resp nclex

A client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. The nurse determines that which data accurately indicate 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.

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 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

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

Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply.

Position on the side until fully recovered Encouraging coughing and deep breathing Monitoring pulse oximetry readings frequently Encouraging the use of an incentive spirometer

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

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

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 with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions should be done? Select all that apply.

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

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 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 told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply.

Enables the client to speak, Must have the cuff deflated when capped

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse should monitor the status of breath sounds in that area by placing the stethoscope in which location?

In the fifth intercostal space

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 monitoring a client for Biot's respirations. Which condition causes Biot's respirations?

Neurological disorders

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

Notify the registered nurse. Begin low-flow oxygen therapy V.S.

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

Obtain a culture and sensitivity of sputum.

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

he 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 should the nurse instruct the client to assume?

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

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.

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.

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

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