Respiratory System

A nurse is planning to administer oxygen to a client who is admitted with chronic obstructive pulmonary disease. The client has dyspnea and a low PaO2 level. Which of the following statements by the nurse is appropriate? Elevating oxygen concentration will promote coughing." "Administering oxygen at 6 L/min may decrease the respiratory drive." "Oxygen administration is contraindicated." "Maintain SpO2 of at least 85% with oxygen therapy."

"Administering oxygen at 6 L/min may decrease the respiratory drive."

The nurse is anticipating discharge for an assigned client following nasal surgery. Which of the following should be included in the discharge teaching for the client? (Select all that apply) A. Keep head elevated while sleeping either using 2 pillows or sleeping in a recliner chair B. Take aspirin for pain C. Use a cool moist humidifier to prevent nasal drying D. Blow your nose frequently to relieve any congestion E. Drink plenty of fluids unless otherwise ordered F. Apply warm compresses to the face

A. Keep head elevated while sleeping either using 2 pillows or sleeping in a recliner chair E. Drink plenty of fluids unless otherwise ordered

1. Entry of pathogens into respiratory system is inhibited by what protective mechanism? (Select all that apply) A. Lymphoid tissue in the pharynx B. Nasal filtration C. Mucus production in the alveoli D. Fluid in the parietal pleura E. Saliva in the oral cavity

A. Lymphoid tissue in the pharynx B. Nasal filtration

A nurse is attending an in-service about influenza. Which of the following statements can the nurse expect to hear regarding the difference between influenza and viral rhinitis? (Select all that apply) A. Muscle aches are common and can be severe with influenza B. Antibiotics may be given for wither is it is important to see a physician C. A runny nose is very common with a cold but not as common with the flu D. Individuals with influenza don't have much chest pain but it is common with a cold E. Symptoms of a cold usually have a slow onset but influenza symptoms often appear more sudden F. Sore throat is more common with cold than flu

A. Muscle aches are common and can be severe with influenza C. A runny nose is very common with a cold but not as common with the flu E. Symptoms of a cold usually have a slow onset but influenza symptoms often appear more sudden F. Sore throat is more common with cold than flu

A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse with inspiration. Which of the following is the priority nursing action? A. Obtain baseline vital signs and oxygen saturation. B. Obtain a sputum culture. C. Obtain a complete history from the client. D. Administer a pneumococcal vaccination.

A. Obtain baseline vital signs and oxygen saturation.

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure is in the client's room? (Select all that apply.) A. Oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit

A. Oxygen equipment C. Pulse oximeter D. Sterile dressing

A nurse is assisting with the reinforcement of information to a group of clients at a clinic about tuberculosis. Which of the following clinical manifestations should be included in the information? (Select all that apply.) A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum

A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum

A nurse is monitoring a client who had a thoracentesis. Which of the following are appropriate nursing actions? (Select all that apply.) A. Position the client in high-Fowler's. B. Monitor chest tube drainage. C. Observe for evidence of infection. D. Auscultate lung sounds every 6 hr. E. Check the client's SaO2.

A. Position the client in high-Fowler's. B. Monitor chest tube drainage. C. Observe for evidence of infection. E. Check the client's SaO2.

A nurse is caring for a client who is on oxygen therapy. Which of the following actions should the nurse take to ensure safe administration. (Select all that apply.) A. Post "Oxygen in Use" signs to alert others. B. Know where the closest fire extinguisher is located. C. Have client wear wool fabrics. D. Check that all electric machinery is grounded. E. Use alcohol products.

A. Post "Oxygen in Use" signs to alert others. B. Know where the closest fire extinguisher is located. D. Check that all electric machinery is grounded.

A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Pallor

A. Restlessness B. Tachypnea E. Pallor

A nurse is caring for a client who has pneumonia. Findings include temperature 37.8° C (100° F), respirations 30/min, BP 130/76 mm Hg, heart rate 100/min, and SaO2 91% on room air. Using a scale of 1 to 4, with 1 being the highest priority, prioritize the following nursing interventions. A. Administer antibiotics. B. Administer oxygen therapy. C. Perform a sputum culture. D. Administer an antipyretic medication.

A. STEP 3: Administration of antibiotics is the third action the nurse should take. The sputum culture should be obtained prior to antibiotic administration. B. STEP 1: The client's respiratory and heart rates are elevated, and her oxygen saturation is 91% on room air. The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to provide oxygen. C. STEP 2: Obtaining a sputum culture is the second nursing intervention. It should be done prior to administering oral medications to obtain an appropriate and adequate specimen. D. STEP 4: Administering an antipyretic medication is the fourth nursing intervention.

The nurse is preparing to administer oxygen as ordered by the physician via a face mask to a client admitted with hypothermia secondary to exposure to the elements. What important nursing intervention will the nurse perform specific to the needs of this client A. apply a heated humidifier B. turn on oxygen flow to 15 liters per minute C. suction the oropharynx before placing the face mask D. pad the sides of the mask

A. apply a heated humidifier

The nurse caring for a client with a chest tube to water seal is bathing and changing the linen when the sealed drainage system becomes damaged and the client suddenly becomes short of breath. The nurse's priority action is to A. clamp the chest tube closer to the client B. have the client cough forcefully C. connect a new sealed drainage system D. notify the charge nurse and physician

A. clamp the chest tube closer to the client

. The nurse is providing education for a client on how to avoid contracting influenza and secondary bacterial infection. Which of the following measures should be included in the teaching? (Select all that apply) A. influenza vaccination B. increases intake of vitamin B C. prophylactic antibiotic D. good hand washing E. avoiding crowds during flu season F. avoiding sharing of eating or drinking utensils

A. influenza vaccination D. good hand washing E. avoiding crowds during flu season F. avoiding sharing of eating or drinking utensils

. The nurse is caring for a client on the physician's office who wished to quit smoking. The client asks the nurse, "If I quit smoking will my risk of lung cancer be the same as a non-smokers?" The nurse's best response includes which of the following A. the risk of lung cancer will decline if he quits but it will be higher than for someone who never smoked B. the risk of lung cancer will return to the same level as that for a person who never smoked C. the clients risk for lung cancer will never drop because the damage has already been done D. no one knows for sure what the risk for someone who quits smoking

A. the risk of lung cancer will decline if he quits but it will be higher than for someone who never smoked

A nurse in the ICU is assisting with the care of a client who has acute respiratory distress syndrome (ARDS) and is receiving mechanical ventilation via an endotracheal tube. The provider plans to extubate her within the next 24 hr. Which of the following is an important criterion for extubating this client? Ability to cough effectively Adequate tidal volume without positive pressure No indications of infection No need for supplemental oxygen

Adequate tidal volume without positive pressure

A nurse is caring for a client who has a femur fracture and, 8 hr after the injury, reports a sudden onset of dyspnea and severe chest pain. Which action should the nurse takes first? Administer oxygen. Prepare for an ICU transfer. Increase the IV fluid infusion rate. Administer pain medication

Administer oxygen.

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? Initiating oxygen therapy Providing immediate rest for the client Positioning the client in high-Fowler's Administering a nebulized beta-adrenergic

Administering a nebulized beta-adrenergic

A nurse in an emergency department is preparing to care for a client who is brought in with multiple system traumas following a motor vehicle crash. Which of the following is the priority focus of care? Airway protection Decreasing intracranial pressure Stabilizing cardiac arrhythmias Preventing musculoskeletal disability

Airway protection

A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first? Fluticasone (Flovent) Budesonide (Pulmicort) Montelukast (Singulair) Albuterol (Proventil)

Albuterol (Proventil)

A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? Cromolyn (Intal) via metered-dose inhaler Oral montelukast (Singular) Budesonide (Pulmicort) via dry-powder inhaler Albuterol (Proventil) via jet nebulizer

Albuterol (Proventil) via jet nebulizer

A nurse is planning care for a client who has quadriplegia. Which of the following nursing actions are most essential for prevention of pulmonary emboli (PE)? (Select all that apply.) Assess legs for redness Apply elastic compression stocking Perform passive range of motion exercises Monitor INR results Massage calves every shift

Assess legs for redness Apply elastic compression stocking Perform passive range of motion exercises Monitor INR results

A nurse collecting data from a client who is 2 days postoperative auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?' Atelectasis Rales Rhonchi Pneumothorax

Atelectasis

A nurse is caring for a client who is postoperative and has developed pneumonia. Which of the following is a possible complication of the pneumonia? Hemorrhage Atelectasis Thrombosis Edema

Atelectasis

A nurse is teaching a group of clients about influenza. Which of the following statements by a client requires clarification? A. "I should wash my hands after blowing my nose to prevent spreading the virus." B. "I need to avoid drinking fluids if I develop symptoms." C. "I need a flu shot every year because of the different flu strains." D. "I should sneeze into my elbow rather than my hands."

B. "I need to avoid drinking fluids if I develop symptoms."

3. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day." C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath."

B. "I take antacids several times a day."

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following statements by the client indicates the teaching was effective? A. "This medication can decrease my immune response." B. "I take this medication to prevent asthma attacks." C. "I need to take this medication with food." D. "This medication has a slow onset to treat my symptoms."

B. "I take this medication to prevent asthma attacks."

A nurse is reinforcing teaching to a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid (Nydrazid) 250 mg PO daily, rifampin (Rifadin) 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol (Myambutol) 1 mg PO daily. Which of the following client statements indicate understanding of the teaching? (Select all that apply.) A. "I can substitute one medication for another if I run out because they all fight infection." B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." D. "I am glad I don't have to have any more sputum specimens." E. "I don't need to worry where I go once I start taking my medications."

B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area."

2. A nurse is reinforcing information to the client's family about the purpose of administering vecuronium to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "This medication is given to treat infection." B. "This medication is given to facilitate ventilation." C. "This medication is given to decrease inflammation." D. "This medication is given to reduce anxiety."

B. "This medication is given to facilitate ventilation."

A nurse is reinforcing teaching a client who has tuberculosis. Which of the following statements should the nurse include when reinforcing the teaching? A. "You will need to continue to take the multimedication regimen for 4 months." B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times."

B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication."

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client to Fowler's position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases

B. Assist the client to Fowler's position

4. A nurse is collecting data on a client who has asthma. Which of the following is a risk factor associated with this disease? A. Male gender B. Environmental allergies C. Alcohol use D. Caucasian race

B. Environmental allergies

A nurse is collecting data from a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration D. Exposed sutures without dressing E. Drainage system upright at chest level

B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal

The nurse admits a 14 month old infant with a history of prematurity born at 25 weeks gestation to the pediatric unit. The mother reports that the infant has had several episodes of sudden respiratory distress with coughing, shortness of breath, circumpolar cyanosis and retractions. When the client is diagnosed with asthma the mother asks the nurse, "will this be a problem he'll have for the rest of his life?" The nurse's best response is: A. "Yes, but there are ways to reduce the frequency of episodes." B. It's possible this could be a lifelong problem or he could outgrow it as he grows C. Everyone is different so is hard to predict what will happen D. He will probably always be asthmatic because he was born prematurely

B. It's possible this could be a lifelong problem or he could outgrow it as he grows

2. A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A. Monitor the client's pain level. B. Obtain a large-bore IV needle for decompression. C. Administer lorazepam (Ativan). D. Prepare the client for chest tube insertion.

B. Obtain a large-bore IV needle for decompression.

A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxemia? (Select all that apply.) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

B. Pale skin E. Elevated blood pressure

4. A nurse is collecting data on a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? (Select all that apply.) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

B. Pleural friction rub D. Petechiae E. Tachycardia

4. A nurse is assisting in the plan of care for a client who has severe acute respiratory distress syndrome (SARS). Which of the following should be included in the plan of care for this client? (Select all that apply.) A. Administration of antibiotics B. Providing supplemental oxygen C. Administration of antiviral medications D. Administration of bronchodilators E. Maintaining ventilatory support

B. Providing supplemental oxygen D. Administration of bronchodilators E. Maintaining ventilatory support

A nurse is caring for a client who is receiving mechanical ventilation. Which mode of ventilation increases the effort of the client's respiratory muscles? (Select all that apply.) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation

A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

B. Venturi mask

A nurse in an urgent care center is caring for a client who is having an acute asthma attack. Which of the following indicates the client's respiratory status is declining? (Select all that apply.) A. SaO2 95% B. Wheezing C. Retraction of sternal muscles D. Pink mucous membranes E. Premature ventricular complexes (PVCs)

B. Wheezing C. Retraction of sternal muscles E. Premature ventricular complexes (PVCs)

The Nurse admits an alert client with a diagnosis of pneumonia and assesses vital signs and oxygen saturation. The client's respiratory rate is 26 and oxygen saturation is 89%. What actions can the nurse take independently to support respirations and reduce hypoxia? A. Apply oxygen B. raise the head of the bed C. Administer a bronchodilator D. Insert an oral airway

B. raise the head of the bed

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? Pigeon Funnel Kyphotic Barrel

Barrel

2. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are heart rate 117/min, respiratory rate 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following actions is the priority action at this time? A. Notify the provider. B. Administer heparin via IV infusion. C. Administer oxygen therapy. D. Obtain a spiral CT scan.

C. Administer oxygen therapy.

A nurse is assisting in the care of a client who has ARDS with absent breath sounds in the lower lobes and dyspnea. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Prepare for chest tube insertion. C. Administer oxygen via a high-flow mask. D. Initiate IV access.

C. Administer oxygen via a high-flow mask.

The nurse is caring for a client scheduled to have a ventilation diffusion scan to determine if the clients hypoxia caused by a problem on ventilation or the respiration. The nurse would suspect a ventilation problem in the client diagnosed with: A. Pulmonary hypertension B. Emphysema C. Amyotrophic lateral sclerosis D. Pulmonary emboli

C. Amyotrophic lateral sclerosis

The nurse is caring for an elderly client who fell down a flight of stairs and experienced a closed head injury. Secondary to loss of respiratory drive caused by increased intracranial pressure the client had a tracheostomy placed. When the daughter visits she asks the nurse, "Are you making sure dad uses his CPAP at night? Because he has sleep apnea." What is the nurse's best response? A. I will inform the doctor and get an order for respiratory therapy to set up a machine before bed tonight B. He doesn't need his CPAP at night anymore, but ill remind the doctor to order it just in case he has problems C. CPAP was prescribed to keep the airway open. Now his tracheostomy will do that and he won't need it until the tracheostomy is closed D. When a client is critically ill and monitored on a cardiorespiratory monitor he doesn't need his CPAP because well know if he stops breathing

C. CPAP was prescribed to keep the airway open. Now his tracheostomy will do that and he won't need it until the tracheostomy is closed

A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. Report any nasal stuffiness, nausea, or fatigue. E. Post "no smoking" signs in a prominent location.

C. Check the position of the cannula frequently. D. Report any nasal stuffiness, nausea, or fatigue. E. Post "no smoking" signs in a prominent location.

The nurse is caring for a client with emphysema. When the nurse enters the client's room, the spouse asks the nurse for the oxygen to be increased because the client is having trouble breathing. The nurse's best intervention is A. Call the physician for an order to increase the oxygen delivered B. Increase the oxygen and monitor the oxygen saturation C. Explain that increasing the oxygen will decrease respiration and make him more sob D. Tell the spouse that increasing oxygen is not possibly

C. Explain that increasing the oxygen will decrease respiration and make him more sob

A nurse is caring for a client who has dyspnea. In which of the following positions should the nurse place the client? A. Supine B. Dorsal recumbent C. Fowler's D. Lateral

C. Fowler's

A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count

C. Incident of exercise-induced asthma 1 week ago

The nurse admits a client who prefers naturopathic remedies whenever possible and who is reporting rhinorrhea chest congestion with dry cough and low grade fever the physician diagnosed a common cold and prescribes OTC palliative treatment. What recommendations can the nurse make in keeping with the clients beliefs A. Take acetaminophen for fever B. Pseudoephedrine for rhinorrhea C. Increase water intake for cough D. Inhale cold air to open airways

C. Increase water intake for cough

5. A nurse is contributing to the plan to instruct a client on how to perform pursed lip breathing. Which of the following should the nurse include in the instructions? A. Take quick breaths upon inhalation. B. Place your hand over your stomach. C. Take a deep breath in through your nose. D. Puff your checks upon exhalation.

C. Take a deep breath in through your nose.

The nurse is caring for a client who just had a bronchoscopy performed and is asking for a drink of water, reporting that his mouth feels very dry. The nurse: A. Gets the client a small glass of water to sip on B. Informs the client he is not allowed to have water C. Tests the clients gag and swallow reflexes D. Uses a lemon glycerine swab to moisten the oral cavity

C. Tests the clients gag and swallow reflexes

. The client with a closed head injury must be carefully monitored by the nurse because she could stop breathing or have inadequate respiratory effort due to what? A. The accident that injured the head might also have injured the chest B. The clients reduced level of consciousness might cause the tongue to block the airway C. The respiratory control mechanism is in the brain and increased cerebral edema could damage its functions D. Closed head injuries mainly occur in very young children whose airways are very narrow and easily occluded

C. The respiratory control mechanism is in the brain and increased cerebral edema could damage its functions

the nurse anticipates which of the following prescribed treatments for a client with symptoms of a cold (viral rhinitis)? (Select all that apply) A. bronchodilator B. steroids C. decongestants D. rest E. antibacterial agents F. fluids

C. decongestants D. rest F. fluids

. The nurse admits a client with a diagnosis of pneumonia with moderate respiratory distress requiring oxygen by nasal cannula. What diagnostic test does the nurse anticipate will be ordered to confirm the cause of the infection? A. CBC with differential B. ELISA C. sputum culture D. biopsy

C. sputum culture

The nurse discovers that the client suddenly has become short of breath. Which of the following assessment findings would increase the nurse's suspicions of a spontaneous pneumothorax of the left lung? (Select all that apply) A. diminished breath sounds in the bases bilaterally with rhonchi in the lower lobe B. trachea is at the midline C. subcutananious emphysema palpable on the left side of the chest D. absence breath sounds on the left side of the chest E. tachycardia and tachypnea

C. subcutananious emphysema palpable on the left side of the chest D. absence breath sounds on the left side of the chest E. tachycardia and tachypnea

The nurse working in an outpatient clinic sees a mother run into the center holding a toddler by the ankles pounding on his back while yelling, "Help me please! He's choking and I can't get it out." What is the nurse's priority intervention? A. call 911 B. call the doctor C. take the child from the mother and assess airway D. take the child from the mother and assess the child for pulse

C. take the child from the mother and assess airway

A nurse is reinforcing discharge teaching to a client who is prescribed home oxygen therapy. Which of the following statements by the client indicates a need for further teaching? "I will be able to tell how much oxygen is being delivered by looking at the flow meter." "I should call my doctor if I experience a decreased ability to concentrate." "I will ensure that visitors smoke outside." "I should see a frosty buildup on the tank when I refill my portable oxygen."

"I should see a frosty buildup on the tank when I refill my portable oxygen."

A nurse is reinforcing teaching with the parents of a child who has a streptococcal infection about preventing disease transmission. Which of the following instructions should the nurse include? "I'll continue to encourage him to drink lots of fluids." "I'll take his temperature every 4 hr." "I'll give him Tylenol for the pain." "I'll discard his toothbrush and buy another."

"I'll discard his toothbrush and buy another."

A nurse is talking with a client about how to use montelukast (Singulair) to treat asthma. Which of the following client statements should indicate that the client understood the nurse's instructions? "I'll rinse my mouth after taking this medication." "I'll take this medication when I get an asthma attack." "I'll take this medication once a day in the evening." "I'll take this medication with meals."

"I'll take this medication once a day in the evening."

A nurse is planning to prioritize client care after receiving report and rounded on assigned patients. Which of the following client's is a high priority for the nurse to see first? A client who is ambulatory and going for an x-ray at 10:00 A.M. A client who is to be discharged at 11:00 A.M. A client who received pain medication 30 minutes ago. A client who is short of breath.

A client who is short of breath.

A nurse is caring for a group of clients. Which of the following clients should the nurse know has an increased risk of aspiration while eating? (Select all that apply.) A client who has a new diagnosis of gastro esophageal reflux disease A client who was admitted with a diagnosis of cerebrovascular accident A client who is 4 hr postoperative following a leg amputation with general anesthesia A client who is 8 hr following traumatic laryngeal nerve damage A client who has a prior shift admission with a recent prolonged coughing episode

A client who was admitted with a diagnosis of cerebrovascular accident A client who is 4 hr postoperative following a leg amputation with general anesthesia A client who is 8 hr following traumatic laryngeal nerve damage A client who has a prior shift admission with a recent prolonged coughing episode

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.

A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward.

A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis? Oral mucosa Finger tips Ear lobes Eye lids

Oral mucosa

A nurse is caring for a client who has asthma. The client is prescribed fluticasone (Flovent). Which of the following is a common adverse effect from this inhalant? Hyperglycemia Hypertension Adrenocortical dysfunction Oropharyngeal candidiasis

Oropharyngeal candidiasis

A nurse is assisting with the discharge plan of a client who has a permanent tracheostomy. The nurse should verify the availability of which of the following equipment (Select all that apply.) Stethoscope Oxygen Suction machine Portable ventilator Replacement cannula

Oxygen Suction machine Replacement cannula

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following is the nurse's monitoring priority? Palpating peripheral pulses Auscultating heart sounds Confirming gag reflex Measuring BP

Confirming gag reflex

A nurse is caring for an older adult client who is physically frail and who has been in bed for more than a week. Which of the following clinical manifestations indicates to the nurse that the client is developing pneumonia? Chills Cough Confusion Chest pain

Confusion

3. A nurse is reinforcing client instructions on the use of an incentive spirometer. Which of the following statements made by the client indicates an understanding of the teaching? A. "I will place the adapter on my finger to read my blood oxygen saturation level." B. "I will lie on my back with my knees bent." C. "I will rest my hand over my abdomen to create resistance." D. "I will take in a deep breath and hold it before exhaling."

D. "I will take in a deep breath and hold it before exhaling."

3. A nurse is reinforcing discharge instructions for a client who experienced a pneumothorax. Which of the following should be included in the instructions? A. "Notify your provider if you experience weakness." B. "You should be able to return to work in 1 week." C. "You need to wear a mask when in crowded areas." D. "Notify your provider if you experience a cough."

D. "Notify your provider if you experience a cough."

A nurse is determining a health promotion activity to assist clients in making positive lifestyle choices. Which of the following indicates an appropriate promotional activity? Present instruction on how to use crutches. Present a class on how to serve others at a soup kitchen. Present a class on the risks of tobacco use Present information on how to pick ripe fresh fruits and vegetables.

Present a class on the risks of tobacco use

2. Two hours after admission to a medical-surgical unit, a client's SaO2 is 91% and he is exhibiting audible wheezes and use of his accessory muscles. Which of the following medications should the nurse caring for the client expect to administer? A. Antibiotic B. Beta-blocker C. Antiviral D. Beta2 agonist

D. Beta2 agonist

A nurse is collecting data from a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Laryngospasms

D. Laryngospasms

A nurse in a clinic is caring for a client who has sinusitis. Which of the following techniques should the nurse use to identify clinical manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctivae D. Palpation of the orbital areas

D. Palpation of the orbital areas

A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side. B. Use the incentive spirometer. C. Cough at regular intervals. D. Perform the Valsalva maneuver.

D. Perform the Valsalva maneuver.

A nurse enters a client's room to administer morning medications and finds the client lying in bed and vomiting. Which of the following is the priority action by the nurse? Provide an emesis basin. Notify housekeeping. Prevent aspiration. Administer an antiemetic.

Prevent aspiration.

A nurse is assigned a group of postoperative clients. Which of the following findings should be of most concern to the nurse? Pulse Ox. 88% Nonproductive cough Shallow respirations 22/min Scattered pulmonary crackles bilaterally

Pulse Ox. 88%

A nurse is preparing to measure a client's level of oxygen saturation and notes edema of both of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations? Finger Earlobe Toe Skin fold

Earlobe

A nurse is reinforcing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide (Lasix). Which of the following instructions should the nurse include? Take aspirin if headaches develop. Eat foods that contain plenty of potassium. Expect some swelling in the hands and feet. Take the medication at bedtime.

Eat foods that contain plenty of potassium.

A nurse enters a client's room to administer medication, and finds the client in bed, pale, and with labored and fast respirations. Which of the following actions should the nurse takes first? Call the rapid response team Elevate the head of the bed Request a chest x-ray Check the client's vital signs

Elevate the head of the bed

On auscultation of a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following is the appropriate nursing intervention? Repeat auscultation after asking the client to breathe deeply and cough. Instruct the client to limit fluid intake to less than 2,000 mL/day. Prepare to administer antibiotics. Place the client on bed rest in semi-Fowler's position.

Repeat auscultation after asking the client to breathe deeply and cough.

A nurse is collecting data from a client who has bronchitis. Which of the following findings should the nurse expect to auscultate? Dullness Resonance Tympany Flatness

Resonance

A client experienced angioedema in response to losartan (Cozaar). Which of the following data indicates a therapeutic response to treatment? Respirations are unlabored. Client reports decreased groin pain of 3 on a 1-10 scale. Blood pressure when arising from resting position is at premedication levels. Client tolerates ordered dose of medication with no greater than 1+ peripheral edema.

Respirations are unlabored.

A nurse is caring for a client who is having difficulty using an incentive spirometer. The nurse should suggest that the client: Start slowly and increase volume over several sessions. Do regular deep-breathing exercises instead. Use another device because this one is might be faulty. Be much more vigorous in increasing increments.

Start slowly and increase volume over several sessions.

A nurse is receiving shift report about assigned clients. Which of the following activities should the nurse plan to attend to first? Notify the provider about a medication error. Reinsert an intravenous catheter that was removed due to infiltration. Suction the tracheostomy of a client who has copious secretions. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift.

Suction the tracheostomy of a client who has copious secretions.

A nurse is caring for a child with a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will the nurse prepare the child for to confirm the diagnosis? Sweat chloride test A sputum culture A stool fat content analysis Pulmonary function test

Sweat chloride test

A charge nurse has one private room available on her unit to accommodate a client who needs airborne precautions. Which of the following clients should the charge nurse assign to the room? The client who has Guillain-Barré syndrome and is on a ventilator. The client who has community pneumonia with copious respiratory secretions. The client who has bronchitis and a tracheostomy. The client who has AIDS and is coughing up blood

The client who has AIDS and is coughing up blood.

A nurse is caring for a client who asks how albuterol (Proventil) helps his breathing. Which of the following should the nurse include in the response? (Select all that apply.) The medication will increase the amount of mucus. The medication will prevent wheezing. The medication will open the airways. The medication will reduce inflammation. The medication will decrease coughing episodes.

The medication will prevent wheezing. The medication will open the airways. The medication will decrease coughing episodes.

A nurse is performing chest physiotherapy for a client with a respiratory infection to help mobilize thick pulmonary secretions so she can expectorate them. To increase the velocity and turbulence of the air the client exhales; the nurses should use which of the following techniques? Postural drainage Nebulization Percussion Vibration

Vibration

A nurse is reinforcing discharge teaching with the parents of a preterm infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?We will rotate the probe of the pulse oximetry every 24 hours." "The probe of the pulse oximeter can be applied to a finger or a toe." "The pulse oximeter may not be accurate during times of excessive movement." "We will notify the doctor if the pulse oximeter consistently reads 100%."

We will rotate the probe of the pulse oximetry every 24 hours."

A nurse is preparing information for a client who has tuberculosis. Which of the following should the nurse include? Wear a mask in crowds until the drugs suppress the infection Alcohol consumption is permitted while on the drug therapy. Sputum cultures will be needed every 6 weeks. Take the medication each morning.

Wear a mask in crowds until the drugs suppress the infection

A nurse is caring for a client who has a prescription for ampicillin (Omnipen). Which of the following client reactions would require priority intervention by the nurse? Urticaria Vomiting Wheezing Hypotension

Wheezing

The nurse is caring for a client who has a newly inserted chest tube connected to suction and a water seal drainage system. Which of the following indicates the chest tube is functioning properly? Fluctuation of the fluid level within the water seal chamber. Secretions in the tubing connected to the drainage system. Bubbling within the water seal chamber. Equal amounts of secretions in each collection chamber.

Fluctuation of the fluid level within the water seal chamber.

A nurse is monitoring a child who has just had a tonsillectomy for signs of hemorrhage. Which of the following findings is a sign of this postoperative complication? Mouth breathing Frequent swallowing Reports of thirst Reports of pain

Frequent swallowing

A nurse is talking with the parents of a child who is about to start using a metered-dose inhaler to treat asthma. The nurse should explain that the child will be using a spacer for which of the following reasons? Increases the amount of medication delivered to the oropharynx Increases the amount of medication delivered to the lungs Increases the amount of medication delivered on exhalation Increases the speed of medication delivery

Increases the amount of medication delivered to the lungs

A nurse is reinforcing teaching for a client about using a metered-dose inhaler (MDI). Identify the sequence the client should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps.)

Inhale deeply and the exhale completely Place lips firmly around mouthpiece Breathe in slowly for 2 to 3 seconds Hold breath for 10 seconds Exhale slowly Wait 30 to 60 seconds between puffs

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following nursing actions is the priority at this time? Increase the oxygen flow to 3 L/min. Evaluate the client's respiratory status. Call emergency services for the client. Have the client cough and expectorate secretions.

Evaluate the client's respiratory status.

4. A nurse is preparing to administer morphine 2.5 mg subcutaneous to a client who has a pneumothorax. Available is morphine injection

0.3 mL

4. A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? A. "There are portable oxygen delivery systems that you can take with you." B. "When you go out, you can remove the oxygen and then reapply it when you get home." C. "You probably will not be able to go out as much as you used to." D. "Home health services will come to you, so you will not need to get out."

A. "There are portable oxygen delivery systems that you can take with you."

According to CDC guidelines which of the following would be considered positive for Tuberculin skin tests? (Select all that apply) A. 5 mm induration in an HIV infected individuals B. 10 mm induration in an individual with no risk factors for tuberculin C. 10 mm induration in a child younger than 4 years old D. 10 mm induration in a foreign born individual E. 10 mm induration in an HIV negative individual who uses illicit injected drugs F. A 5 mm induration in an individual from a low-income group

A. 5 mm induration in an HIV infected individuals C. 10 mm induration in a child younger than 4 years old E. 10 mm induration in an HIV negative individual who uses illicit injected drugs

3. A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? (Select all that apply.) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced a drug overdose

A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery D. A client who has dysphagia E. A client who experienced a drug overdose

A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism? (Select all that apply.) A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation

A. A client who has a BMI of 30 C. A client who has a fractured femur E. A client who has chronic atrial fibrillation

A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? (Select all that apply.) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis, every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts

A. Apply suction while withdrawing the catheter. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts

Which of the following clients have an increased risk for developing pneumonia? (Select all that apply.) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A nurse is assisting in the care of a client who has experienced a pneumothorax. Findings include blood pressure 108/55 mm Hg, heart rate 124/min, respiratory rate 36/min, temperature 38.6° C (101.4° F), and SaO2 95% on oxygen 15 L/min via nonrebreather mask. The client reports dyspnea and pain. The nurse checks on the client 30 min later. Which of the following manifestations should the primary nurse report to the provider? (Select all that apply.) A. Distended neck veins B. Tracheal deviation C. Headache D. Nausea E. Heart rate 154/min

A. Distended neck veins B. Tracheal deviation E. Heart rate 154/min

A nurse is caring for a client following a thoracentesis. Which of the following clinical manifestations should the nurse recognize as risks for complications? (Select all that apply.) A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site

A. Dyspnea C. Fever D. Hypotension

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) A. Encourage the client to cough every 2 hr. B. Check for continuous bubbling in the suction chamber. C. Strip the drainage tubing every 4 hr. D. Clamp the drainage tube once a day. E. Obtain a chest x-ray.

A. Encourage the client to cough every 2 hr. B. Check for continuous bubbling in the suction chamber. E. Obtain a chest x-ray.

A nurse is assisting in the care of a client who is receiving vecuronium for acute respiratory distress syndrome (ARDS). Which of the following medications should the client receive with this medication? (Select all that apply.) A. Fentanyl (Duragesic) B. Furosemide (Lasix) C. Midazolam D. Famotidine (Pepcid) E. Dexamethasone

A. Fentanyl (Duragesic) C. Midazolam

2. A nurse is caring for a client who has COPD and a new prescription prednisone. Which of the following should the nurse monitor for? (Select all that apply.) A. Hypokalemia B. Tachycardia C. Fluid retention D. Nausea E. Black, tarry stools

A. Hypokalemia C. Fluid retention E. Black, tarry stools

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following should the nurse include as effective for preventing this disorder? Maintenance of ideal weight Annual influenza immunization Smoking cessation Regular moderate exercise

Smoking cessation

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? Resting in a supine position Elevating arms while performing ADLs Breathing in through her nose and out through pursed lips. Increasing oxygen delivery to 5 L/min during times of distress.

Breathing in through her nose and out through pursed lips.

A nurse is evaluating an older adult client who is receiving end-of-life care for Cheyne-Stokes respirations. Which of the following observations confirms this respiratory pattern? Breathing ranging from very deep to very shallow with periods of apnea Shallow breathing alternating with periods of apnea Rapid respirations that are unusually deep and regular An inability to breathe without dyspnea unless sitting upright

Breathing ranging from very deep to very shallow with periods of apnea

A nurse is reinforcing discharge teaching with a client who has COPD and has a new prescription for albuterol (Proventil). Which of the following statements made by the client indicates an understanding of the teaching? A. "This medication can increase my blood sugar levels." B. "This medication can decrease my immune response." C. "I can have an increase in my heart rate while taking this medication." D. "I can have mouth sores while taking this medication."

C. "I can have an increase in my heart rate while taking this medication."

3. A nurse is reinforcing discharge teaching with a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates a need for further teaching? A. "I will drink plenty of fluids while taking this medication." B. "I will tell the doctor if I have black, tarry stools." C. "I will take my medication on an empty stomach." D. "I will monitor my mouth for canker sores."

C. "I will take my medication on an empty stomach."

A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse reinforce with the client related to the medication ethambutol (Myambutol)? A. "Your urine may turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily."

C. "Watch for any changes in vision."

A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. Which of the following is an appropriate statement by the nurse about this medication? A. "You may notice yellowing of your skin." B. "You may experience pain in your joints." C. "You may notice tingling of your hands." D. "You may experience a loss of appetite."

C. "You may notice tingling of your hands."

A nurse is caring for a client who has respiratory failure, is intubated, and is mechanically ventilated. The client pulls out the endotracheal tube. Which of the following is a priority nursing action? Prepare for reintubation. Ensure the airway is open. Provide nasotracheal suctioning. Deliver 100% oxygen via manual bag with facemask.

Ensure the airway is open.

A nurse is caring for a client who has a chest tube in place due to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? Oxygen saturation of 95% No fluctuations in the water seal chamber No reports of pleuritic chest pain Occasional bubbling in the water-seal chamber

No fluctuations in the water seal chamber

A nurse is preparing to administer diphenhydramine (Benadryl) 30 mg IM to a client who is having an allergic reaction. Available is diphenhydramine 50 mg/1 mL. How many mL should the nurse administer? (Round to the nearest tenth.)

O.6 ml