NURS305 Resp function NCLEX

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 10 L/min b. 1 L/min c. 2 L/min d. 6 L/min

2 L/min?

A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? a. When bronchospasms occur b. When secretions have mobilized c. Immediately before a meal d. At least 2 hours after a meal

2 hours after a meal

A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a. pH, 5.0; PaCO2 30 mm Hg b. pH, 7.40; PaCO2 35 mm Hg c. pH, 7.35; PaCO2 40 mm Hg d. pH, 7.25; PaCO2 50 mm Hg

7.25 - Pa CO2 50 mm Hg

What is the normal pH range for arterial blood? a. 7.50 to 7.60 b. 7.55 to 7.65 c. 7 to 7.49 d. 7.35 to 7.45

7.35 to 7.45

The nurse is planning to assess the apex of a client's lungs. Which area of the body will the nurse be assessing? a. Below the scapula b. Above the clavicles c. Right of the sternum, sixth intercostal space b. Above the clavicles d. Left of the sternum, third intercostal space

Above the clavicles

What is wheezing

Air moving through a narrow space: Wheezing is a high-pitched whistling sound made while breathing. Most commonly wheezing occurs during breathing out (expiration), but it can sometimes be related to breathing in (inspiration).

What is wheezing?

Air moving through a narrow space: Wheezing is a high-pitched whistling sound made while breathing. Most commonly wheezing occurs during breathing out (expiration), but it can sometimes be related to breathing in (inspiration).

What are fine and coarse crackles

Air moving through fluid in the small bronchioles. A common, abnormal respiratory sound consisting of discontinuous bubbling noises heard on auscultation of the chest during inspiration. Fine crackles have a popping sound produced by air entering distal bronchioles or alveoli that contain serous secretions, as in congestive heart failure, pneumonia, or early tuberculosis. Coarse crackles may originate in the larger bronchi or trachea and have a lower pitch. Crackles are not cleared by coughing.

What are fine crackles? What are course crackles?

Air moving through fluid in the small bronchioles. A common, abnormal respiratory sound consisting of discontinuous bubbling noises heard on auscultation of the chest during inspiration. Fine crackles have a popping sound produced by air entering distal bronchioles or alveoli that contain serous secretions, as in congestive heart failure, pneumonia, or early tuberculosis. Coarse crackles may originate in the larger bronchi or trachea and have a lower pitch. Crackles are not cleared by coughing.

what is atelectasis

Atelectasis is the complete or partial collapse of the lung or lobe of the lung.

What is atelectasis?

Collapse of the alveoli in the lung prevents normal exchange of O2 and co2 hypoventilation occurs

A 48-year-old client doesn't smoke cigarettes yet is demonstrating signs of lung irritation. Which of the following questions could help with the assessment of this client? a. Have you had allergy testing? b. Have you tried to stop smoking? c. Do you smoke or inhale marijuana or other herbal products? d. Have you received a flu or pneumonia vaccination?

Do you smoke weed?

Presence of overdistended and non-functional alveoli is a condition called: a. Emphysema b. Atelectasis c. Empyema d. Bronchitis

Emphysema

How often should a nurse assess the skin and nares of the patient with a nasal cannula? a. Every 2 hours b. Every 15 minutes c. Every 24 hours d. Every 6 hours

Every 6 hours

Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? a. Myasthenia gravis b. Type 1 diabetes mellitus c. Extreme anxiety d. Narcotic overdose

Extreme anxiety

Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Asking the client to obtain the specimen after eating b. Asking the client to split into the collection container c. Having the clients take three deep breaths d. Limiting fluids

Having the clients take three deep breaths.

A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to: a. Hold the breath after inhalation b. Inhale through the nose c. Take two inhalations during one breath d. Inhale quickly

Hold the breath after inhalation

A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia b. A widened diaphragm noted on the chest x-ray c. A hyperinflated chest noted on the chest x-ray d. Increase oxygen saturation with exercise

Hyper inflated chest noted on the chest-x-ray

A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? a. Presses the canister down with the finger as he breathes in b. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed c. Removes the cap and shakes the inhaler well before use d. Inhales the mist and quickly exhales

Inhales the mist and quickly exhales

For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care? a. Keeping the collection chamber at chest level b. Measuring and documenting the drainage in the collection chamber c. Stripping the chest tube every hour d. Maintaining continuous bubbling in the water-seal chamber

Measure and document the drainage in the collection chamber

A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? a. Non-rebreather mask b. Simple mask c. Face tent d. Nasal cannula

Non-nebreather mask

Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg? a. Offer the client fluids frequently b. Administer a prescribed decongestant c. Instruct the client to breathe into a paper bag d. Administer prescribed supplemental oxygen

Paper bag

The accumulation of fluids in the pleural space is called: a. Pyothorax b. Hydrothorax c. Hemothorax d. Pleural Effusion

Pleaural Effusion

A patient has been instructed in pursed-lip breathing. The patient asks the nurse the purpose behind the breathing pattern. The nurse's best response to this question would be: a. "Pursed-lip breathing prevents airway collapse and enhances effective breathing." b. "You will be more comfortable if you use pursed-lip breathing techniques." c. "Pursed-lip breathing exercises help to prevent the accumulation of secretions." d. "Pursed-lip breathing increases the strength of the respiratory muscles."

Prevents airway collapse and enhances effective breathing

Which of the following is a normal finding when assessing the respiratory system of an elderly client? a. Bronchovesicular breath sounds throughout the lungs b. A decreased anteroposterior diameter and increased alveolar surface c. Decreased mobility of the thorax and increased chest wall stiffness d. Increased thoracic expansion and relaxation of elastin tissues

Put Decreased Mobility

The nurse notes that a client with COPD demonstrates more dyspnea in certain positions. Which position is most likely to alleviate the client's dyspnea? a. Standing or sitting upright b. Lying with head slightly lowered c. Side lying with head elevated d. Lying supine with a single pillow

Standing or sitting upright

A 57-year-old client tells the nurse, "I need two to three pillows to sleep." How should this information be documented? a. Resting apnea b. Dyspnea at rest c. Dyspnea on excursion d. Two to three pillow orthopnea

Two to three pillow orthopnea

A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience: a. hyperglycemia and glycosuria. b. GI bleeding. c. acute adrenocortical insufficiency. d. restlessness and seizures

acute adrenocortical insufficiency

Chest percussion has been ordered for a client on bed rest with respiratory infections and increased secretions. The nurse should use which of the following hand positions to administer chest percussion? a. Flat-hand position b. Flexed-hand position c. Cupped-hand position d. Fisted-hand position

cupped hand

A nurse is assessing a male client with chronic airflow limitations and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitations? a. Bronchial asthma b. Emphysema c. Bronchial asthma and bronchitis d. Chronic obstructive bronchitis

emphysema

When performing an assessment on the client with emphysema, the nurse finds that the client has a barrel chest. The alteration in the client's chest is due to: a. Long-term chronic hypoxia b. Use of accessory muscles c. Hyperinflation of the lungs d. Collapse of distal alveoli

hyperinflation of the lungs

An adult client is admitted to the acute care hospital with bacterial pneumonia. On admission she was pale to dusky in color. Her respirations were 32, temperature 1030F and pulse 110. Auscultation revealed decreased or absent lung sounds in both bases and rhonchi in both upper lung fields. She was oriented to person, time and place, but her responses were brief. Oxygen per nasal cannula is started at 7 l / minute. IV antibiotics were started. While checking the client one hour after admission the nurse notes that she is less responsive, answering only yes or no questions. Her respirations are somewhat shallower and have decreased to 27 per minute. What is the best INITIAL action for the nurse to take? a. Continue to stimulate her until she responds appropriately. b. Increase the IV infusion rate to increase the amount of circulating antibiotics. c. Increase the oxygen flow rate to 10 liters / minute. d. Notify the physician of the client's changed mental status and await further orders

notify the physician of the clients changed mental status and await further orders

Nurse Joana is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? a. It helps prevent early airway collapse b. It prolongs the inspiratory phase of respiration c. It increases inspiratory muscle strength d. It decreases use of accessory breathing muscles

prevent early airway collapse

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Strengthen the diaphragm. b. Strengthen the intercostal muscles. c. Promote carbon dioxide elimination. d. Promote oxygen intake.

promote 02 intake

A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem? a. Chills and night sweats b. Cough c. High-grade fever d. Anorexia and weight loss

high-grade fever

What does central cyanosis indicate? a. Hypotension b. Decreased level of consciousness c. Hypoxemia d. Atelectasis

hypoxemia

Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a. Delirium b. Hypoxia c. Semiconsciousness d. Hyperventilation

hypoxia

The physician has ordered O2 at 3 liters/minute via nasal cannula. O2 amounts greater than 3 liters / minute are contraindicated in the client with COPD because: a. Higher levels will be required later to raise the pO2 b. Hypoxic drive is needed for breathing. c. Higher concentrations result in severe headache. d. Hypercapnic drive is necessary for breathing.

hypoxic drive is needed for breathing

All of the following nursing diagnoses are important for a client with chronic pulmonary emphysema (COPD). Which would receive priority when planning nursing interventions? a. Self-care deficit b. Activity intolerance c. Impaired gas exchange d. Ineffective airway clearance

impaired gas exchange

Nurse Mickey is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true? a. The PPD can be read within 12 hours after the injection b. A positive reaction indicates that the client has active tuberculosis (TB) c. A positive reaction indicates that the client has been exposed to the disease d. A negative reaction always excludes the diagnosis of TB

the client has been exposed

The nurse is teaching the client the appropriate way to use a metered dose inhaler. Which action indicates the client needs additional teaching? a. The client places the inhaler two fingers from the mouth. b. The client waits 15 seconds before using the inhaler a second time. c. The client takes a deep breath while depressing the inhaler. d. The client exhales slowly using purse lipped breathing.

wait 15 secs before using the inhaler a second time