nclex ms respiratory

The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure?

Administer pain medication 15 to 30 minutes before the procedure.

A client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. The nurse determines that which accurately indicates effectiveness of the treatments prescribed for this problem?

Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, and Pco2 of 40 mm Hg.

The nurse is assessing a client who has frequent episodes of asthma. Which assessment finding is most closely associated with asthma?

Bilateral wheezing

The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter?

10 seconds

The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse signs and symptoms indicating acute pulmonary edema?

Frothy sputum

The nurse is assessing a client diagnosed with sinusitis. Which are signs and symptoms of sinusitis?

Headache especially in the morning Elevated white blood cell (WBC) count Feeling of heaviness over affected areas

The nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which should the nurse do first?

Check for kinks in the chest drainage tube

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement?

Check the amount of suction pressure being applied.

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?

Check the client for spontaneous breathing

A client is at risk of developing a pulmonary embolism. The nurse monitors for which initial sign/symptom?

Chest pain that occurs suddenly

The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which finding?

Complaints of night sweats

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs with suctioning.

The nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. Which action should the nurse implement?

Cover the insertion site with sterile Vaseline gauze.

A client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation?

Directly observe therapy

The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. Which nursing action would be immediate?

Reattach the chest tube to the drainage system.

The nurse is collecting data on a client with chronic sinusitis. The nurse interprets that which client sign/symptom is unrelated to this problem?

Severe evening headache

The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles?

mask

The nurse is checking 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 data collection, the nurse notes that the bubbling in the water-seal chamber is now constant, and the client appears dyspneic. Based on these findings, which action should the nurse do first?

Inspect chest tube connections

While assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder?

Knifelike pain that worsens on inspiration

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?

Lateral position

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next?

Notify RN

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action?

Notify the registered nurse

The nurse is caring for a restless client who keeps biting down on an orotracheal tube. The nurse uses which intervention to prevent the client from obstructing the airway with the teeth?

Oral airway

A client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions should be done?

Administer humidified oxygen. Instruct on the use of the incentive spirometer Monitor vital signs and pulse oximetry frequently.

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action?

Assess the client

A clinic nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. Which intervention should the client be encouraged to perform?

Avoid foods that are highly seasoned

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?1. 1.An uninsured man who is homeless 2.A woman newly immigrated from Korea 3.A man who is an inspector for the U.S. Postal Service 4.An older woman admitted from a long-term care facility

3

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which best action to ensure accurate readings on the oximeter?

Ask the client to limit motion in the hand attached to the pulse oximeter.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience?

Dyspnea

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client?

Dyspnea on exertion Presence of a productive cough Difficulty breathing while talking

The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis?

Early onset cough Purulent mucous production Mild episodes of dyspnea

A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. Which recommendation by the nurse is therapeutic?

Get plenty of rest Take antipyretics for fever. Increase intake of liquids.

The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining a proper specimen?

Have the client take three deeps breaths

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect the client to experience?

Hyperinflated lungs on chest x-ray

Which statement by the client indicates a need for further teaching regarding the reinforced home care instructions for acute sinusitis?

I will need surgery to drain my sinusus

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 complication of this disorder?

Increased intracranial pressure

The nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a Pao2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client?

Ineffective oxygen and carbon dioxide exchange

The nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which intervention is important to ensure accurate monitoring of the client's oxygenation status?

Instruct the patient to not move sensor

The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observation by the nurse is inconsistent with the need for suctioning?

Low peak inspiratory pressure on the ventilator

The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery?

Obturator

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 results that are consistent with this disorder?

Pao2 49 mm Hg, Paco2 52 mm Hg

A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect?

Peripheral neuritis

The nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub, which was auscultated the previous day. How should this finding be interpreted?

Pleural fluid has accumulated in the inflamed area.

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which arterial blood gas supports this diagnosis?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse should take which action after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour?

Refrigerate the spiceman

The nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux tuberculin skin test. Which action by the nurse is the priority?

Report the findings

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?

Respiratory distress

The 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?

Rest Local heat Analgesics

The nurse is reinforcing 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?

SOB

The nurse is assisting in caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse monitors the portable wound suction for which types of drainage expected in the immediate postoperative period?

Serosanguineous

The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion should the nurse make?

The chest tube is functioning as expected.

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly?

The client breaths out slowly through the mouth

The nurse reinforces instructing 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 their nose

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.

The nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. Which statement represents the nurse's accurate interpretation of this finding?

This finding requires further data collection

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 which diagnosis?

Trauma

A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?

Use a picture or word board

The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. Which would be the next immediate nursing action?

Ventilate the client with a resuscitation bag.

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?

Aspiration of gastric contents occurs when suctioning.

The nurse is collecting data from a client who is experiencing the typical signs/symptoms of tuberculosis (TB). The nurse should expect the client to report having symptoms of fatigue and cough that have been present for how long?

Several weeks to a month

The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax?

Shortness of breath

The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement?

"After maximal inspiration, I will hold my breath for 10 seconds and then exhale."

The nurse is reinforcing discharge teaching with a client diagnosed with tuberculosis (TB) and has been on medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made?

"I should not be contagious after 2 to 3 weeks of medication therapy."

The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action should the nurse implement?

Stop the suctioning procedure

The nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms?

Hemoptysis A sensation of a "lump" in the throat Hoarseness lasting more than 3 weeks

The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement?

Shortness of breath and tracheal deviation

The nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique?

The client's exhalation is twice as long as inhalation.

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. The nurse develops a response to the client's question, based on which understanding?

The disease is transmitted by droplet nuclei.

The nurse is caring for a client with emphysema receiving oxygen. The nurse should check the oxygen flow rate to ensure the client does not exceed how many L/min of oxygen?

2L/min

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure?

Apply suction for up to 10 to 15 seconds. Hyperoxygenate the client before suctioning. Apply intermittent suction while rotating and withdrawing the catheter. Advance the catheter until resistance is met and then pull the catheter back 1 cm.

The 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 observation is noted for the client?

Abdominal distention

A client arrives in the emergency department with a bloody nose. Which is the initial nursing action?

Assist the client to a sitting position with the head tilted slightly forward.

The nurse is assisting in preparing a list of instructions for an adult client who is being discharged following a tonsillectomy. Which instructions should the nurse include in the list?

Avoid hot fluids Avoid rough foods Rest for the next 24 hours

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?

Disconnect the suction source from the catheter.

The nurse is caring for a client with laryngitis. Which interventions should the nurse implement?

Discourage smoking. Use a room humidifier. Use lozenges that contain a topical anesthetic agent.

A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which signs and symptoms?

Dyspnea

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 forms of CAL?

Emphysema

A client enters the urgent care center with epistaxis(bleeding from the nose) but no obvious facial injury. The nurse should take which action?

Have the client sit down, lean forward, and apply pressure to the nose.

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 which fact with regard to turning up the wall suction?

It 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 client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit?

Nasal obstruction

The nurse is reading the results of a Mantoux tuberculin skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. Which interpretation should the nurse make of these results?

Negative

A client with pneumonia is admitted to the hospital, and the health care provider writes prescriptions for the client. Which prescription should the nurse complete first?

Obtain a C&S of sputum

A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action?

Place the client in high fowler's position

The nurse is monitoring the respiratory status of a client who has suffered a fractured rib. The nurse monitors the client and understands that which sign/symptom is unrelated to the rib fracture?

Slow, deep respirations

The nurse is preparing to assist a health care provider with the insertion of a chest tube. The nurse anticipates that which supplies will be required for the chest tube insertion site?

Sterile 4 × 4 gauze pads Povidone-iodine gauze Petrolatum (Vaseline) gauze Elastoplast tape

A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse should perform which action?

Tell the RN

A client being discharged from the hospital to home with a diagnosis of tuberculosis (TB) is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely?

The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

The nurse is preparing to perform chest physiotherapy (CPT) on a client. Before determining the correct position in which to place the client, which information should the nurse ascertain?

The lung areas involved

The nurse is assisting a client, who underwent radical neck surgery, to get out of bed. How does the nurse provide support to this client, who is afraid to move the head?

The nurse places a hand behind the client's head

A client reports the chronic use of nasal sprays. The nurse reinforces 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 nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination?

The system is functioning as expected

A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. Which finding does this indicate?

The tube may be occluded

A client with arthritis of the hands and fingers is having difficulty using a metered-dose inhaler (MDI). The nurse suggests asking the health care provider for which prescription?

Use of a spacer

The nurse is admitting a client to the nursing unit who is suspected of having tuberculosis (TB). The nurse plans to admit the client to which type of room?

Venting to the outside, six air exchanges per hour, and ultraviolet light

The nurse is assisting a health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan to ensure that which is done as a final measure to determine correct tube placement?

Verify placement by a chest x-ray

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?

pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L

The nurse is assigned to assist in caring for a client with a chest tube drainage system. In planning for the client, the nurse makes certain that what equipment is available, in the event that the drainage system needs to be changed?

rubber shod clamps