Nclex Respiratory

The client is diagnosed with pleurisy. The nurse would expect to see which signs and symptoms? Select all that apply.

Pleural friction rub Sharp, knife like pain Pain that occurs most often during inspiration

The nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer?

Cough

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?

Coughing occurs with suctioning g

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 would the nurse implement?

Cover the insertion site with sterile gauze.

The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions would the nurse anticipate performing during this process? Select all that apply.

Cover the site with an occlusive dressing after the tube is removed. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

The nurse is talking with a client who is going to have a radical neck dissection and total laryngectomy. Which client statement indicates a need for further teaching concerning postoperative management

"I will require a lot of pain medication after surgery."

The nurse is caring for a client with fractured ribs. Which statement indicates a need for further teaching?

"My ribs will be healed in a month."

The nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms? Select all that apply.

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

The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis?

High-grade fever

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 perform which action?

Notify the registered nurse.

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

Obtain a culture and sensitivity of sputum

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

Obturator

The nurse is preparing a plan of care for a client who will be returning from surgery following a right lung wedge resection. Included in the plan of care is that in the postoperative period, the nurse would avoid which positioning?

On the right side

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.

The nurse is giving discharge instructions to the client concerning theophylline. Which client statement indicates a need for further teaching?

"I can keep on being the charcoal grill king and eat a lot of beef steak."

The 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.

A

The 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.

A

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding would be reported immediately to the primary health care provider (PHCP)?

Bronchospasm

The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications?

Changing the client's position every 2 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 would the nurse implement? Select all that apply.

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

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

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

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 client not to move the sensor

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 position for the procedure?

Left side-lying with the head of the bed elevated at 45 degrees

The nurse is collecting data on a client with chronic sinusitis. Which are signs and symptoms of chronic sinusitis? Select all that apply.

Loss of smell Chronic cough Nasal stuffiness

A client is admitted to the emergency department with carbon monoxide poisoning. Which signs and symptoms indicate carbon monoxide poisoning? Select all that apply.

Mental changes cardiac irregularities Cherry- red skin color

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. Which statements indicate prevention of transmission of tuberculosis? Select all that apply.

My family and I will practice good hand hygiene I will discard disposable tissues into a plastic bag I will cover my mouth when I cough, sneeze, or laugh

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 collecting data from a client who is experiencing the typical signs/symptoms of tuberculosis (TB). Which are signs and symptoms of tuberculosis? Select all that apply.

Night sweats mucopurulent sputum Afternoon low grade fever

In which area of the chest would the nurse expect to auscultate this breath sound? (Refer to audio.)

Over the peripheral lung fields

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method would be used to monitor the client for crepitus?

Palpating the skin around the chest and neck for a crackling sensation

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 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

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and has an arterial blood gas test done. Which results would the nurse expect to note?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

The nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Which instructions would the nurse provide 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.

A client has a chest tube that is attached to a chest drainage system. The chest tube becomes disconnected. What would the nurse do immediately?

Put open end under sterile water

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

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

Refrigerate the specimen

A client has just returned from intrathoracic surgery where a chest tube was placed. The nurse notes a small amount of serosanguineous drainage on the chest tube's dressing. Which action would the nurse take?

Reinforce the dressing.

A licensed practical nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. Which action should the nurse take?

Report the client's symptoms to the registered nurse (RN).

Cycloserine is added to the medication regimen for a client with tuberculosis. Which instruction would the nurse include in the client teaching plan regarding this medication?

Return to the clinic weekly for serum drug levels

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 is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position would the nurse instruct the client to assume?

Sitting on the side of the bed leaning on an overbed table

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which would be the nurse's next action?

Stop the procedure and oxygenate the client.

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 would the nurse implement?

Stop the suctioning procedure.

The nurse is assisting in caring for a client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client would be reported immediately to the registered nurse (RN)?

Stridor

A client with respiratory congestion is scheduled to receive acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer. The nurse checks the client's room to ensure that which equipment is available for use following administration of this medication?

Suction equipment

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 breathes out slowly through the mouth.

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

A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason?

To expel mucus from the airways

A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which sign or symptom observed by the nurse clearly indicates that the pneumothorax is rapidly worsening?

Tracheal deviation to the right

The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action would the nurse take?

Ventilate the client manually. Rationale:If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR.

The nurse is assisting in admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. 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 determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)?

A client with pancreatitis and gram-negative sepsis

The nurse is caring for a client with emphysema receiving oxygen. The nurse would consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen?

2 L/min

Which are signs and symptoms characteristic of emphysema? Select all that apply.

Cyanosis Weight loss Barrel chest shortness of breath Decreased lung sounds

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially?

Determine the client's ability to follow verbal commands.

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 observed therapy

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 has undergone fluoroscopy-assisted aspiration biopsy of a lung lesion. The nurse determines that the client is experiencing complications from the procedure if the nurse makes which observation?

Absence of breath sounds in the right upper lobe

The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse reinforce? Select all that apply.

Activities should be resume gradually A sputum culture is needed every 2-4 weeks once medication therapy is initiated Respiratory isolation is not necessary because family members have already been exposed Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags

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 preparing to suction an adult client through the client's tracheostomy tube. Which interventions would the nurse perform for this procedure? Select all that apply.

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

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 assisting in planning care for a client with a chest tube. The nurse would suggest including which interventions in the plan? Select all that apply

Be sure all connections remain airtight Be sure all connections are taped and secure Monitor closely for tubing that is kinked or obstructed

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 assisting in caring for a client with a tracheal tube attached to a ventilator when an alarm sounds. Which action would the nurse do first?

Check the client

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

Check the client.

The nurse is preparing to assist a primary 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? Select all that apply.

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

The nurse in the emergency department has just assumed care from emergency medical services for a client that has a large penetrating stab wound. A chest x-ray has determined the diagnosis of hemothorax. Which initial action would the nurse take?

Ensure a patent airway

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation?

Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased. The nurse explains that this can be harmful because it could cause which difficulty?

It could decrease the client's oxygen-based respiratory drive.

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 in which location?

Just under the left clavicle

A primary health care provider is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the primary health care provider asks the client to do which action?

Perform the Valsalva maneuver. Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seals itself off and the wound heals in less than a week. Therefore, options 1, 2, and 3 are incorrect.

The nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB?

Residents of long-term facility

The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse would monitor for which item as the best indicator of an adequate respiratory status?

Respiratory rate of 18 beats per minute

The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention?

Suction the client.

A postoperative client has received a dose of naloxone for respiratory depression. The nurse anticipates that the client will have which additional effect from the administration of this medication?

Sudden increase in pain

The 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 uses this data to make which interpretation?

The behavior is likely the result of hypoxia.

A client with chronic obstructive pulmonary disease has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if which action is taken

The client plans to eat the largest meal of the day at a time when hungry

The 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

The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder?

Arterial Pao2 of 48

A client at risk for pulmonary embolism (PE) suddenly develops respiratory distress, chest pain, and anxiety. The nurse would plan to take which actions? Select all that apply.

Check vital signs Notify the RN Begin low-flow oxygen therapy

Which diagnostic tests indicate active tuberculosis? Select all that apply.

Chest x-ray Gastric analysis washings Sputum smear and culture

The 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?

Chill and night sweats

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 diagnosed with a pneumothorax who has a chest tube connected to a closed-chest drainage system. The client asks the nurse why a chest tube was inserted. Which response by the nurse explains the purpose of a chest tube?

"To allow for reexpansion of the lung." Rationale: A chest tube may be inserted after a pneumothorax and connected to water-seal drainage to remove the air and allow reexpansion of the lung. It does not lessen discomfort, prevent further damage to the lung, or help prevent lung infections.

The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator that suctioning has been effective?

Breath sounds are now clear.

The nurse is preparing to perform chest physiotherapy (CPT) on a client. In performing postural drainage, which statement is incorrect?

Breathe in a fast-paced pattern

The nurse is collecting data from a client with pneumonia. Chest auscultation over areas of consolidation reveals this breath sound. (Refer to audio.) The nurse should interpret this sound to be indicative of which breath sound?

Bronchial breath sounds

The 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 coexisting problems? Select all that apply.

Hypotension Use of peripheral vasoconstrictions

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 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 that was auscultated the previous day. How would this finding be interpreted?

Pleural fluid has accumulated in the inflamed area.

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, which interpretation would the nurse make?

The client should be repeating the sequence 10-20 times in each session

The licensed practical nurse (LPN) in the emergency department is caring for a client who was assaulted and sustained blunt force injuries to the chest and abdomen. Which priority client data would the LPN immediately report to the registered nurse (RN)?

Tracheal deviation to the left

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 who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes which sign/symptom?

Breath sounds greater on the right than the left

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 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.

A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse would provide which explanation for these symptoms?

Expected, and the client should very gradually increase activity as tolerated

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points would be included in the instructions? Select all that apply.

The client leans over a bedside table. The client should sit on the edge of the bed. A time-out is performed before the procedure A local anesthetic is administered before the procure

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 sinuses

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 would the nurse do first

Inspect chest tube connections.