Respiratory System

A client is admitted to an intensive care unit with a diagnosis of acute respiratory distress syndrome (ARDS). Which clinical finding would the nurse expect when assessing this client? 1. Hypertension 2. Tenacious sputum 3. Altered mental status 4. Slowed rate of breathing

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The nurse reviews the results of a client's preoperative chest radiograph. The radiograph reveals that the client has pulmonary tuberculosis. Which evidence of tuberculosis is provided by the radiograph? 1. Cavities caused by caseation 2. Sensitized T cells 3. Presence of acid-fast bacilli 4. Microscopic primary infection

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A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention? 1. Administer opioids frequently. 2. Assess for signs of pneumonia. 3. Give medication to suppress coughing. 4. Limit fluid intake to prevent pulmonary edema.

2

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action? 1. Obtain vital signs. 2. Administer oxygen. 3. Notify the health care provider. 4. Auscultate the client's lung sounds

2

When a client who has seemed cheerful after a diagnosis of lung cancer and pneumonectomy becomes withdrawn after being discharged home, which action by the home health nurse will be best? 1. Suggest that an antidepressant may be helpful. 2. Ask the client to describe the current emotional state. 3. Reassure the client that depression is a normal reaction. 4. Ask the health care provider to make a mental health referral.

2

Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? 1. Apply a thoracic binder for support. 2. Encourage coughing and deep breathing. 3. Defer pain medication the first day after injury. 4. Position the client face-down on a soft mattress.

2

A client is admitted to the emergency department with a stab wound of the chest. Which is a priority nursing assessment? 1. Level of pain 2. Quality and depth of respirations 3. Amount of serosanguinous drainage 4. Blood pressure and pupillary response

2

A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue? 1. Provide small, frequent meals. 2. Encourage pursed-lip breathing. 3. Schedule nursing activities to allow for rest. 4. Encourage bed rest until energy level improves.

2

A client with a 10-year history of emphysema is hospitalized for acute respiratory distress. Which assessment finding would the nurse expect to identify? 1. Chest pain on inspiration 2. Prolonged expiration with use of accessory muscles 3. Signs and symptoms of respiratory alkalosis 4. Decreased respiratory rate

2

A client is admitted to the hospital with a diagnosis of emphysema. When teaching the client about breathing exercises, the nurse would include which instruction? 1. Spend more time inhaling than exhaling to blow off carbon dioxide. 2. Perform sit-ups to strengthen abdominal muscles to improve breathing. 3. Perform diaphragmatic exercises to improve contraction of the diaphragm. 4. Use abdominal exercises to limit the use of accessory muscles of respiration.

3

Which instruction would the nurse teach the client concerned about dislodging a laryngectomy tube at a 3-week postoperative follow-up visit? 1. Reinsert another tube immediately. 2. Notify the health care provider at once. 3. Keep calm because this is not an immediate emergency. 4. Quickly take action to prevent the tracheal stoma from closing

3

When a client in the clinic is offered the influenza vaccine and states, "I had the vaccination already last year, so I won't need it now," which response will the nurse give? 1. "The flu vaccine is recommended for everyone." 2. "You only need 1 flu shot in your lifetime to achieve immunity." 3. "As long as you are younger than 50 years old, you will not really need vaccination." 4. "The immunization changes, so you need to get vaccine annually to stay protected."

4

When a client is scheduled for a mediastinoscopy, which action will the nurse plan to take? 1. Ask about iodine or shellfish allergy. 2. Teach that local anesthesia will be used. 3. Keep client on bed rest before procedure. 4. Check that the informed consent is signed

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