ATI COPD and Asthma Oxygenation, Med surg quiz questions (test 2), Nursing 330 Exam 3 questions resp/gi/gu, ATI pulmonary questions, ATI Airway Management (2 - Exam 1), ATI Med Surge Ch. 18 Chest Tube Insertion Questions, ATI closed-chest pretest, R...

A nurse is reinforcing teaching to a client who has chronic obstructive pulmonary disorder. Which of the following statements by the client indicates a need for further teaching? 1. "I will rest for at least 30 minutes before eating" 2. "I will take my bronchodilators after meals" 3. "I will eat five or six small meals each day" 4. "I will increase my intake of dietary fiber"

"I will take my bronchodilators after meals"; should be taken before meals to reduce shortness of breath.

A nurse is evaluating teaching on a client who has a new prescription of montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching?

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

A nurse is performing chest physiotherapy for a patient who needs help mobilizing and expectorating thick pulmonary secretions. To increase the turbulence of the air the patient exhales, the nurse should use which of the following techniques? A) Vibration B) Percussion C) Nebulization D) Postural drainage

A) Vibration

A nurse in an urgent care center is caring for a client who is having a acute asthma exacerbation. Which of the following actions is the nurse's highest priority?

Administering a nebulized beta-adrenergic

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? 1. initiating oxygen therapy 2. providing immediate rest for the client 3. positioning the client in high fowlers 4. administering a nebulized beta-adrenergic

Administering a nebulized beta-adrenergic; decrease the inflammatory response that triggers narrowing of the airways. Provides prompt relief of airflow obstruction

A home health nurse visits a client who has COPD and receives oxygen at 2L /min via nasal cannula. the client reports difficulty breathing. Which of the following actions is the nurse's priority>

Assess the client's respiratory status.

10. A nurse is caring for a client following a CT scan with dye who has an anaphylaxis reaction. Which of the following conditions requires a priority nursing response? A. urticaria B. stridor C. tachypnea D. angioedema

B. stridor

A nurse is caring for a client who has asthma and developed viral pharyngitis. Which of the following findings should the nurse expect? A) perechiae on the chest and abdomen B) White blood cell count of 16,000/MM3 C) negative throat culture D) severe hyperemia of pharyngeal mucosa

C) negative throat cultures A client who has bacterial pharyngeal usually has a throat culture positive for beta hemolytic streptococcus

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following is the nurse's monitoring priority? 1. palpating peripheral pulses 2. auscultating heart sounds 3. confirming the gag reflex 4. measuring blood pressure

Confirming the gag reflex; greatest risk is aspiration resulting from depressed gag reflex.

A nurse in the emergency department is assessing an older adult client who has community acquired pneumonia which of the following findings should the nurse expect? A) equal pupils B) hypertension C) tympany upon chest percussion D) confusion

D) confusion Confusion is due to hypoxemia

A nurse is caring for a client diagnosed with CHF who experiences respiratory arrest. Which of the following is the first action the nurse should take? 1. establish IV access 2. feel for a carotid pulse 3. establish an open airway 4. auscultate for breath sounds

Establish an open airway

Mrs. Clark is an 83-year-old woman admitted with symptoms of heart failure. Her nurse, after performing an assessment, tries to decipher between right and left sided heart failure. Which symptoms are consistent with left-sided heart failure

Fatigue, weakness, and palpitations

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? 1. fluctuation of the fluid level within the water seal chamber 2. secretions in the tubing connected to the drainage system 3. bubbling within the water seal chamber 4. equal amounts of secretions in each collection chamber

Fluctuation of the fluid level within the water seal; fluctuation occurs with inspiration and expiration until the client's lungs have re-expanded or the system is occluded.

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for the client?

Increase anteroposterior diameter of the chest

A nurse is caring for a client who has a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1. increase fluid intake 2. perform chest physiotherapy prior to suctioning 3. pre-lubricate the suction catheter tip with sterile saline when suctioning the airway 4. hyperventilate the client with 100% oxygen before suctioning the airway

Increase his fluid intake; also providing adequate humidification.

A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow.

Inhaling deeply and then exhaling completely is the first step. Next, the client should place her lips firmly around the mouthpiece to direct the spray to the airways, then breathe in deeply over 2 to 3 seconds while pushing down on the canister. This slow, deep inhalation directs the medication down into the lower respiratory tract. Holding her breath for 10 seconds is next; it allows time for absorption of the medication. Then, pursed-lip breathing keeps the small airways open during slow exhalation. And finally, waiting 60 seconds between puffs allows for deeper penetration of the medication into the respiratory tract.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Instruct the client to use pursed-lip breathing

A 20-year-old client has arrived in the postanesthesia care unit (PACU) after having a tracheostomy. All of the following interventions are included in the standardized post-tracheostomy plan of care. Which action should the nurse take first?

Listen to lung sound. Breath sounds can be clear. Need airway maintenance/patency

To decrease the risk of aspiration in a client with a tracheostomy, the nurse implements which actions?

Maintain client upright for 30 minutes after eating.

A client has returned to the PACU after a bronchoscopy. Which of the following nursing tasks is best for the charge nurse to delegate to the experienced nursing assistant working in PACU?

Monitor blood pressure and pulse.

A nurse is the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Movement of the ET tube into the right main bronchus

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? 1. O2 sat 95% 2. no fluctuations in the water seal chamber 3. no reports of pleuritic chest pain 4. occasional bubbling in the water-seal chamber

No fluctuations in the water seal chamber; fluctuation stop when the lung has re-expanded or when the tubing is obstructed

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

Repeat auscultation after the client to breathe deeply and cough

A nurse is monitoring a client who has two chest tubes inserted for a right-sided pneumothorax. The client complains of chest burning. Which of the following is an appropriate nursing action? 1. increase the client's wall suction 2. strip the client's chest tube 3. clamp the client's chest tube 4. reposition the client

Reposition the client; relieves chest burning from the chest tube

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

Smoking Cessation

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 order? 1. Maintenance of ideal weight 2. annual influenza immunization 3. smoking cessation 4. regular moderate exercise

Smoking cessation

The nurse collaborates with which other health care provider to assist the intubated client with communication issues?

Speech therapist

A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication which has which of the following actions?

Stimulates secretions

A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?

Stop the infusion

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse taek?

Suction two to three times with a 60 sec pause between passes.

The nurse recognizes that the trigger for erythropoiesis is:

Tissue oxygen

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past three days. Which of the following findings should the nurse expect? (Select all that apply) a) poor skin turgor B) bradycardia C) hypotension D) pale yellow urine E) flat neck veins

a) poor skin turgor C) hypotension E) flat neck veins Frequent vomiting and diarrhea causes dehydration which manifests as skin and lacks elasticity. Frequent vomiting and diarrhea causes dehydration which manifests as postural hypotension. And also manifest as flat neck beans when the client is laying supine. Urine color manifest as a dark yellow or concentrated color and tachycardia presents

A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make? a. "These organs support immunity." b. "These organs are used in digestion." c. "These organs regulate electrolyte balance." d. "These organs assist vitamin absorption."

a. "These organs support immunity."

A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? a. Administer high-flow oxygen at 5 L/min by facemask to the client b. Place the client in high-Fowler's position with legs dependent c. Give the client sublingual nitroglycerin d. Reassure the client

a. Administer high-flow oxygen at 5 L/min by facemask to the client

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? a. Give morphine IV b. Administer oxygen therapy c. Start an IV infusion of lactated Ringer's d. Initiate cardiac monitoring

b. Administer oxygen therapy

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 100/min, respiratory rate 40/min, and blood pressure 140/80 mmHg, HCO₃ mEq/L, and SaO₂ 86%. Which of the following is the priority nursing intervention? a. Prepare for mechanical ventilation b. Administer oxygen via face mask c. Prepare to administer a sedative d. Assess for indications of pulmonary embolism

b. Administer oxygen via face mask

A nurse is caring for a client who is 12hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? a. Constant bubbling in the suction-control chamber b. Continuous bubbling in the water-seal chamber c. Bloody drainage in the collection chamber d. Fluid-level fluctuations in the water-seal chamber

b. Continuous bubbling in the water-seal chamber

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest movement inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? a. Atelectasis b. Flail chest c. Hemothorax d. Pneumothorax

b. Flail chest

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first? a. Mask b. Gloves c. Gown d. Goggles

b. Gloves

A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take? a. Place the client in a negative airflow room b. Keep blood pressure equipment in the client's room c. Monitor the client's vital signs once every 8hr d. Provide the client with 1000mL of water to drink every 12hr

b. Keep blood pressure equipment in the client's room

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? a. Restlessness b. Retractions c. Dependent edema d. Clubbing of the fingers

d. Clubbing of the fingers

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? a. Intracranial pressure b. Spinal cord perfusion c. Renal function d. Hemodynamic status

d. Hemodynamic status

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? a. Administer oxygen at 2 L/min b. Administer prescribed analgesic medication c. Encourage coughing and deep breathing d. Raise head of bed

d. Raise head of bed

A nurse is assessing a client who has long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client wll report that her earliest manifestation was.

hoarseness

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, boht by nebulizer. Which of the following statements by the client indicates an understanding of the teaching?

"I will be sure to take the albuterol before taking the cromolyn"

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching?

"I will follow a daily diet high in calories and protein."

A nurse is reinforcing discharge instructions with the parent of a 6-year-old who just had a tonsillectomy. Which of the following statements by the parent indicates understanding of postop care? 1. "I'll call the doctor if my child is swallowing continuously" 2. "It's okay for my child to have plenty of ice cream" 3. "I'll help my child gargle with salt water a few times a day" 4. "It's alright for my child to ride his bike in a few days"

"I'll call the doctor if my child is swallowing continuously"; frequent swallowing is a sign of hemorrhage following a tonsillectomy. Should avoid coughing, clearing throat, vigorous toothbrushing because they cause bleeding. Activities resumed within 1-2 weeks.

A nurse is caring for a client who has a chest tube in place. Which of the following strategies should the nurse use to help promote comfort for the client?

*1. Have the client splint the affected side during coughing* It is essential for a client with a chest tube to cough to prevent postoperative complications and to help drain the pleural space and expand the lungs. Splinting the affected side, such as with a pillow, can help minimize the pain of coughing. The nurse should also administer analgesia to help reduce the pain of coughing and other activities. 2. Perform passive range-of-motion exercises 3. Place the client in a supine position with minimal elevation 4. Encourage ambulation

A nurse is planning education for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following instructions should the nurse plan to provide when the client is ready to ambulate?

*1. keep the collection device upright at all times* The closed-chest drainage system must be kept upright at all times to ensure that the tubing drains optimally and the system functions correctly. 2. Disconnect the system when showering. 3. Keep the collection deice at chest level at all times. 4. Allow the tubing to hang in a dependent loop when ambulating.

A nurse is assessing a client 5 hours after insertion of a chest tube that is attached to a water-seal drainage system. Which of the following observations about the drainage should the nurse report to the provider?

1. 400 mL drainage since insertion. 2. A gush of fluid when repositioning the patient *3. About 150 mL/hr drainage over the past 2 hours. After the first few hours, the nurse should report drainage that exceeds 70 mL/hr. Clients who lose 100 mL of blood every 15 min might require autotransfusion within 6 hr. 4. Significant decrease in drainage in the past 3 hours.

A nurse is caring for a client who is 6 hours post operative and has a chest tube in place that is attached to a closed-chest water-seal drainage system. The nurse should identify that which of the following is an indication of a problem in the drainage system?

1. Constant bubbling in the suction-control chamber. 2. Fluctuations in the fluid level in the water seal chamber 3. Occasional bubbling in the water seal chamber. *4. Continuous bubbling in the water-seal chamber* Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse should use rubber-tipped clamps to try to locate the leak by clamping the tube momentarily near the site of the chest tube insertion.

A nurse is caring for a client who has a chest tube in place that is attached to a water-seal drainage system. Which of the following findings should the nurse recognize as an indication of subcutaneous emphysema?

1. Diminished lung sounds on the affected side *2. A dry, crackling sound at the insertion site when pulled* A dry, crackling sound at the insertion site is an indication of subcutaneous emphysema, which is a result of air leaking into the subcutaneous tissue surrounding the chest-tube insertion site. 3. Absence of drainage in the collection chamber 4. hyperresonance when percussing the affected lung

A nurse is caring for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following actions should the nurse take if the chest tube becomes dislodged from the closed chest drainage system?

1. Instruct the client to inhale deeply *2. Submerge the end of the chest tube in 1 inch of sterile water* This action creates a water seal and prevents air from entering the pleural space through the open end of the chest tube when the client inhales. 3. Gently milk the chest tube in a proximal-to-distal direction 4. Tape sterile gauze around the open end of the chest tube.

A nurse is caring for a client who requires a chest tube. The provider asks for the suction pressure of the closed-chest drainage system to be set at -40 cm of water. Which of the following closed-chest drainage systems should the nurse prepare for this client?

1. Pneumostat 2. Water-seal system 3. Heimlich valve *4. Dry suction-control system* Systems that use dry-suction control allow for higher suction pressures by adjusting a dial on the front surface of the system to deliver suction pressure up to −40 cm of water. Some clients need high suction pressures due to a massive air leak from the lung surface, emphysema or viscous pleural effusion, or a reduction in pulmonary compliance.

A nurse is preparing to transport a client who has a chest tube and a closed-chest wet-suction drainage system to radiology. Which of the following actions should the nurse take when detaching the suction source for transportation?

1. clamp the chest tube. 2. Milk the chest tube *3. Make sure the air vent is open* Some closed-chest drainage systems and suction devices contain a vent from the water-seal chamber. This allows the drainage unit to remain vented without suction. So, the nurse should make sure this exit vent is open when disconnecting the suction source. 4. Empty the collection chamber.

A nurse is preparing to instill 840 mL of enteral nutrition via a clients Gastrostomy tube over 24 hours using the infusion pump. The nurse should set the infusion pump to deliver how many milliliters per hour?

35ml/hour The volume the nurse should infuse is 840 mL. The total infusion time is 24 hours. 840 mL divided by 24 hours equals 35 mL per hour infusion rate

A nurse is preparing to administer antibiotic X over 20 minutes. Available is antibiotic X in 50 mL of 0.9% sodium chloride (NSS). The drop factor of the manual IV tubing is 20 GTT/ML. The nurse should set the manual IV infusion to deliver how many GTT/min?

50 Calculating GTT/min. The quantity of those available is 20 GTT/min. The total infusion time is 20 minutes. The volume the nurse should infuse at is 50 mL. There is no need to convert the units of measurement. 20 gtt/1 mL x 50ml/20 min =50

A nurse is caring for a client who is to receive liquid medications via a Gastrostomy tube. The client is prescribed phenytoin 250mg. The amount available is phenytoin oral solution 25 mg/ 5 mL. How many milliliters should the nurse administer per dose?

50 ml 250mg/25mg x5ml =50 ml

A nurse is caring for a client who is post operative following an appendectomy and is prescribed D5 lactated ringer's at 150 mL per hour by continuous IV infusion for 12 hours. The drop factor of the manual IV tubing is 20 GTT per milliliter. The nurse should set the manual IV infusion to deliver how many GTTs per minute?

50gtt/min Volume equals 150 mL per hour. Total infusion time one hour. Conversion measurement of one hour is 60 minutes. 150 mL divided by 60 minutes times 20 GTT per milliliter equals 50 GTT per minute

Which of the following clients should the medical-surgical nurse consider transferring to the intensive care unit?

75 y/o client with a diagnosed pulmonary embolism who is receiving heparin and who is currently experiencing hemoptysis. Signs of pulmonary infarction or bleeding abnormality d/t heparin.

A nurse is prioritizing client care after receiving change-of -shift report. Which of the following clients should the nurse plan to see first?

A client who told an CNA he is short of breath

A nurse is caring for a client who is receiving oxygen at 2 L per minute via nasal cannula. The nurse recognizes that the client is receiving which of the following inspired oxygenation concentrations? A) 28% B) 36% C) 50% D) 70%

A) 28% The nurse should recognize that the flow rate of 2 L per minute via nasal cannula delivers an oxygen concentration about 28%

A nurse is caring for a patient who has a cuffed endotracheal (ET) tube in place. Which of the following is an appropriate component of ET tube care for this patient? A) Repositioning the ET tube in the patient's mouth every 12 hr B) Providing oral care every 24 hr C) Applying the securing tape over the patient's ears D) Maintaining a cuff pressure of 35 mm Hg

A) Repositioning the ET tube in the patient's mouth every 12 hr

A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medication should the nurse instruct the client to use to abort an acute asthma attack? A) abutyryl B) formoterol C) salmeterol D) beclomethasone

A) abutyryl Albuterol is an inhaled short acting beta two agonist used to rescue medications to relieve an acute asthma attack. This dilates the airways decreases wheezing and improves oxygenation

A nurse is caring for a child who is experiencing status asthmatics. Which of the following interventions is the priority for the nurse to take? A) administer a short acting b2 agonist (SABA) B) obtaining a peak flow reading C) administering an inhaled glucocorticoid D). Determine the cause of the acute excaberation

A) administer a short acting b2 agonist (SABA) When using the urgent versus non-urgent approach to client care the nurse to determine that the priority nursing action is to administer a nebulizer Thai does SABA to relieve bronchial constriction and improve ventilation

A nurse is caring for a client who has gastrointestinal bleeding. Which of the following action should the nurse take first? A) assess orthostatic blood pressure B) explain the procedure for an upper and gastrointestinal series C) administer pain medication D) test the clients emesis for blood

A) assess orthostatic blood pressure Using the nursing process, the first action the nurse should take to assess the client is by measuring the clients orthostatic blood pressure. This action determines if the client is hypovolemic an established as a baseline for further measurements

A nurse is caring for a client who has the pneumonia and a prescription for oxygen therapy at 5 L per minute via nasal cannula. Which of the following action should the nurse take? A) attach a humidifier bottle to the base of the flowmeter B) remove the nasal cannula while the client eats C) secure the oxygen tubing to the bed sheet near the clients head D) apply petroleum jelly to the nares as needed to smooth mucous membranes

A) attach a humidifier bottle to the base of the flowmeter Oxygen therapy can dry mucous membranes the nurse should attach a humidifier to the base of the flowmeter to help the client receive oxygen greater than 4 L per minute via nasal cannula.

A nurse is caring for a client who has heart failure in histories of asthma. The nurse reviews the providers orders and recognizes that a clarification is needed for which of the following medications? A) carvediol B) fluticasone C) captipril D) isosorbide dinitrate

A) carvediol Medications that block beta-2 receptors are contraindicated in clients with asthma

A nurse is providing teaching discharge information to a client who has a new prescription for home oxygen. Which of the following instruction should the nurse include in the teaching? A) do not adjust the oxygen flow rate B) check your oxygen equipment each week C) store on use oxygen tanks horizontally D) do not use for blankets in your bed

A) do not adjust the oxygen flow rate This ensures that the patient receives the prescribed rate

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? A) oral mucosa B) conjunctiva C) earlobes D) soles of the feet

A) oral mucosa According to the evidence-based practice the nurse should monitor for the clients tongue and lips for manifestations of central cyanosis because I gnosis is the most evident in areas with minimal pigmentation

A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent and IV bolus. 10 minutes into the infusion of the third does, the client reports that IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse first take? a) stop the infusion B) call the provider C) elevate the head of bed D) auscultate the clients breath sounds

A) stop the infusion When using the airway breathing circulation approach to client care, the nurse should place the priority on stopping the infusion. The client is exhibiting signs of penicillin anaphylaxis in the first action should be taken to withdraw this medication

A nurse is teaching a client who has asthma about how to use an a butyryl inhaler. Which of the following actions should the client indicates as an understanding of teaching? A) the client hold his breath for 10 seconds after inhaling the medication B) the client takes a quick inhalation while releasing the medication from the inhalator C) and the client exhales as the medication is released from the inhaler D) the client wait 10 minutes between inhalation

A) the client hold his breath for 10 seconds after inhaling the medication The medication should be retained in the lungs for a minimum of 10 seconds so the maximum amount of dosage can be delivered properly to the airways. Do use the inhaler, the client exhales normally just prior to releasing the medication, inhales deeply as the medication is released, then holds the medication in the lungs for approximately 10 seconds prior to exhaling

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the providers orders, the nurse recognizes that clarification is needed with which of the following medications? A)propranolol B) theophylline C) montelukast D) prednisone

A)propranolol Medications that beat a block to receptors are contraindicated in clients with asthma

A nurse preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing

A, B, C, E Oxygen should be readily available in case the client develops respiratory distress following chest tube placement. If the chest tube becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal Hemostat clamps should be available for the nurse to use to check air leaks Immediately place an occlusive dressing over the chest tube insertion site if becomes disconnected. This allows air to escape and reduces the risk for a tension pneumothorax

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 hours B Check for continuous bubbling in the suction chamber C. Strip the drainage tubing every 4 hours D. Clamp the tube once a day E. Obtain a chest x ray

A, B, E Cough every 2 hours to promote oxygenation and lung reexpansion Check for continuous bubbling in the suction chamber to verify that suction is being maintained at an appropriate level A chest x ray is obtained following the procedure to verify chest tube placement

22. A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should be aware that initially the client is at greatest risk for A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus

A. Airway obstruction

25. 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.) A. Assess legs for redness B. Apply elastic compression stockings C. Perform passive range of motion exercises D. Monitor INR results E. Massage calves every shift

A. Assess legs for redness B. Apply elastic compression stockings C. Perform passive range of motion exercises D. Monitor INR results

24. 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 take first? A. administer oxygen B. prepare for an ICU transfer C. increase the IV fluid infusion rate D. administer pain medication

A. administer oxygen

19. A nurse is caring for a client who has just returned from the surgical suite following a thoracotomy. Which of the following postoperative interventions should the nurse give highest priority to? A. administer oxygen by mask or NC at 6L/min B. monitor urinary output via FC q2h C. assess chest tube drainage hourly D. maintain IV of D5 1/2NS at 125mL/hr

A. administer oxygen by mask or NC at 6L/min

18. A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following is the priority focus of care? A. airway protection B. decreasing ICP C. stabilizing cardiac arrhythmias D. preventing musculoskeletal disability

A. airway protection

6. A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first? A. auscultate lung fields B. assess pulse and respirations C. assess characteristics of her sputum D. instruct to slowly exhale with pursed lips

A. auscultate lung fields

12. A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client has had intermaxillary fixation to repair and stabilize the fracture. The nurse should recognize that the most important goal in the immediate postoperative period is to do which of the following? A. prevent aspiration B. ensure adequate nutrition C. promote oral hygiene D. relieve the client's pain

A. prevent aspiration

A nurse is caring for a client who sustained multiple injuries related to a motor vehicle crash. When monitoring the client for manifestations of pneumothorax, the nurse should observe for which of the following? 1. inspiratory stridor 2. expiratory wheeze 3. absence of breath sounds 4. coarse crackles

Absence of breath sounds; due to partial or total collapse of the lung

A nurse in the ICU is assisting with the care of a client who has acute respiratory distress syndrome and is receiving mechanical ventilation via an endotracheal tube. The provider plans to extubate within the next 24 hours. Which of the following is an important criterion for extubating this client? 1. ability to cough effectively 2. adequate tidal volume without positive pressure 3. no indications of infection 4. no need for supplemental oxygen

Adequate tidal volume without positive pressure; weaning criteria include ability to maintain adequate vital capacity, tidal volume, and minute ventilation without positive pressure or other manually assisted breaths

A client with chronic obstructive pulmonary disease has a physician's order stating "Oxygen at 2 L/min to keep the SpO2 at 90% to 92%." Which of the following nursing tasks could best be delegated to a nursing assistant working under the supervision of a registered nurse?

Adjust the position of the oxygen tubing.

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?

Administer a short- acting B2-agonist (SABA)

A child has a prescription to receive chest physiotherapy (CPT). Which of the following should the nurse do? 1. perform CPT 15 min prior to meals 2. perform CPT immediately after the child eats 3. administer albuterol prior to CPT 4. perform CPT prior to administering albuterol

Administer albuterol prior to CPT; bronchodilators relax and dilate the airway to promote air exchange. Facilitates removal of the secretions as the chest wall is being percussed.

A nurse in the ED is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority?

Administer high-flow O2 at 5L/min by facemask to the client

A nurse is teaching a client who has been taking prednisone to treat asthma and has new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effect?

Adrenocortical Insufficiency Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

Agitation due to neurological changes from poor oxygen exchange.

The nurse is caring for a client with a chest tube. The nurse understands that continuous air bubbling in the water-seal chamber may indicate which situation? 1. air is passing out of the pleural space 2. air is being removed from within the lung tissue 3. air is leaking into the drainage system 4. such bubbling is expected

Air is leaking into the drainage system; make sure all connections are tight and taped.

A nurse is caring for a client admitted with major burns of the head, neck, and chest. In planning the client's care, the nurse is aware that the client is at the greatest risk for 1. hypothermia 2. hyponatremia 3. fluid imbalance 4. airway obstruction

Airway obstruction; may involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation

A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack?

Albuterol

A nurse is performing pulmonary hygiene for a client with a respiratory infection. The nurse should explain that sitting on the side of the bed helps mobilize secretions from which of the following lung segments? 1. apical segments 2. both upper lobes 3. anterior segments of both lower lobes 4. posterior segments of both lower lobes

Apical segments

Which of the following tasks would be appropriate to delegate to the LPN working with you on a client who has pulmonary edema?

Assist respiratory therapy in applying BiPAP to the client.

A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following condition?

Asthma

A nurse is caring for a client who is postop and has developed pneumonia. Which of the following is a possible complication of pneumonia? 1. hemorrhage 2. atelectasis 3. thrombosis 4. edema

Atelectasis; can be caused by retained secretions often associated with pneumonia.

A nurse collecting data from a client who is 2 days postop auscultates bilateral breath sounds but absent breath sounds in the bases. The nurses should suspect which of the following postop complications. 1. Atelectasis 2. Rales 3. Rhonchi 4. Pneumothorax

Atelectasis; incomplete alveolar expansion or collapse. Breath sounds are absent over areas of alveolar collapse.

A nurse is caring for a client who is immobile. which of the following actions is the priority for the nurse to include in the client's plan of care?

Auscultate breath sounds at least every 2 hr.

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first?

Auscultate lung fields.

A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide?

Avoid caffeine while taking this medication

A nurse is preparing to suction secretions from the mouth of a patient who has dysphagia. Which of the following is the appropriate suction device or method for the nurse to use? A) In-line suctioning B) Yankauer catheter C) Bulb syringe D) Open suctioning

B) Yankauer catheter

A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects? A) hyperglycemia B) adrenocortical insufficeny C) Severe hydration D) rebound pulmonary congestion

B) adrenocortical insufficeny Prednisone is a quarter steroid and is similar to cortisol the glucorcocticod Ramon produced by the adrenal glands. It relieves inflammation and it is used to treat certain forms of arthritis, severe allergies, auto immune disorders, and asthma. Administration of this can compress production of the glucocortoifs, and an abrupt withdrawal of the drug which can lead to a syndrome of adrenal insufficiency

A home health nurse visit a client who has the pneumonia and is receiving oxygen at 2 L per minute via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurses priority? A) increase the oxygen flow to 3 L per minute B) assess the clients respiratory status C) call emergency services for the client D) had the client cough and expectorate the secretions

B) assess the clients respiratory status The first action the nurse should take is using the nursing process is to collect data from the client. The nurse should immediately assess the clients respiratory status before determining an appropriate intervention

A nurse is caring for a school age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply) a) symptoms are continuous throughout the day B) daytime symptoms occur more than twice a week C) nighttime symptoms occur approximately twice a month D) minor limitations occur with normal activity E) peak expiratory flow PEF is greater than or equal to 80% of the predicted value

B) daytime symptoms occur more than twice a week D) minor limitations occur with normal activity E) peak expiratory flow PEF is greater than or equal to 80% of the predicted value Daytime symptoms in a child who has persistent asthma typically have daytime symptoms more than twice per week but not daily a child who has mild persistent asthma will have some minor limitations with normal daily activities and PEF will be greater equal to 80% of the predicted value

A nurse is performing pulmonary hygiene for a client who has Pneumonia And position the client on his left side in the transdelenbutg position. From which of the following long segment should the nurse expect secretions to meet mobilized with the client in this position? A) lateral segment of the left lower lobe B) lateral segment of the right lower lobe C) posterior segment of the right middle lobe D) posterior segment of the right lower lobe

B) lateral segment of the right lower lobe The nurse would position the client in the left lateral transdelenburg position had lower than feet to help drain the lateral segment of the right lower lobe

A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client in which of the following clinical manifestations? A) metabolic acidosis B) metabolic alkalosis C) respiratory acidosis D) respiratory alkalosis

B) metabolic alkalosis Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid

A nurse is administering platelets to a client following a large G.I. bleed. The client reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first? A) notify the provider B) stop the infusion C) collect a urine sample from the client D) return the platelet bag and tubing to the blood bank

B) stop the infusion The greater risk is to the client injury from a transfusion reaction, which can be more harmful if the client receives more of the blood product. Therefore the first action the nurse to take is to stop the perfusion

A nurse is teaching the parent of a child who is to start a metered dose inhaler MDI to treat asthma. Which of the following information should the nurse include in the teaching? A) the spacer increases the amount of medication delivered to the oropharynx B) the space or increases the amount of medication delivered to the lungs C) and heal rapidly using the space or with the MDI D) cover exhalation slots of the spacer with lips went in hailing

B) the space or increases the amount of medication delivered to the lungs

A nurse is assessing 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 D. Exposed sutures without dressing E. Drainage system upright at chest level

B, C Gentle bubbling in the suction control chamber is an expected finding as air is being removed A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that the drainage system is functioning properly

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the client's chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Place the tubing in sterile water to restore the water seal B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess the client's respiratory status

B. Using ABC priority framework, the application of a sterile gauze to the site should be the first action for the nurse to take. This allows the air to escape and reduces the risk of the tension pneumothorax

16. A nurse is caring for a client with burns to face, ears, and eyelids. Which of the following is the priority finding to report to the provider? A. urinary output 25mL/hr B. difficulty swallowing C. heart rate 122 bpm D. lip edema

B. difficulty swallowing

4. A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. give morphine IV B. administer oxygen therapy C. start an iv infusion of LR D. initiate cardiac monitoring

B. administer oxygen therapy

14. A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture. Which of the following is the nurse's priority? A. pain control B. airway management C. oral hygiene D. nutritional support

B. airway management

8. A nurse is dining at a restaurant when a woman begins to scream that her husband is choking. Which of the following should the nurse do first? A. instruct the wife to call 911 B. ask the victim if he can speak C. use the jaw-thrust maneuver D. administer an abdominal thrust

B. ask the victim if he can speak

5. A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention? A. insert an IV line B. count the RR C. administer oxygen D. prepare equipment for intubation

B. count the RR

17. 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? A. increase the oxygen flow to 3L/min B. evaluate the client's respiratory status C. call EMS for the client D. have the client cough and expectorate secretions

B. evaluate the client's respiratory status

15. A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia B. hoarseness C. dyspnea D. weight loss

B. hoarseness

21. A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is the priority nursing action when the client is brought into the emergency room? A. cover the burned area with sterile gauze B. inspect mouth for signs of inhalation injuries C. administer IV pain medications D. draw blood for a CBC count

B. inspect mouth for signs of inhalation injuries

23. A nurse is caring for a client who is immediately postoperative following thoracic surgery. The nurse administers a narcotic analgesic to the client frequently for pain. Which of the following should the nurse recognize as the primary reason for this action? A. it decreases the client's level of anxiety B. it facilitates the client's deep breathing C. it suppresses the client's cough reflex D. it reduces the client's RR

B. it facilitates the client's deep breathing

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

Barrel

A nurse is caring for a client who is conscious and has an airway obstruction. Which of the following is an appropriate intervention? 1. tilt the head and lift the chin 2. begin the Heimlich maneuver 3. turn the client to the side 4. perform a blind finger sweep

Begin the Heimlich maneuver; should continue until the obstruction is clear or the client loses consciousness

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? 1. resting in a supine position 2. elevating arms while performing ADLs 3. breathing in through her nose and out through pursed lips 4. increasing oxygen delivery to 5 L/min during times of distress

Breathing in through her nose and out through pursed lips; slows expirations, prevents collapse of alveoli, and helps client control the rate and depth of respirations

A nurse is admitting an Infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect? A) bulging anterior fontanel B) bradypnea C) 3% weight loss D) capillary refill three seconds

C) 3% weight loss A weight-loss greater than 10% is a manifestation of severe dehydration in an infant

A nurse is caring for a patient who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the patient's tracheostomy tube after cleaning it? A) Paper towels B) Cotton-tipped applicators C) Folded pipe cleaners D) Facial tissues

C) Folded pipe cleaners

A nurse is evaluating teaching on a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching? A) I'll rinse my mouth after taking this medicine B) I'll take this medication when I get an asthma attack C) I'll take this medication once a day in the evening D) I'll use a spacer device when I inhale this medication

C) I'll take this medication once a day in the evening

A nurse is assessing a client for hypoxemia During an asthma attack. Which of the following manifestation should the nurse expect? A) nausea B) dysphasia C) agitation D) hypotension

C) agitation This is due to neurological changes from poor oxygen exchange

A nurse in a providers office is assessing an older adult client who son reports that the client has been sick with a respiratory illness for the past six days. Which of the following assessment findings is a manifestation of pneumonia in an older adult client? A) Bradycardia B) night sweats C) Confusion D) narrowed pulse pressure

C) confusion Weakness and anorexia are manifestations of pneumonia is in an older adult client

A nurse suspects anaphylaxis when caring for a client following an initial administration of oral antibiotic for treatment of pneumonia which of the following should the nurse says a priority intervention? A) Insert an IV line B) count the respiratory rate C) administer oxygen D) prepare equipment for into Bashan

C) count the respiratory rate

A nurse is teaching a client who has a prescription of a nasogastric tube NG to treat a polyuric obstruction. Which of the following rationales for the use of a nasal gastric tube should the nurse include in the teaching? A) determine the pH of the gastric secretions B) supply nutrients be a tube feedings C) decompress the stomach D) administer medications

C) decompress the stomach A poly uric obstruction also called gastric outlet obstruction is caused by Adema, scarring, or spasm, often the result of gastritis or peptic ulcer disease. The nurse should inform the client that because the stomach is dilated it may contain undigested food, it may deep compress, necessitating the placement of the NG tube

A nurse is caring for a client who is receiving oxygen therapy via nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? A) delivers a constant rate of specific concentration of oxygen B) Delivers a high concentration of oxygen C) delivers a low concentration of oxygen D) restricts the clients ability to eat speak or drink

C) delivers a low concentration of oxygen The nasal cannula is set to about 24% to 44%

The nurse is caring for a client who has the pneumonia . Which of the following actions should the nurse take to promote thinning of the respiratory secretions? A) encourage the client to ambulate frequently B) encourage coughing and deep breathing C) encourage the client to increase fluid intake D) encourage regular use of incentive spirometry

C) encourage the client to increase fluid intake Increasing fluids to 1500 to 2500 mL per day promotes liquefaction and thinning of pulmonary secretions, which improves the clients ability to cough and remove the secretions

A nurse is caring for a client who has endotracheal tube and is receiving mechanical ventilation. Which of the following intervention should the nurse take to reduce the risk of ventilator associated pneumonia? A) position the head of the clients bed in the flat position B) turn the client every four hours C) rinse the clients mouth with an anti-microbe solution every two hours D) perform hand hygiene prior to suctioning the client endotracheal tube

C) rinse the clients mouth with an anti-microbe solution every two hours The nurse should brush the clients teeth every eight hours and rinse the clients mouth every two hours to reduce the growth of bacteria

A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. To the following instruction should the nurse provide? A) check the pulse after medication administration B) take the medication with meals C) rinse the mouth after medication D) limit caffeine intake

C) rinse the mouth after medication The use of glucocorticoid By metered dose inhaler can allow fungal overgrowth in the mail. Rinsing them out after administration can lessen the likelihood of this complication

A nurse is caring for a three year old child who has been admitted with acute diarrhea and dehydration which of the following findings indicate that oral rehydration therapy has been effective? A) heart rate 130 bpm B) respiratory rate of 24 per minute C) urine specific gravity of 1.0 15 D) capillary refill greater than three seconds

C) urine specific gravity of 1.0 15 The expected reference range of uterine specific gravity is 1.01021. 025. As a result of 1.015 indicates that the child is hydrated. A result greater than 1.025 indicates dehydration. Dehydration results when the total output of fluid exceeds the total intake. Infants and children who have diarrhea and dehydration should be treated first with oral rehydration therapy, such as Pedialyte and infalyate. After rehydration, oral rehydration therapy can be alternated with a low sodium solution, such as water, breast milk, lactose-free formula, or half strength Lactose containing formula

A nurse is assessing a client who has hypoKalmia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A) Hyperactive reflexes B) extreme thirst C) weak, irregular pulse D) hyperactive bowel signs

C) weak, irregular pulse Common manifestations of potassium depletion include a week and irregular pulse, muscle weakness, fatigue, and venticular dysrhythmias

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects of the nurse instruct the client to report to the provider? A) sedation B) increased appetite C) white coating in the mouth D) dry oral he goes in membranes

C) white coating in the mouth This is an I handed glucocorticoid and long acting beta2 adrenergic Agnes combustion inhalation medication that is used for daily management of asthma. If it is not a rescue medication. An adverse effect of the medication is oral pharyngeal candidiasis. The nurse should instruct the client to gargle after each use use a spacer to reduce the amount of drug in the mouth and throat and report any white patches inside the mouth or on the tongue to the provider

7. A nurse is caring for a client who has sustained life-threatening injuries due to a motor-vehicle accident. Identify the sequence the nurse should take in treating the client. A. Control bleeding B. Treat shock C. Check breathing D. Use head-tilt method if airway is obstructed

C. Check breathing D. Use head-tilt method if airway is obstructed A. Control bleeding B. Treat shock

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

C. Confirming the gag reflex

9. A nurse is caring for a client who had an evacuation of a subdural hematoma. Immediately after the evacuation, which of the following nursing actions is a priority? A. observe for CSF leaks from the evacuation site B. assess for an increase in temperature C. check the oximeter D. monitor for signs of increasing ICP

C. check the oximeter

The nurse caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following prescribed medications? 1. Carvedilol 2. Fluticasone 3. Captopril 4. Isosorbide dinitrate

Carvedilol; medications that block beta-2 receptors are contraindicated in clients with asthma.

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (sata)

Check the cannula position on a regular basis Check the tops of the ears for skin breakdown Post "no smoking" signs in a prominent location in the home

A nurse is caring for client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Cheyne-Strokes respirations Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Continue to monitor the client's respiratory status Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with client inspiration? 1. continue to monitor the client 2. immediately notify the provider 3. reposition the client toward the left side 4. clamp the chest tube near the water seal

Continue to monitor the client; the fluid in the water seal chamber rises 2-4 inches during inhalation and falls during exhalation

A nurse is providing discharge instructions to a client who has asthma and a new prescription for montelukast. The nurse should instruct the client to report which of the following adverse effects to the provider? A) blurred vision B) palpations C) constipation D) depression

D) Depression This can cause behavioral changes, depression, hallucinations, suicidal Idelation. The nurse should instruct the client to report any adverse effects in a change in medication might be prescribed

A nurse is providing discharge teaching's to a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A) I will be able to tell how much oxygen I am getting by looking at the flowmeter B) I should call my doctor if I find it hard to concentrate C) I will make sure my visitor smoke outside D) I will wear synthetic clothing and woolen socks when I use my oxygen

D) I will wear synthetic clothing and woolen socks when I use my oxygen Woolen in synthetic material can generate static electricity. Because oxygen is flammable gas, the client should wear cotton clothing and use cotton blending in blankets

A nurse in an urgent care center is caring for a client who has an acute asthma exacerbation. Which of the following actions is the nurses highest priority? A) initiating oxygen therapy B) providing immediate rest for the client C) positioning the client in high Fowlers D) administering a nebulized beta adrenergic

D) administering a nebulized beta adrenergic Greatest risk to the client safety is airway obstruction. Beta adrenergic Medications act as bronchial dilator's. They provide prompt relief to airway obstructing by relaxing bronchial are smooth muscles and are the initial priority intervention when a client has an acute asthma exacerbation

A nurse in an emergency department is caring for a child who is experiencing an acute asthma attack. Which of the following medication should the nurse expect to administer? A) fluticasone B) budesonide C) montelukast D) albuterol

D) albuterol This is considered a rescue medication due to its rapid onset of action asthma is a chronic inflammatory disease of the airways. Asthmatic episodes are associated with airflow limitations or reversible obstruction. Albuterol is used for the treatment of acute exaggerations of asthma by promoting bronchial dilation and suppressing histamine release in the lungs. This medication can be given by inhalation, orally, or in preparation. The inhaled medication has more rapid onset of an action then the oral form and also reduces the risk for adverse effects such as irritability, tremors, nervousness and insomnia

A nurse is implementing a plan of care for a client who has aids with reoccurring Pneumonia . Which of the following actions should the nurse take? A) encourage fluid intake of 1500 mL per day B) position had a bed at 10° C) cough and deep breathe every eight hours D) attain a sputum and culture

D) attain a sputum and culture The nurse should obtain a sputum culture to determine which antibiotics is needed for the organism that is causing the Pneumonia

A nurse is providing education to a school age child who has a new diagnosis of asthma. Which of the following statement should the nurse include in teaching? A)take cromolyn sodium at the first sign of breathing difficulty B) you should stop playing basketball but you can swim instead C) use the peak expiratory flow meter once per week D) avoid triggers that can cause an attack

D) avoid triggers that can cause an attack The nurse should emphasize that the ability to prevent asthma attacks can be improved by avoiding allergens that the child is sensitive to. Triggers can include animals, dust, certain foods, pollen, and grass. Clients who have asthma manifestations throughout the year should receive allergy testing to determine specific triggers. The child should use a peak expiratory flow meter once or twice per day participation of sports is prohibited when asthma is not adequately controlled abutyryl should be used as a first sign of asthma where chromolyn sodium is a mast cell stabilizer

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of a long-term in adequate oxygenation? A) restlessness B) retractions C) dependent edema D) clubbing of the fingers

D) clubbing of the fingers The nurse should expect at the client who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen in the edge of the fingers and ends of the toes can increase in size

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adrenal carcinoma. The client has had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A) decrease in respiratory rate from 20 to 16 per minute B) increase in urinary output from 30 mL to 50 mL per hour C) increase in temperature from 37.5 degrees south CS238.6°C D) increase in heart rate from 88 to 110 per minute

D) increase in heart rate from 88 to 110 per minute Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of the blood loss or in adequate blood volume. In an effort to compensate for this, the heart rate increases steadily. In the first stage of shock compenstory the heart rate is greater than 100 bpm. Ashok progresses, the heart rate continues to accelerate and becomes more than 150 bpm. In the final irreversible or refractory stage, the heart rate becomes very erratic and may develop asystole.

A nurse is caring for a child who has acute gastritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid? A) broth B) water C) diluted apple juice D) oral rehydration solution

D) oral rehydration solution This is a fluid of choice for infants and children who have dehydration due to diarrhea

A nurse is caring for a client who has pneumonia. The clients oxygen saturation is 85%. Which of the following actions should the nurse take first? A) administer oxygen 2 L per minute B) administer prescribed analegestic medication C) encourage coughing and deep breathing D) raise the head of the bed

D) raise the head of the bed Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head of the net can be extended, which promotes the patient's airway. This is the first action that should be taken and is least invasive

A nurse is auscultating the breath sounds of a Client who has asthma. When the client exhales, the nurse here is continuous high-pitched squeaking sounds. The nurse should document this as which of the following advent tacious breath sounds? A) crackle B) rhonchi C) stridor D) Wheezes

D) wheezes Wheezes are often audible without a stethoscope

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. The client should be instructed to take a deep breath, exhale, and bear down as the chest tube is being removed. This increases intrathoracic pressure and reduces the risk of an air embolism

3. 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. a client who is ambulatory and going for an x-ray at 10am B. a client who is to be discharged at 11am C. a client who received pain medication 30 min ago D. a client who is SOB

D. a client who is SOB

11. 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? A. initiating oxygen therapy B. providing immediate rest for the client C. positioning the client in high-Fowler's D. administering a nebulized beta-adrenergic

D. administering a nebulized beta-adrenergic

2. A nurse is caring for a client admitted to the nursing unit from the PACU following a craniotomy. The initial nursing assessments should focus on A. intracranial pressure B. pupillary reflexes C. level of consciousness D. airway patency

D. airway patency

13. A nurse is caring for a client following a total laryngectomy. Which of the following should the nurse be aware of as the priority observation in the client's care? A. patency of the IV line B. level of pain C. integrity of the dressing D. need for suctioning

D. need for suctioning

In administering oxygen to the client with chronic hypercarbia, it is most important for the nurse to understand that the respiratory drive in this client is stimulated by:

Decreased PaO2

In reviewing laboratory data in a client, the nurse recognizes which hematologic change associated with aging?

Decreased RBCs

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in the client? (SATA)

Dyspnea Barrel Chest Clubbing of the fingers Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back.

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nail. The nurse should apply the pulse oximeter probe to which of the following locations?

Earlobe

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse included in the plan to prevent pulmonary complications?

Encourage the use of an incentive spirometer

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up". Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?

Encouraging the client to drink 2 to 3 L of water daily

A nurse is caring for a client diagnosed with COPD who has tenacious bronchial secretions. Which of the following actions should the nurse perform? 1. encouraging the client to drink 8 glasses of water a day 2. administering oxygen via nasal cannula at 3 L/min 3. helping the client select a low-salt diet 4. maintaining the client in a semi-Fowlers position as much as possible

Encouraging the client to drink 8 glasses of water a day; will help to liquefy the tenacious (thick) secretions.

A nurse is reinforcing nutritional teaching with a client who has COPD. Which of the following instructions by the nurse is appropriate? 1. drink carbonated beverages 2. decrease fiber intake 3. use bronchodilators after meals 4. increase protein intake

Increase protein intake; pulmonary diseases increases metabolic demands and can cause anorexia or fatigue

A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations indicates a complication that requires notifying the provider immediately? 1. serosanguineous drainage from puncture site 2. discomfort at puncture site 3. increased heart rate 4. decreased temperature

Increased heart rate; clients can develop pulmonary edema or cardiovascular distress after mediastinal content shift suddenly.

A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postop period? 1. malnourishment r/t NPO status and dysphagia 2. impaired verbal communication r/t tracheostomy 3. high risk for infection r/t surgical incisions 4. ineffective airway clearance r/t thick, copious secretions

Ineffective airway clearance related to thick, copious secretions; a client with a new tracheostomy requires frequent suctioning in the early postop period.

A nurse is caring for a client who has COPD. When contributing to this client's plan of care, the nurse should include which of the following interventions? 1. restrict the client's fluid intake to less than 2 L/day 2. encourage to use upper chest for respiration 3. have client use early-morning hours for exercise and activity 4. instruct client to use pursed-lip breathing

Instruct the client to use pursed-lip breathing; lengthens the expiratory phase of respiration and increases the pressure in the airway during exhalation. Clients who have COPD should breathe from the diaphragm.

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside form managing plan, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?

It facilitates the client's deep breathing

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Keep the drainage system below the level of the client's chest at all times.

A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect? 1. lethargy 2. high fever 3. edema 4. dry cough

Lethargy; manifestations of pulmonary tuberculosis are lethargy, nausea, fatigue, night sweats, low-grade fever, productive cough, anorexia

Harvey is now exhibiting signs of pulmonary edema as a result of CHF. Which nursing intervention demonstrates best practice in the care of this client?

Notify the hc provider If the client does not experience a rapid improvement and diuresis

An RN and LPN are working together to provide care for a client hospitalized with dyspnea who requires all the following nursing actions. Which of these actions is best accomplished by the RN?

Plan client teaching about the procedure for pulmonary function testing. Most complex skill

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Oral mucosa

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

Perform pre-oxygenation prior to suctioning

A nurse is caring for a client who reports pleuritic pain on the right side. The nurse notices that the client has dyspnea, decreased movement of the chest wall, and absent breath sounds on the right side. The nurse should suspect that the client has which of the following? 1. pleural effusion 2. pulmonary embolism 3. pulmonary infection 4. empyema

Pleural effusion; manifestations of pleural effusion are dyspnea, decreased movement of the chest on the affected side. There may be pleuritic pain and absent or decreased breath sounds over affected area.

Karen is caring for a CHF client in the CCU who is now exhibiting signs of air hunger and anxiety. Which nursing intervention should Karen perform first for this client?

Position the client to alleviate dyspnea

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?

Preoxygenate the client with 100% oxygen for up to 3 min

The nurse implements anticoagulant therapy in order to:

Prevent new clot formation

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders , the nurse recognize that clarification is needed for which of the following medications?

Propranolol

The nurse implements which action to decrease viscosity of secretions in the client with a tracheostomy?

Provide humidification via a tracheostomy collar.

A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect?

Resonance characterizes chronic bronchitis. It is a loud, low-pitched sound of long duration. *Dullness =pneumonia *Tympany- pneumothorax *Flatness=pleural effusion

A nurse is collecting data from a client who has bronchitis. Which of the following findings should the nurse expect to auscultate? 1. dullness 2. resonance 3. tympany 4. flatness

Resonance; loud, low-pitched sound of long duration

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balance?

Respiratory Acidois

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid base imbalances?

Respiratory acidosis

A client is admitted to the ED with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate of the ABG's? ph 7.22 PaCO2 68mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/q

Respiratory acidosis Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).

A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of the medication?

Sedation

A nurse is caring for a client who has asthma and developed viral pharyngitis. Which of the following findings should the nurse expect?

Severe hyperemia of pharyngeal mucosa A client who has viral pharyngitis will have scant or no tonsillar exudate with slight erythema of the pharynx and tonsils. A client who has bacterial pharyngitis is likely to have severe hyperemia of pharyngeal mucosa, tonsils, tongue and uvula, as well as erythema of the tonsils with yellow exudate and petechiae on the soft palate.

A nurse is caring for a client who is scheduled to undergo thoracentesis. How should the nurse position the client for the procedure? 1. Prone with arms raised over the head 2. sitting, leaning forward over the bedside table 3. supine with head of bed elevated 4. side-lying with knees drawn up to the chest

Sitting, leaning forward over the bedside table; upright position ensures that the diaphragm is dependent and facilitates the removal of accumulated fluid

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Tachycardia

A nurse is providing discharge instructions to a client who has asthma and is about to start taking theophylline (Theo-24). The nurse should tell the client that this medication might cause which of the following adverse effects?

Tachycardia

A nurse is caring for a client who is taking montelukast. Which of the following outcomes indicates a therapeutic effect of the medication?

The client experiences as increased ease of breathing

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teachng?

The client holds his breath for 10 sec after inhaling the medication

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

The client who has gastroenteritis and is febrile.

The nurse correlates which clinical manifestation to a client with pneumothorax?

Tracheal deviation toward the affected side

A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear a OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?

Tuberculosis transmitted by small droplets

A nurse is providing oral care for a client who is immoblie. Which of the following actions should the nurse take?

Turn the client on his side before starting oral care.

A nurse is caring for a client who is 1 day postop following a left lower lung lobectomy. When checking the client's closed chest drainage system, the nurse notes that there is no bubbling in the suction control chamber. The nurse should 1. notify the provider 2. verify that the suction regulator is on 3. continue to monitor the client as this is an expected finding 4. milk the chest tube to dislodge any clots in the tubing that may be occluding it

Verify that the suction regulator is on

A nurse is auscultating the breath of a client who has asthma. When the client exhales, the nurse hears continues pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

Wheezes Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

Which of the following statements made by the nursing assistant helping you with caring for a client who has received t-PA (tissue plasminogen activator) for treatment of an MI would indicate understanding of this client's care needs?

When helping with oral care I need to be aware if bleeding of the gums occurs." Bleeding is a serious side effect of t-PA and should be reported to the RN in charge of care. It is imperative that caregivers have a basic understanding of the client's condition when giving even basic care

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider?

White coating in the mouth

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

a. Airway protection

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following orders? a. Carvedilol b. Fluticasone c. Captopril d. Isosorbide dinitrate

a. Carvedilol

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? a. Continue to monitor the client b. Immediately notify the provider c. Reposition the client toward the left side d. Clamp the chest tube near the water seal

a. Continue to monitor the client

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. Continuous bubbling in the water-seal chamber b. Occasional bubbling in the water-seal chamber c. Constant bubbling in the suction-control chamber d. Fluctuations in the fluid level in the water-seal chamber

a. Continuous bubbling in the water-seal chamber

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? a. Evaluate chest expansion b. Check pupillary response to light c. Assess the capillary refill d. Check client's response to questions about place and time

a. Evaluate chest expansion

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? a. Fluctuation of the fluid level within the water seal chamber b. Absence of fluid in the drainage tubing c. Continuous bubbling within the water seal chamber d. Equal amounts of fluid drainage in each collection chamber

a. Fluctuation of the fluid level within the water seal chamber

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? a. Mask b. Gloves c. Gown d. Goggles

a. Mask

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply) a. Severe dyspnea b. Nausea c. Decreased level of consciousness d. Headache e. Hypotension

a. Severe dyspnea c. Decreased level of consciousness d. Headache e. Hypotension

A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take? a. Clamp the tube with the client is ambulating b. Keep the collection device below the level of the client's chest c. Coil the tubes carefully to prevent kinking d. Lay the client flat to avoid leaks in the tubing

b. Keep the collection device below the level of the client's chest

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

b. No fluctuations in the water seal chamber

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? a. Pinnae of the ears b. Dorsal surface of the hand c. Conjunctivae d. Dorsal surface of the foot

c. Conjunctivae

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Furosemide b. Dexamethasone c. Heparin d. Atropine

c. Heparin

A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? a. Blockage of the ET tube by the client's tongue b. Passage of the ET tube into the esophagus c. Movement of the ET tube into the right main bronchus d. Infection of the vocal cords

c. Movement of the ET tube into the right main bronchus

A nurse id planning care for a client who has acute respiratory distress syndrome (ADRS). Which of the following interventions should the nurse include in the plan of care? a. Administer low-flow oxygen continuously via nasal cannula b. Encourage oral intake of at least 3000 mL of fluids per day c. Offer high-protein and high-carbohydrate foods frequently d. Place in a prone position

d. Place in a prone position