Respiratory from NCLEX book

Paradoxical chest movement

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

Complaints of night sweats

A nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note?

maintain airway patency & prevent aspiration

If the client begins to hemorrhage from the surgical site following radical neck dissection, the nurse elevates the head of the bed to

Avoid foods that are highly seasoned.

The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client?

Displacement of the ET

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?

Perform the Valsalva maneuver

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?

suction, Vaseline gauze, & a clamp

The nurse should anticipate that a client with a lobectomy will have a chest tube and will need ___ at the bedside for emergency use

Lobes

A RN and an UAP are assisting the respiratory therapist to position a client for postural drainage. The UAP asks theRN how the respiratory therapist selects the position to be used for the procedure. The RN responds that a position is chosen that will use gravity to help drain secretions from

Contact the HCP

A RN is caring for a client who had tb skin testing (Mantoux test) 48 hours ago on admission to the nursing unit. The RN reads the test result as positive. Which action by the RN has the highest priority?

Serosanguineous

A RN is caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The RN should assess for which characteristic of wound drainage expected in the immediate postoperative period?

The bifurcation of right & left main bronchi

A RN is reading the report for a chest x-ray study in a pt who has just been intubated. The report states that the tip of the ET lies 1 cm above the carina. The RN determines that the tube is positioned above which area of the respiratory system?

Maintain inflation of the alveoli.

A RN is reinforcing instructions to a pt about the use of an incentive spirometer. The RN tells the pt to sustain the inhaled breath for 3 seconds. When the pt asks the RN about the rationale for this action, the RN explains that the primary benefit

Collapse of alveoli and ↓ compliance

A RN who is participating in pt care conference with other members of the health care team is discussing the condition of a pt with ARDS. The HCP states that as a result of fluid in the alveoli, surfactant production is falling. The RN understands that which is the natural consequence of insufficient surfactant?

Just under the left clavicle

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location?

Assist pt to a sitting position w/ head tilted forward.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?

Pleural pain and fever

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The RN should assess the client for which S/S associated with this problem?

Absence of dyspnea

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding?

Chest pain that occurs suddenly

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?

Plan short sessions with the client to obtain data

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?

Bloody

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?

tachypnea, tachycardia, dyspnea, & chest px

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism?

pt has mild ventilation restriction & fibrosis on chest x-ray

A client tells the nurse that a health care provider has stated a diagnosis of uncomplicated or simple silicosis and asks the nurse exactly what this means. What knowledge should the nurse use in formulating a response?

Blocked nasal passages that impair sense of smell

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. In formulating a response, the nurse understands that this is owing to which symptom?

The respiratory muscles relax.

A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses?

Admin of O2, intubation, & mechanical vent w/ + end-expiratory pressure

A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies?

RR of 16 breaths/min

A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status?

Dyspnea

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?

No symptoms

A client with uncomplicated or simple silicosis is being monitored yearly at the health care clinic. In this type of silicosis, which symptom should the nurse expect that the client will exhibit?

Petrolatum gauze & sterile 4 × 4 gauze

A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use?

Cough, dyspnea, chills & nightsweats

A 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?

Accumulation of respiratory secretions

A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding?

Disconnection of the ventilator tubing

A nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding?

Low arterial Pao2

A nurse is caring for a client with acute respiratory distress syndrome. What should the nurse expect to note in the client?

2L/min

A nurse is caring for a client with emphysema who has chronic hypercarbia and is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed which value?

The client's pH will fall.

A nurse is caring for a hospitalized client who is retaining Co2 because of respiratory disease. The nurse plans care, anticipating that which physical response will initially occur?

Cough

A nurse is caring for the client who is suspected of having lung cancer. The nurse should assess the client for which most frequent early symptom of lung cancer?

Bronchodilation

A nurse is monitoring the status of a client who is being treated for dyspnea. The nurse is aware that which factor will decrease the work of breathing for this client?

Obturator

A nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment should the nurse plan to have at the bedside when the client returns from surgery?

Moves downward and out

A nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because, in normal respiration, as the diaphragm contracts, it takes which action?

Anosmia, Chronic Cough, purulent nasal discharge

An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client?

2 to 4 weeks once medication therapy is initiated.

For a client who has been hospitalized and treated for tuberculosis, the RN should advise that a sputum culture is needed every

manually ventilate pt w/ a resuscitation device.

If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the nurse should

High pressure alarm sounds

Obstructions such as pt biting on tube, kinking of tube or mucous plugging that requires suctioning are all things that will set off _____ on ventilator

right sided heart function

Peripheral edema, jugular vein distention, and hepatojugular reflux all are indicators of impaired

↑the risk of atelectasis & pneumonia.

Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually

Aspiration of gastric contents during suctioning

The RN is caring for a client w/ a tracheostomy tube who is receiving mechanical ventilation. The RN is monitoring for complications R/T the tracheostomy & suspects tracheoesophageal fistula when which occurs?

A kink in the ventilator circuit

The RN is caring for a pt with an ET attached to a mechanical ventilator. The high-pressure alarm sounds, and the RN assesses the pt. The RN determines that the cause of the alarm is most likely to be due to which complication?

Percussion and vibration

The RN is discussing the techniques of chest physiotherapy and postural drainage to a pt having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The RN explains that after the pt is positioned for postural drainage the RN will perform which action to help loosen secretions?

Accumulation of pleural fluid in the inflamed area

The RN is providing care for a pt recently admitted with new onset pleurisy. Upon auscultation of the pt's lungs, the RN notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds?

Rapid, shallow respirations

The RN monitors the respiratory status of the client being treated for acute exacerbation of COPD. Which assessment finding would indicate deterioration in ventilation?

short periods of time

The T-piece requires that the client be removed from the mechanical ventilation for

after 2 to 3 weeks of medication therapy

The client diagnosed with TB generally is considered noncontagious

larger than 5 mm

The client with (HIV) infection is considered to have positive results on tuberculin skin testing with an area of induration

A cough with the expectoration of mucoid sputum

The community health nurse is conducting an educational session with community members regarding the symptoms associated with tuberculosis. Which is one of the first manifestations associated with tuberculosis?

Diminished breath sounds

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client?

Ventilate the client manually.

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?

end of the tube is placed in a bottle of sterile water held below the level of the chest

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. What initial nursing action should you do?

The chest tubes are obstructed.

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water-seal compartment has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence?

Continue to monitor the client

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water-seal chamber after the tube is inserted. Based on this assessment, which action is most appropriate?

I should perform arm exercises 2-3/day

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?

Promote carbon dioxide elimination

The nurse instructs a 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

↑Respiratory Rate

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Several weeks to months

The nurse is assessing a client with the typical clinical manifestations of tuberculosis. The nurse should expect the client to report having fatigue and cough that have been present for how long?

Pain, especially with inspiration

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

Bronchospasm

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?

Stridor

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client?

Water/kink in tubing, Biting on ET, ↑secretions in the airway

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?

Shortness of Breath

The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

Document the findings.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

Hypotension

The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem?

Coughing occurs with suctioning.

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?

Suction the ET tube.

The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider in this procedure, which is the initial nursing action?

Inflate the cuff on the trach tube.

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?

Deflate the cuff on the tube.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

N95 respirator, gown, and gloves

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which item when performing this care?

Hyperoxygenate the client.

The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action?

10 seconds

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?

the inhalation of spores from bird droppings

The nurse is providing an educational session to community members regarding histoplasmosis. The nurse should provide that it can be caused by

Lying on the back in a low-Fowler's position

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position that could aggravate breathing?

Sputum culture

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?

Exposure to TB

The nurse reads a client's tuberculin (Mantoux) skin test as positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation?

ventilating pt w/ an Ambu bag & auscultating for breath sounds bilaterally

The nurse verifies the placement of an ET tube immediately by

Suctioning the client every hour

The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction?

Grasp the retention sutures to spread the opening.

While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action?

Lung crackles

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema?

Negative

A nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result?

21%

A nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure?

Shunt unit

A nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. The nurse interprets this occurrence correctly as the presence of which physical response?

instruct the pt to avoid C/DB

A nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-Evac drainage system. Which intervention in the care plan indicates the need for further teaching for the student?

RR 22 breaths/min

A pt baseline VS are : temperature 98.8° F, PR 74, resp 18 breaths/min, and BP 124/76. The pt temp suddenly spikes to 103° F. Which RR should the RN anticipate in this pt as part of the body's response to the change in status?

↓in pt oxygen-based respiratory drive

A pt with COPD who is beginning oxygen therapy asks the RN why the flow rate cannot be ↑ to more than 2 to 4 L/min. The RN responds that this would be harmful because a higher oxygen flow rate could lead to a

Venturi mask

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed?

left sided heart function

Breath sounds are an accurate indicator of

air leak in the system

Constant bubbling occurring in the water seal chamber may indicate an

flushing, HA, ↓visual activity, ↓cerebral functioning, & slight breathlessness

Carbon monoxide levels between 11% and 20% result in

N/V, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia

Carbon monoxide levels between 21% to 40% result in

seizure & coma

Carbon monoxide levels between levels of 41% to 60% result in

a hyperinflated chest and a flattened diaphragm if the disease is advanced

Chest x-rays for a patient with COPD will reveal

Rhonchi are auscultated.

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted?