Quiz 3 - Respiratory
50. The nurse writes a problem of "impaired gas exchange" for a client diagnosed with cancer of the lung. Which interventions should be included in the plan of care? Select all that apply. 1. Apply O2 via nasal cannula. 2. Have the dietitian plan for six (6) small meals per day. 3. Place the client in respiratory isolation. 4. Assess vital signs for fever. 5. Listen to lung sounds every shift.
1,2,4,5
129. The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. 1. Cough 2. Dyspnea 3. Weight gain 4. High-grade fever 5. Chills and night sweats
1,2,5
1. Place the client on oxygen delivered by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1,000 mL/day. 4. Restrict the client's smoking to two (2) to three (3) cigarettes per day. 5. Monitor the client's pulse oximetry readings every four (4) hours.
1,2,5 Fluids loosen secretions
63. The client's arterial blood gas (ABG) results are pH 7.34, PaCO2 50, HCO3 24, PaO2 87. Which intervention should the nurse implement first? 1. Have the client turn, cough, and deep breathe. 2. Place the client on oxygen via nasal cannula. 3. Check the client's pulse oximeter reading. 4. Notify the HCP of the ABG results.
1 1. These blood gases indicate respiratory acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn, cough, and deep breathe. 2. The PaO2 level is within normal limits, 80 to 100. Administering oxygen is not the first intervention.
52. The client involved in a motor vehicle accident is being prepped for surgery when the client asks the emergency department nurse, "What happened to my child?" The nurse knows the child is dead. Which statement is an example of the ethical principle of non-malfeasance? 1. "I will find out for you and let you know after surgery." 2. "I am sorry but your child died at the scene of the accident." 3. "You should concentrate on your surgery right now." 4. "You are concerned about your child. Would you like to talk?"
1 Nonmalfeasance means to do no harm. This statement is letting the client know that the concern has been heard but does not give the client bad news before surgery. The nurse is aware that someone having surgery should be of sound mind, and finding out your child is dead would be horrific.
16. The client in the intensive care unit is on a ventilator. Which interventions should the nurse implement? Select all that apply. 1. Ensure there is a manual resuscitation bag at the bedside. 2. Monitor the client's pulse oximeter reading every shift. 3. Assess the client's respiratory status every 2 hours. 4. Check the ventilator settings every 4 hours. 5. Collaborate with the respiratory therapist.
1, 3, 4, 5 1. There must be a manual resuscitation bag at the bedside in case the ventilator does not work appropriately. The nurse must use this to bag the client. 2. The pulse oximeter reading should be done more often than every shift. 3. The client's respiratory status should be assessed frequently—every 2 hours. 4. The ventilator's settings should be monitored throughout the shift. 5. The respiratory therapist is the member of the multidisciplinary team who is responsible for ventilators.
47. The nurse is caring for a client who has a chest tube. What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Assess the client's lung sounds. 2. Note the amount of suction being used. 3. Check the chest tube dressing for drainage. 4. Make sure that the chest tube is securely taped. 5. Place a bottle of sterile saline at the bedside.
1, 4, 3, 2, 5
38. 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 ceasing spontaneous breathing
1,2,3 Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator. A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.
124. The nurse should provide which home care instructions to a client who had a laryngectomy and has a stoma? Select all that apply. 1. Increase the humidity in the home. 2. Obtain and wear a MedicAlert bracelet. 3. Wear clothing that does not cover the stoma. 4. Stay away from people who have a respiratory infection. 5. Be careful with showering to avoid water entering the stoma. 6. Decrease fluid intake to prevent excessive secretions from the stoma.
1,2,4,5
23. The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? (SATA) 1. Dyspnea 2. Headache 3. Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum
1,3,4,5
8. The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1. Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members, for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.
1,3,4,5
80. Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.
1,3,4,5
74. The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging.
1.
82. The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) L/day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.
1. Increase fluid intake to two (2) to three (3) L/day. 1. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE.
71. 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. Answer: 1. Inflate the cuff on the tracheostomy tube. Rationale: Tracheostomy tubes are available in many sizes and are made of plastic or metal. The tubes may be reusable; however, most tubes are disposable. A tracheostomy tube may or may not have a cuff. It also may have an inner cannula. For clients receiving mechanical ventilation, a cuffed tube is used. A noncuffed tube may be used when mechanical ventilation is not required. If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration
1. Inflate the cuff on the tracheostomy tube.
99. The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.
1. Low arterial oxygen when administering high concentration of oxygen. 1. The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.
60. 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 (FiO2) that is 10% higher than a ventilator setting.
2,3,5
13. The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? 1. Check the tubing for any dependent loops. 2. Auscultate the client's posterior breath sounds. 3. Prepare to remove the client's chest tubes. 4. Notify the HCP that the lungs have re-expanded.
2. Auscultate the client's posterior breath sounds. After 3 days, the nurse should assess the lung sounds to determine whether the lungs have re-expanded. This would be the nurse's first intervention.
15. The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube. Which intervention should the nurse include in the plan of care? 1. Inspect the insertion line at the naris prior to instilling formula. 2. Elevate the head of the bed after feeding the client. 3. Place the client in the Sims position following each feeding. 4. Change the dressing on the feeding tube every three (3) days.
2. Elevate the head of the bed after feeding the client. Elevating the head of the bed uses gravity to keep the formula in the gastric cavity and help prevent it from refluxing into the esophagus, which predisposes the client to aspiration.
51. The nurse is discussing cancer statistics with a group from the community. Which information about death rates from lung cancer is accurate? 1. Lung cancer has a low mortality rate because of new treatment options. 2. Lung cancer is the number-one cause of cancer deaths in both men and women. 3. Lung cancer deaths are not significant in relation to other cancers. 4. Lung cancer deaths have continued to increase in the male population.
2. Lung cancer is the number-one cause of cancer deaths in both men and women
7. The client who is 1 day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? 1. Assess the client's pulse oximeter reading. 2. Notify the Rapid Response Team. 3. Place the client in the Trendelenburg position. 4. Check the client's surgical dressing.
2. Notify the Rapid Response Team.
12. The primary nurse in the critical care respiratory unit is very busy. Which nursing task should be the nurse's priority? 1. Assist the HCP with a sterile dressing change for a client with a left pneumonectomy. 2. Obtain a tracheostomy tray for a client who is exhibiting air hunger. 3. Transcribe orders for a client with cystic fibrosis who was transferred from the ED. 4. Assess the client diagnosed with mesothelioma who is upset, angry, and crying.
2. Obtain a tracheostomy tray for a client who is exhibiting air hunger.
84. The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first? 1. Administer oxygen 10 L via nasal cannula. 2. Place the client in high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.
2. Place the client in high Fowler's position.
58. The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse? 1. The client has an intake of 1,500 mL IV and an output of 1,000 mL. 2. The client has 450 mL of bright-red drainage in the chest tube. 3. The client is complaining of pain at a "10" on a 1-to-10 scale. 4. The client has absent lung sounds on the side of the surgery.
2. The client has 450 mL of bright-red drainage in the chest tube.
39. The home health client is diagnosed with chronic obstructive disease. The unlicensed assistive personnel (UAP) tells the home health nurse that the client has trouble breathing when the client lies in a supine position. Which priority instruction should the nurse provide to the UAP? 1. To ensure the client's oxygen is in place correctly. 2. To allow the client to sleep in a recliner. 3. To allow a fan to blow on the client when lying in bed. 4. To have the client take slow, deep breaths.
2. To allow the client to sleep in a recliner.
51. The healthcare provider ordered the loop diuretic, bumetanide (Bumex), to be administered STAT to a client diagnosed with pulmonary edema. After 4 hours, which of the following assessment data indicates the client may be experiencing a complication of the medication? 1. The client develops jugular vein distention. 2. The client has bilateral rales and rhonchi. 3. The client complains of painful leg cramps. 4. The client's output is greater than the intake.
3 Leg cramps may indicate a low serum potassium level, which can occur as a result of the administration of a diuretic.
24. The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1. Chest x-ray 2. Bronchoscopy 3. Sputum culture 4. Tuberculin skin test Answer: 3. Sputum culture
3. Skin test is presumptive
8. The client in the post-anesthesia care unit (PACU) has noisy and irregular respirations (Rs) with a pulse oximeter reading of 89%. Which intervention should the PACU nurse implement first? 1. Increase the client's oxygen rate via nasal cannula. 2. Notify the respiratory therapist to draw arterial blood gases. 3. Tilt the head back and push forward on the angle of the lower jaw. 4. Obtain an intubation tray and prepare for emergency intubation.
3. The client is exhibiting signs/symptoms of hypo-pharyngeal obstruction, and this maneuver pulls the tongue forward and opens the air passage.
33. The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? 1. Tape the ET tube in place, and note the centimeter marking at the lip line. 2. Ask the radiology department to obtain a stat portable radiograph at the client's bedside. 3. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 4. Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.
3. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.
17. The unlicensed assistive personnel (UAP) is bathing the client diagnosed with adult acute respiratory distress syndrome (ARDS) who is on a ventilator. The bed is in the high position with the opposite side rail elevated. Which action should the ICU nurse take? 1. Demonstrate the correct technique when giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Explain that the client on a ventilator should not be bathed. 4. Give the UAP praise for performing the bath safely
4.
57. The client in the intensive care unit (ICU) has been on a ventilator for 2 weeks with an endotracheal tube in place. Which intervention should the nurse prepare the client for next? 1. Transfer to a long-term care facility. 2. Daily arterial blood gases. 3. Removal of life support. 4. Placement of a tracheostomy.
4. A client who has been intubated for 10 to 14 days and still requires mechanical ventilation should have a surgically placed tracheostomy to prevent permanent vocal cord damage.
81. Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a Medic Alert band at all times."
4. "I will wear a Medic Alert band at all times."
6. The client who is 2 days postoperative following a left pneumonectomy has an apical pulse (AP) rate of 128 beats per minute and a blood pressure (BP) of 80/50 mm Hg. Which intervention should the nurse implement first? 1. Notify the healthcare provider (HCP) immediately. 2. Assess the client's incisional wound. 3. Prepare to administer dopamine, a vasopressor. 4. Increase the client's intravenous (IV) rate.
4. Increase the client's intravenous (IV) rate.
1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bedrest.
4. Institute and maintain bedrest. IV anticoagulants and not oral for PE
141. The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? 1. Rhonchi are auscultated. 2. Pleural friction rub is heard. 3. Fine crackles are auscultated. 4. Pulse oximetry reading is 96%.
Answer: 1. Rhonchi are auscultated. Rationale: Presence of rhonchi is an indication that there are secretions in the large airways.
72. 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 2 or 3 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."
Answer: 2. "I should perform arm exercises 2 or 3 times a day." Rationale: The client should be instructed to perform arm and shoulder exercises 2 or 3 times a day to prevent frozen shoulder. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the health care provider if these symptoms occur.
78. 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 (HCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation? 1. "It will enter the left main bronchus if inserted too far." 2. "It will enter the right main bronchus if inserted too far." 3. "It may enter the left main bronchus if not inserted far enough." 4. "It may enter the right main bronchus if not inserted far enough."
Answer: 2. "It will enter the right main bronchus if inserted too far."
89. The nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. How does the nurse correctly interpret these findings? 1. It is at the first tracheal cartilaginous ring. 2. It is at the bifurcation of the right and left main bronchi. 3. It is at the point at which the larynx connects to the trachea. 4. It is at the area connecting the oropharynx to the laryngopharynx.
Answer: 2. It is at the bifurcation of the right and left main bronchi.
37. The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with 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.
Answer: 2. Suction the ET tube. Rationale: Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed.
68. RESPIRATORY QUESTION: A client is receiving external radiation to the neck for cancer of the larynx. Which is the most likely expected effect? 1. Dyspnea 2. Diarrhea 3. Sore throat 4. Constipation
Answer: 3. Sore throat
48. The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time? 1. 1 or 2 days 2. 1 to 2 weeks 3. Almost 1 week 4. Several weeks to months
Answer: 4. Several weeks to months Rationale: The client with TB may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care
142. A client is returning from surgery after a pulmonary lobectomy. Which pieces of equipment should the nurse have at the bedside? Select all that apply. 1. Clamp 2. Code cart 3. Central line kit 4. Vaseline gauze 5. Tracheotomy set 6. Suction equipment
Answers: 1. Clamp 4. Vaseline gauze 6. Suction equipment
35. The home health nurse is visiting the client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) while the unlicensed assistive personnel (UAP) is providing care. Which action by the UAP would warrant intervention by the nurse? 1. Keeping the bedroom at a warm temperature. 2. Maintaining the client's oxygen rate at 2 L/min. 3. Helping the client sit in the orthopneic position. 4. Allowing the client to sleep in the recliner.
Correct answer: 1 1. The client with end-stage COPD usually prefers a cool climate, with fans to help ease breathing. A warm area would increase the effort the client would require to breathe. This action would warrant intervention by the nurse.
62. The client diagnosed with acute respiratory distress syndrome (ARDS) is having increased difficulty breathing. The arterial blood gas indicates an arterial oxygen level of 54% on O2 at 10 LPM. Which intervention should the intensive care unit nurse implement first? 1. Prepare the client for intubation. 2. Bag the client with a bag/mask device. 3. Call a Code Blue and initiate cardiopulmonary resuscitation (CPR). 4. Start an IV with an 18-gauge catheter.
Correct answer: 1 Acute respiratory distress syndrome is diagnosed when the client has an arterial blood gas of less than 50% while receiving oxygen at 10 LPM. The nurse should prepare for the client to be intubated.
34. The clinic nurse encounters a client who does not respond to verbal stimuli and initiates cardiopulmonary resuscitation (CPR). What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Open the client's airway. 2. Check the client's carotid pulse. 3. Assess the client for unresponsiveness. 4. Perform compressions at a 30:2 rate. 5. Pinch the nose and give two breaths.
Correct answer: 3, 4, 1, 5, 2
