NUR2308 Test #4 ATI Respiratory Questions 17-20 and 25-26

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? Select all that apply A) A client who experienced a near-drowning incident B) A client following coronary artery bypass graft surgery C) A client who has a hemoglobin of 15.1 mg/dL D) A client who has dysphagia E) A client who experienced a drug overdose

A) A client who experienced a near-drowning incident B) A client following coronary artery bypass graft surgery D) A client who has dysphagia E) A client who experienced a drug overdose

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? Select all that apply A) Encourage the client to cough every 2 hr B) Check for continuous bubbling in the suction chamber C) Strip the drainage tubing ever 4 hr D) Clamp the tube once a day E) Obtain a chest x-ray

A) Encourage the client to cough every 2 hr B) Check for continuous bubbling in the suction chamber E) Obtain a chest x-ray

A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome (ARDS). Which of the following medications should the nurse anticipate administering with this medication? Select all that apply A) Fentanyl B) Furosemide C) Midazolam D) Famotidine E) Dexamethasone

A) Fentanyl C) Midazolam

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? Select all that apply A. Oxygen B. Sterile Water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing

A) Oxygen B) Sterile water C) Enclosed hemostat clamps E) Occlusive dressing

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? Select all that apply A) Tachypnea B) Deviation of the trachea C) Bradycardia D) Decreased use of accessory muscles E) Pleuritic pain

A) Tachypnea B) Deviation of the trachea E) Pleuritic pain

Which of the following clients have an increased risk for developing pneumonia? (Select all that apply) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis Difficulty swallowing, immunocompromised, invasive procedure, and difficulty clearing secretions

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site

A. Dyspnea C. Fever D. Hypotension Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the provider immediately. Fever can indicate an infection. The nurse should notify the provider immediately. Hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately.

A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The partner states that the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following is the priority nursing action? A. Obtain baseline vital signs and oxygen saturation B. Obtain a sputum culture C. Obtain a complete history from the client D. Provide a pneumococcal vaccination

A. Obtain baseline vital signs and oxygen saturation Assessment is the first step of the nursing process and is essential to patient centered care

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply.) A. Oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit

A. Oxygen equipment C. Pulse oximeter D. Sterile dressing Oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure. Pulse oximetry is necessary to monitor oxygen saturation level during the procedure A sterile dressing is necessary to apply to the puncture site following the procedure.

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure. C. Obtain ABGs. D. Administer benzocaine spray.

A. Position the client in an upright position, leaning over the bedside table. Positioning the client in an upright position and bent over the bedside table widens the intercostal space for the provider to access the pleural fluid.

A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV? A) "It keeps the alveoli open and prevents atelectasis." B) "It allows preset pressure delivered during spontaneous ventilation" C) "It guarantees minimal minute ventilator" D) "It delivers a preset ventilatory rate and tidal volume to the client."

B) "It allows preset pressure delivered during spontaneous ventilation"

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A) "This medications is given to treat infection" B) "This medication is given to facilitate ventilation" C) "This medication is given to decrease inflammation" D) "This medication is given to reduce anxiety"

B) "This medication is given to facilitate ventilation"

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess respiratory status

B) Apply sterile gauze to the insertion site

A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? Select all that apply A) Bradycardia B) Cyanosis C) Hypotension D) Dyspnea E) Paradoxic chest movement

B) Cyanosis C) Hypotension D) Dyspnea E) Paradoxic chest movement

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? Select all that apply A) Continuous bubbling in the water seal chamber B) Gentle constant bubbling in the suction control chamber C) Rise and fall in the level of water in the water seal chamber with inspiration and expiration D) Exposed sutures without dressing E) Drainage system upright at chest level

B) Gentle constant bubbling in the suction control chamber C) Rise and fall in the level of water in the water seal chamber with inspiration and expiration

A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A) Assess the client's pain B) Obtain a large-bore IV needle for decompression C) Administer lorazepam D) Prepare for chest tube insertion

B) Obtain a large-bore IV needle for decompression

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? Select all that apply A) Confusion B) Pale skin C) Bradycardia D) Hypotension E) Elevated blood pressure

B) Pale skin E) Elevated blood pressure

A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for the client? Select all that apply A) Administer antibiotics B) Provide supplemental oxygen C) Administer antiviral medications D) Administer of bronchodilators E) Maintain ventilatory support

B) Provide supplemental oxygen D) Administer of bronchodilators E) Maintain ventilatory support

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client's respiratory muscles should the nurse include in the plan of care? Select all that apply. A) Assist control B) Synchronized intermittent mandatory ventilation C) Continuous positive airway pressure D) Pressure support ventilation E) Independent lung ventilation

B) Synchronized intermittent mandatory ventilation C) Continuous positive airway pressure D)Pressure support ventilation

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A) Nonrebreather mask B) Venturi mask C) Nasal Cannula D) Simple face mask

B) Venturi mask

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 (100 F), respirations 30/min, BP 130/76, HR 100/min, and SaO2 91% on room air. Using a scale of 1 to 4, with 1 being the highest priority, prioritize the following nursing intervention: A. Administer antibiotics as prescribed B. Administer oxygen therapy C. Perform a sputum culture D. Administer an antipyretic medication to promote client comfort

B. Administer oxygen therapy C. Perform a sputum culture A. Administer antibiotics as prescribed D. Administer an antipyretic medication to promote client comfort

A nurse is teaching a group of clients about influenza. Which of the following statements by a client requires clarification? A. I should wash my hands after blowing my nose to prevent spreading the virus B. I need to avoid drinking fluids if I develop symptoms C. I need a flu shot every year because of the different flu strains D. I should sneeze into my elbow rather than my hands

B. Fluid intake should be increased if findings develop

A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.40, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid‐base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis A client who is experiencing respiratory alkalosis will have an increased pH and a decreased PaCO2. Possible causes of respiratory alkalosis include hyperventilation, fever, and respiratory infections.

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, BP 118/68 mmHg, HR 124 bpm, RR 38, Temp 38.6 C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first? A) Obtain a CXR B) Prepare for chest tube insertion C) Administer oxygen via a high-flow mask D) Initiate IV access

C) Administer oxygen via a high-flow mask

A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client? A) "Notify your provider if you experience weakness" B) "You should be able to return to work in 1 week" C) "You need to wear a mask when in crowded areas" D) "Notify your provider if you experience a productive cough"

D) "Notify your provider if you experience a productive cough"

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A) Apply a vest restraint if self-extubation is attempted B) Monitor ventilator settings every 8 hr C) Document tube placement in centimeters at the angle of jaw D) Assess breath sounds every 1-2 hrs

D) Assess breath sounds every 1-2 hours

A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A) Lie on his left side B) Use the incentive spirometer C) Cough at regular intervals D) Perform the Valsalva maneuver

D) Perform the Valsalva maneuver

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood‐tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms

D. Bronchospasms

A nurse in a clinic is caring for a client who has sinusitis. Which of the following techniques should the nurse use to identify clinical manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctiva D. Palpation of the orbital areas

D. Palpation of the orbital areas Palpation of the orbital, frontal, and facial areas will elicit a report of tenderness, which is a clinical manifestation in a client who has sinusitis