left main bronchus if not inserted far enough 4. Right main bronchus if not inserted far enough
2. Right main bronchus if inserted too far
The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider in this procedure, which is the initial nursing action? 1. Deflate the cuff. 2. Suction the ET tube. 3. Turn off the ventilator. 4. Obtain a code cart, and place it at the bedside.
2. Suction the ET tube.
A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? 1. Air flows by gravity. 2. The respiratory muscles relax. 3. The respiratory muscles contract. 4. Air is flowing against a pressure gradient
2. The respiratory muscles relax.
The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction? 1. "I need to protect the stoma from water." 2. "Soaps should be avoided near the stoma." 3. "I should use diluted alcohol on the stoma to clean it." 4. "I should apply a non-oil-based ointment to the skin surrounding the stoma."
3. "I should use diluted alcohol on the stoma to clean it."
A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate? 1. "Strapping is useful only if the ribs are fractured in several places at once." 2. "That's a good idea. I'll ask the health care provider for a prescription for the needed supplies." 3. "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." 4. "That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store."
3. "That isn't done because people often would develop pneumonia from the constricting effect on the lungs."
A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. In formulating a response, the nurse understands that this is owing to which symptom? 1. Anorexia, triggered by the infectious organism 2. Lack of client energy to cook wholesome meals 3. Blocked nasal passages that impair the sense of smell 4. Infection, which blocks sensation in the taste buds of the tongue
3. Blocked nasal passages that impair the sense of smell
The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made? 1. The skin color becomes cyanotic. 2. Secretions are becoming bloody. 3. Coughing occurs with suctioning. 4. Heart rate decreases from 78 to 54 beats per minute.
3. Coughing occurs with suctioning.
A nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1. A tubing obstruction or kink 2. The accumulation of secretions 3. Disconnection of the ventilator tubing 4. Condensation of water in the ventilator tubing
3. Disconnection of the ventilator tubing
The nurse reads a client's tuberculin (Mantoux) skin test as positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation? 1. Systemic tuberculosis 2. Pulmonary tuberculosis 3. Exposure to tuberculosis 4. No evidence of tuberculosis
3. Exposure to tuberculosis
A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose? 1. Prevents the client from getting a nosebleed 2. Gives the client added fluid via the respiratory tree 3. Humidifies the oxygen that is bypassing the client's nose 4. Prevents fluid loss from the lungs during mouth breathing
3. Humidifies the oxygen that is bypassing the client's nose
The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem? 1. Fever 2. Epilepsy 3. Hypotension 4. Respiratory failure
3. Hypotension
A nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-Evac drainage system. Which intervention in the care plan indicates the need for further teaching for the student? 1. Position the client in semi-Fowler's position. 2. Add water to the suction chamber as it evaporates. 3. Instruct the client to avoid coughing and deep breathing. 4. Tape the connection sites between the chest tube and the drainage system.
3. Instruct the client to avoid coughing and deep breathing.
The nurse is providing an educational session to community members regarding histoplasmosis. The nurse should provide which information about this disease? 1. It is caused by a tick bite. 2. It is caused by contamination from cat feces. 3. It can be caused by the inhalation of spores from bird droppings. 4. It can be contagious by respiratory contact with an infected person.
3. It can be caused by the inhalation of spores from bird droppings.
A nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? 1. Dilate the major bronchi. 2. Increase surfactant production. 3. Maintain inflation of the alveoli. 4. Enhance ciliary action in the tracheobronchial tree.
3. Maintain inflation of the alveoli.
A young adult client has never had a chest x-ray examination before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse should provide valid reassurance to the client? 1. "You'll wear a lead shield to partially protect your organs from harm." 2. "The amount of x-ray exposure is not sufficient to cause DNA damage." 3. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." 4. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."
4. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."
A nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, which nursing action is appropriate? 1. Document the findings. 2. Reassess the pH in 4 hours. 3. Instill 30 mL of sterile water. 4. Administer a dose of a prescribed antacid.
4. Administer a dose of a prescribed antacid.
The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm? 1. Shut the alarm off and call for help. 2. Call the respiratory therapy department to fix the problem. 3. Call the health care provider (HCP) for further instructions. 4. Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.
4. Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.
The nurse is caring for a client with tuberculosis who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness? 1. Allow the client to deal with the disease in an individual fashion. 2. Ask family members whether they wish a psychiatric consultation. 3. Encourage the client to visit with the pastoral care department chaplain. 4. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.
4. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.
The nurse is assessing a client with the typical clinical manifestations of tuberculosis. The nurse should expect the client to report having fatigue and cough that have been present for how long? 1. 1 or 2 days 2. 1 to 2 weeks 3. Almost 1 week 4. Several weeks to months
4. Several weeks to months
The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water-seal compartment has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? 1. The system needs changing. 2. Suction needs to be increased. 3. Suction needs to be decreased. 4. The chest tubes are obstructed.
4. The chest tubes are obstructed.
