NCA - Test #3 - PrepUs (Chap 20...)

c) Dull

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated? a) Hyperresonant b) Resonant c) Dull d) Tympanic

c) The sternum protrudes and the ribs are sloped backward.

An 18-year-old male client is described as having pectus carinatum. The nurse is aware that the manifestation of this condition would be: a) The thoracic and lumbar spine have a lateral S-shaped curvature. b) The chest is rounded, ribs are horizontal, and sternum is pulled forward. c) The sternum protrudes and the ribs are sloped backward. d) The sternum is depressed from the second intercostal space.

c) 20 minutes

Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation? a) 10 minutes b) 15 minutes c) 20 minutes d) 25 minutes

c) Auscultating the lungs for bilateral breath sounds

For a client with an endotracheal (ET) tube, which nursing action is the most important? a) Monitoring serial blood gas values every 4 hours b) Turning the client from side to side every 2 hours c) Auscultating the lungs for bilateral breath sounds d) Providing frequent oral hygiene

c) Diaphragm contracts and elongates the chest cavity.

For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration. a) Anteroposterior rib diameter decreases. b) Intercostals muscles relax to allow for expansion. c) Diaphragm contracts and elongates the chest cavity. d) Lungs are pulled up and pushed back against the thoracic cage.

c) Emphysema

High or increased compliance occurs in which disease process? a) Pneumothorax b) Pleural effusion c) Emphysema d) ARDS

a) manage decreased energy levels.

It is important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders to a) manage decreased energy levels. b) aid the caregivers of the patient. c) manage respiratory distress. d) ensure adequate rest periods.

d) Trachea

Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharynx to the bronchi? a) Larynx b) Pharynx c) Bronchioles d) Trachea

d) Emphysema

Lung compliance (the ability of the lungs to stretch) is a physical factor that affects ventilation. A nurse is aware that a patient who has lost elasticity in the lung tissue has a condition known as: a) Pleural effusion b) Pulmonary edema c) Atelectasis d) Emphysema

d) Hypotension

On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? a) Tachycardia b) Tachypnea c) Fever d) Hypotension

d) Reduced cardiac output

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? a) Increased blood pressure b) Bradycardia c) Tachycardia d) Reduced cardiac output

c) Evidence of muscle weakness

The Family Nurse Practitioner is performing a physical examination of a client. The Nurse Practitioner examines the client's anterior, posterior, and lateral chest walls. What is the Nurse Practitioner assessing? a) Deviation from the midline b) Difficulty in swallowing c) Evidence of muscle weakness d) Suppressed gag reflex

c) Respiratory acidosis

The arterial blood gas results for your patient show the following: pH = 7.35; pCO2 = 52; H2CO3 = 26. You interpret this reading as: a) Metabolic acidosis b) Compensated respiratory acidosis c) Respiratory acidosis d) Respiratory alkalosis

d) Cut the contaminated tip of the tube and insert a sterile connector and reattach.

The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? a) Immediately reconnect the chest tube to the drainage apparatus. b) Clamp the chest tube close to the connection site. c) Call the physician. d) Cut the contaminated tip of the tube and insert a sterile connector and reattach.

c) Take deep breaths and cough forcefully.

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample? a) Drink 8 oz of water to thin the secretions for expectoration. b) Use the secretions present in the oral cavity. c) Take deep breaths and cough forcefully. d) Tickle the back of the throat to produce the gag reflex.

c) No sensation during palpation

Upon palpation of the sinus area, what would the nurse identify as a normal finding? a) Light not going through the sinus cavity b) Tenderness during palpation c) No sensation during palpation d) Pain sensation behind the eyes

d) Clubbing of the fingers

What finding by the nurse may indicate that the patient has chronic hypoxia? a) Peripheral edema b) Crackles c) Cyanosis d) Clubbing of the fingers

d) PET scan

Which diagnostic is more accurate in detecting malignancies than a CT scan? a) MRI b) Pulmonary angiography c) Gallium scan d) PET scan

c) A puncture at the radial artery

You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? a) The pleural surfaces b) The trachea and bronchi c) A puncture at the radial artery d) A catheter in the arm vein

c) mucous membranes.

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: a) lips. b) earlobes. c) mucous membranes. d) nail beds.

a) Substernal pain c) Fatigue e) Dyspnea

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. a) Substernal pain b) Bradycardia c) Fatigue d) Mood swings e) Dyspnea

c) Don't eat.

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? a) Don't talk. b) Don't cough. c) Don't eat. d) Don't walk.

d) 95%

A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient? a) 75% b) 80% c) 40% d) 95%

a) encourage coughing and deep breathing.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) encourage coughing and deep breathing. b) report fluctuations in the water-seal chamber. c) clamp the chest tube once every shift. d) milk the chest tube every 2 hours.

b) Bilateral lower lobes

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment? a) Posterior bronchioles b) Bilateral lower lobes c) Left lower lobe d) Anterior bronchioles

b) Pneumonectomy

In general, chest drainage tubes are not indicated for a patient undergoing which of the following procedures? a) Wedge resection b) Pneumonectomy c) Segmentectomy d) Lobectomy

c) the only complete cartilaginous ring in the larynx

In relation to the structure of the larynx, the cricoid cartilage is a) used in vocal cord movement with the thyroid cartilage. b) the largest of the cartilage structures. c) the only complete cartilaginous ring in the larynx. d) the valve flap of cartilage that covers the opening to the larynx during swallowing.

b) 5 g/dL

Inspection of a patient's skin color is part of the assessment of the integumentary system. Cyanosis, which is a late indicator of hypoxia, is present when the unoxygenated hemoglobin level is: a) 3 g/dL b) 5 g/dL c) 4 g/dL d) 2 g/dL

b) The nursing assistant is pouring a glass of water to wet the client's mouth.

The client is returning from the operating room following a broncho scopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment? a) The nursing assistant is assisting the client to a semi-Fowler's position. b) The nursing assistant is pouring a glass of water to wet the client's mouth. c) The nursing assistant is asking a question requiring a verbal response. d) The nursing assistant is assisting the client to the side of the bed to use a urinal.

b) Pulmonary edema

The clinical finding of pink frothy sputum may be an indication of which of the following? a) Bronchiectasis b) Pulmonary edema c) An infection d) A lung abscess

a) Circulatory hypoxia

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? a) Circulatory hypoxia b) Anemic hypoxia c) Hypoxic hypoxia d) Histotoxic hypoxia

d) Wheezes

The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated? a) Rhonchi b) Crackles c) Rubs d) Wheezes

d) Angiotensin converting enzyme (ACE) inhibitors

The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking? a) Aspirin b) Cardiac glycosides c) Bronchodilators d) Angiotensin converting enzyme (ACE) inhibitors

b) PaCO2

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation? a) SaO2 b) PaCO2 c) pH d) PaO2

b) Ventilation is the movement of air in and out of the respiratory tract.

What is the difference between respiration and ventilation? a) Ventilation is the process of gas exchange. b) Ventilation is the movement of air in and out of the respiratory tract. c) Ventilation is the process of getting oxygen to the cells. d) Ventilation is the exchange of gases in the lung.

d) Ventilation is the movement of air in and out of the respiratory tract.

What is the difference between respiration and ventilation? a) Ventilation is the process of getting oxygen to the cells. b) Ventilation is the process of gas exchange. c) Ventilation is the exchange of gases in the lung. d) Ventilation is the movement of air in and out of the respiratory tract.

d) Emphysema

Which of the following disease processes cause increased compliance? a) Pulmonary fibrosis b) Pulmonary edema c) Acute respiratory distress syndrome d) Emphysema

d) Cyanosis

Which of the following is a late sign of hypoxia? a) Somnolence b) Restlessness c) Hypotension d) Cyanosis

a) Emphysema

While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding? a) Emphysema b) Funnel chest c) Pneumonia d) Pigeon chest

b) Impaired Gas Exchange

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority? a) Acute Pain b) Impaired Gas Exchange c) Potential for Infection d) Ineffective Airway Clearance

d) Apply a dressing over the wound and tape it on three sides.

A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Prepare a chest tube insertion tray. b) Draw blood for a hematocrit and hemoglobin level. c) Prepare to start an I.V. line. d) Apply a dressing over the wound and tape it on three sides.

b) a possible hematologic problem.

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has: a) left-sided heart failure. b) a possible hematologic problem. c) poor peripheral perfusion. d) a psychosomatic disorder.

a) Continues assessing the client's respiratory status frequently

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse a) Continues assessing the client's respiratory status frequently b) Changes the setting on the ventilator to increase breaths to 14 per minute c) Consults with the physician about removing the client from the ventilator d) Contacts the respiratory therapy department to report the ventilator is malfunctioning

d) 84 mm Hg

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? a) 45 mm Hg b) 120 mm Hg c) 58 mm Hg d) 84 mm Hg

d) Hypoxia

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a) Hyperventilation b) Semiconsciousness c) Delirium d) Hypoxia

c) Ventilation exceeds perfusion.

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient? a) There is an absence of perfusion and ventilation. b) Perfusion exceeds ventilation. c) Ventilation exceeds perfusion. d) Ventilation matches perfusion.

a) Impaired gas exchange

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority? a) Impaired gas exchange b) Deficient knowledge: Home care c) Anxiety d) Impaired physical mobility

a) Respiratory acidosis

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic alkalosis d) Metabolic acidosis

a) Cyanosis

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour? a) Cyanosis b) Crackles c) Respiratory rate d) Son's statement

d) The lungs

The nurse answers the call light of a male patient. The patient is complaining of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from which of the following? a) The nose b) The rectum c) The stomach d) The lungs

c) Vesicular

The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart? a) Adventitious b) Bronchial c) Vesicular d) Tracheal

c) The patient is hypoxic from suctioning.

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? a) The patient is having a stress reaction. b) The patient is having a myocardial infarction. c) The patient is hypoxic from suctioning. d) The patient is in a hypermetabolic state.

a) Hyperbaric

Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere? a) Hyperbaric b) Low-flow systems c) Transtracheal d) High-flow systems

d) Volume cycled

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration? a) Pressure cycled b) Time cycled c) Negative pressure d) Volume cycled

d) Rhonchi

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds? a) Bronchovesicular b) Venous hum c) Rales d) Rhonchi

a) synchronized intermittent mandatory ventilation (SIMV).

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: a) synchronized intermittent mandatory ventilation (SIMV). b) assist-control (AC) ventilation. c) continuous positive airway pressure (CPAP). d) pressure support ventilation (PSV).

c) Water-seal chamber

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) Air-leak chamber b) Suction control chamber c) Water-seal chamber d) Collection chamber

a) Deviation from the midline

The nurse is completing a physical assessment of a patient's trachea. The nurse inspects and palpates the trachea for which of the following? a) Deviation from the midline b) Evidence of exudate c) Color of the mucous membranes d) Evidence of muscle weakness

a) Aspiration pneumonia

Which of the following is a potential complication of a low pressure in the ET cuff? a) Aspiration pneumonia b) Pressure necrosis c) Tracheal ischemia d) Tracheal bleeding

d) The alveolar walls contain fewer capillaries.

Which of the following results in decreased gas exchange in older adults? a) The elasticity of the lungs increases with age. b) The alveolar walls become thicker. c) The number of alveoli decreases with age. d) The alveolar walls contain fewer capillaries.

a) Type II cells

A 53-year-old male is a regular client in the respiratory group where you practice nursing. As with all adults, millions of alveoli form most of the pulmonary mass. The squamous epithelial cells lining each alveolus consist of different types of cells. Which type of the alveoli cells produce surfactant? a) Type II cells b) Type I cells c) Type III cells. d) Type IV cells.

c) Eustachian tubes

A 6-month-old male client and his elder brother, a 3-year-old male, are being seen in the pediatric clinic for their third middle ear infection of the winter. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event? a) Genetics b) Oropharynx c) Eustachian tubes d) Epiglottis

a) Endotracheal suctioning

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Endotracheal suctioning b) Incentive spirometry c) Use of a cooling blanket d) Encouragement of coughing

b) "I just finished eating my lunch, I'm ready for my CPT now."

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated. a) "I have been coughing all morning and am barely bringing anything up." b) "I just finished eating my lunch, I'm ready for my CPT now." c) "I received my pain medication 10 minutes ago, let's do my CPT now." d) "I just changed into my running suit; we can do my CPT now."

a) Impaired gas exchange

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? a) Impaired gas exchange b) Ineffective airway clearance c) Impaired spontaneous ventilation d) Decreased cardiac output

b) Asthma

The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely? a) Pneumothorax b) Asthma c) Acute respiratory obstruction d) Adult respiratory distress syndrome

b) "I will breathe in through my mouth and out through my nose."

The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify? a) "I am ordered a bronchodilator to note lung improvement following use." b) "I will breathe in through my mouth and out through my nose." c) "I brought comfortable clothes and shoes for the test." d) "My study is scheduled for 10AM, several hours after I eat."

d) Respiratory acidosis

The nurse is caring for a client with chronic obstructive pulmonary disease. The client calls the doctor and states having difficulty breathing and overall feeling fatigued. The nurse realizes that this client is at high risk for which condition? a) Metabolic alkalosis b) Metabolic acidosis c) Respiratory alkalosis d) Respiratory acidosis

d) Increased thickness of the alveolar membranes

Which of the following is an age-related change associated with the lung? a) Decreased diameter of alveoli ducts b) Increased elasticity of alveolar sacs c) Decreased collagen of alveolar membranes d) Increased thickness of the alveolar membranes

d) Venturi mask

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? a) Nasal cannula b) T-piece c) Partial-rebreathing mask d) Venturi mask

c) Inspiratory reserve volume

Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration? a) Tidal volume b) Expiratory reserve volume c) Inspiratory reserve volume d) Residual volume

b) The client has a funnel chest.

A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document? a) The client has pneumonia in the bases. b) The client has a funnel chest. c) The client needs a cough suppressant. d) The client has chronic respiratory disease.

b) Crackles

A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type? a) Rhonchi b) Crackles c) Pleural rub d) Wheezes

b) The pons

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth? a) Wernicke's area b) The pons c) Central sulcus d) The frontal lobe

b) Lungs are clear on auscultation.

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following? a) Client can perform incentive spirometry. b) Lungs are clear on auscultation. c) Respiratory rate is 12 to 18 breaths per minute. d) Client reports no chest pain.

b) They help prevent cardiac arrhythmias.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions? a) They help prevent subcutaneous emphysema. b) They help prevent cardiac arrhythmias. c) They help prevent pulmonary edema. d) They help prevent pneumothorax.

d) Take prescribed albuterol (Ventolin) before performing postural drainage.

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: a) Perform drainage 1 hour after meals. b) Lay in bed with the head on a pillow. c) Hold each position for 5 minutes. d) Take prescribed albuterol (Ventolin) before performing postural drainage.

a) Ask the client to write, use a picture board, or spell words with an alphabet board.

A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client? a) Ask the client to write, use a picture board, or spell words with an alphabet board. b) Ask a family member to interpret what the client is trying to communicate. c) Ask the physician to wean the client off the mechanical ventilator to allow the client to talk. d) Assure the client that everything will be all right and that he shouldn't become upset.

a) Kinking of the ventilator tubing

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? a) Kinking of the ventilator tubing b) An ET cuff leak c) A disconnected ventilator tube d) A change in the oxygen concentration without resetting the oxygen level alarm

b) Monitor pulmonary status as directed and needed. d) Regularly assess the client's vital signs every 2 to 4 hours. e) Encourage deep breathing exercises.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. a) Maintain an open airway. b) Monitor pulmonary status as directed and needed. c) Monitor and record hourly intake and output. d) Regularly assess the client's vital signs every 2 to 4 hours. e) Encourage deep breathing exercises.

b) To reduce stress on the myocardium c) To provide adequate transport of oxygen in the blood d) To decrease the work of breathing

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. a) To provide visual feedback to encourage the client to inhale slowly and deeply b) To reduce stress on the myocardium c) To provide adequate transport of oxygen in the blood d) To decrease the work of breathing e) To clear respiratory secretions

c) Rhonchi

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds? a) Pleural friction rub b) Crackles c) Rhonchi d) Bronchial

c) Administering a prn cough suppressant

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client saftey? a) Obtaining arterial blood gas values immediately after the procedure b) Applying oxygen via nasal cannula c) Administering a prn cough suppressant d) Assisting the client to a prone position

a) Suction the client's artificial airway.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? a) Suction the client's artificial airway. b) Increase the oxygen percentage. c) Ventilate the client with a handheld mechanical ventilator. d) Check for an apical pulse.

c) Auscultate the lung for adventitious sounds.

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? a) Assess the CO2 level to determine if the patient requires suctioning. b) Have the patient cough. c) Auscultate the lung for adventitious sounds. d) Have the patient inform the nurse of the need to be suctioned.

a) By supplying a magic slate or similar device

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? a) By supplying a magic slate or similar device b) By suctioning the client frequently c) By providing a tracheostomy plug to use for verbal communication d) By placing the call button under the client's pillow

b) Impaired gas exchange related to ventilator setting adjustments

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? a) Impaired physical mobility related to being on a ventilator b) Impaired gas exchange related to ventilator setting adjustments c) Risk for trauma related to endotracheal intubation and cuff pressure d) Risk for infection related to endotracheal intubation and suctioning

b) Place the end of the chest tube in a container of sterile saline.

A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? a) Apply an occlusive dressing and notify the physician. b) Place the end of the chest tube in a container of sterile saline. c) Clamp the chest tube immediately. d) Secure the chest tube with tape.

d) Impaired gas exchange

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? a) Decreased cardiac output b) Ineffective airway clearance c) Impaired spontaneous ventilation d) Impaired gas exchange

b) Runs of ventricular tachycardia

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped? a) Blood pressure increase from 120/74 mm Hg to 134/80 mm Hg b) Runs of ventricular tachycardia c) Respiratory rate of 16 breaths/minute d) Oxygen saturation of 93%

a) The system has an air leak.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a) The system has an air leak. b) The system is functioning normally. c) The client has a pneumothorax. d) The chest tube is obstructed.

c) On the cheeks below the eyes

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. a) Behind the ethmoid sinuses b) Between the eyes and behind the nose c) On the cheeks below the eyes d) Above the eyebrows

c) Auscultation

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? a) Inspection b) Arterial blood gas (ABG) levels c) Auscultation d) Chest X-ray

d) Assessing the client's respiratory status, orientation, and skin color

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? a) Applying an oil-based lubricant to the client's mouth and nose b) Posting a "No smoking" sign over the client's bed c) Changing the mask and tubing daily d) Assessing the client's respiratory status, orientation, and skin color

b) A client experiencing hypothermia

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? a) A client receiving oxygen therapy via Venturi mask b) A client experiencing hypothermia c) A client sitting in a chair after prolonged bed rest d) A client on a ventilator with PEEP

b) Pleurisy

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse? a) Lung infarction b) Pleurisy c) Bacterial pneumonia d) Bronchogenic carcinoma

b) Pulmonary embolism

A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions? a) Tumor b) Pulmonary embolism c) Infective process d) Atelectasis

a) An infection with pneumococcal pneumonia

A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum? a) An infection with pneumococcal pneumonia b) A lung abscess c) Bronchitis d) Bronchiectasis

a) Inspecting the roof of the nasopharynx.

A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by: a) Inspecting the roof of the nasopharynx. b) Inspecting the posterior region of the epiglottis. c) Palpating the throat above the cricoid cartilage. d) Examining the base of the oropharynx.

b) MRI can view soft tissues and can help stage cancers.

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. Included in teaching would be which of the following regarding the MRI? a) Lung blood flow can be viewed after a radiopaque agent is injected. b) MRI can view soft tissues and can help stage cancers. c) Tumor densities can be seen with radiolucent images. d) Narrow-beam x-ray can scan successive lung layers.

c) Negative-pressure ventilator

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client? a) Positive-pressure ventilator b) Bilevel positive airway pressure (Bi-PAP) c) Negative-pressure ventilator d) Continuous positive airway pressure (CPAP)

d) Anterior surface of the right side of the chest, between the fourth and fifth rib.

The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the: a) Posterior surface of the left side of the chest, near the sixth rib. b) Posterior surface of the right side of the chest, near T3. c) Anterior surface of the left side of the chest, near the sixth rib. d) Anterior surface of the right side of the chest, between the fourth and fifth rib.

a) Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing

The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following? a) Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing b) Promote the strengthening of the patient's diaphragm c) Promote the patient's ability to intake oxygen d) Promote a more efficient and controlled ventilation and to decrease the work of breathing

d) Swallow reflex

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? a) Presence of carotid pulse b) Medication allergies c) Ability to deep breathe d) Swallow reflex

a) A bottle of sterile water

The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside? a) A bottle of sterile water b) A set of hemostats c) An incentive spirometer d) An Ambu bag

b) They can be heard during inspiration and expiration.

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes? a) They occur when the pleural surfaces are inflamed. b) They can be heard during inspiration and expiration. c) They are heard in clients with decreased secretions. d) They result from air passing through widened air passages.

d) Pulse oximetry

The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first? a) Chest x-ray b) Pulmonary function test c) Arterial blood gases d) Pulse oximetry

b) Assume a left side-lying position while in bed

The nurse is caring for a patient complaining of chest discomfort. The patient's admitting diagnosis is left lower lobe pneumonia. Which of the following strategies will the nurse instruct the patient to use to help alleviate the discomfort? a) Request narcotic medication when pain is experienced b) Assume a left side-lying position while in bed c) Lying on the right side d) Complete deep breathing exercises when chest discomfort occurs

b) Chest tube drainage of 190 mL/hr

The nurse is caring for a patient following a thoracotomy. Which of the following findings requires immediate intervention by the nurse? a) Heart rate: 112 bpm b) Chest tube drainage of 190 mL/hr c) Moderate amounts of colorless sputum d) Pain of 5 on a 1 to 10 pain scale

c) The patient will return to the nursing unit with two chest tubes.

The nurse is caring for a patient who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on which of the following? a) The patient will require mechanical ventilation following surgery. b) The patient will return from surgery with no drainage tubes. c) The patient will return to the nursing unit with two chest tubes. d) The patient will require sedation until the chest tube (s) are removed.

b) Sitting on the edge of the bed

The nurse is caring for a patient who is to undergo a thoracentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions? a) Lateral recumbent b) Sitting on the edge of the bed c) Prone d) Supine

a) Deflating the cuff routinely

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? a) Deflating the cuff routinely b) Ensuring that humidified oxygen is always introduced through the tube c) Checking the cuff pressure every 6 to 8 hours d) Deflating the cuff prior to tube removal

a) The imaging time will amount to 20 to 40 minutes. c) The patient will be expected to lie under the camera. d) A mask will be placed over the nose and mouth during the test.

The nurse is instructing a patient who is scheduled for a perfusion lung scan. What should be included in the information about the procedure? (Select all that apply.) a) The imaging time will amount to 20 to 40 minutes. b) An injection will be placed into the lung during the procedure. c) The patient will be expected to lie under the camera. d) A mask will be placed over the nose and mouth during the test. e) The patient will be expected to be NPO for 12 hours prior to the procedure.

d) "I will feel warm and an urge to cough."

The nurse is instructing the client on the normal sensations, which can occur when contrast medium is infused during pulmonary angiography. Which statement, made by the client, demonstrates an understanding? a) "I will feel light-headed when the contrast medium is introduced." b) "I will feel a dull pain when the catheter is introduced." c) "I will feel waves of nausea throughout the procedure." d) "I will feel warm and an urge to cough."

b) "When the tube is being removed, take a deep breath, exhale, and bear down."

The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient? a) "While the chest tube is being removed, raise your arms above your head." b) "When the tube is being removed, take a deep breath, exhale, and bear down." c) "During the removal of the chest tube, do not move because it will make the removal more painful." d) "Exhale forcefully while the chest tube is being removed."

b) Purse the lips when exhaling air from the lungs.

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to a) Initially inhale through the mouth. b) Purse the lips when exhaling air from the lungs. c) Hold the breath for 5 seconds and then exhale. d) Sit in an upright position only.

a) Absent distal pulses

The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about? a) Absent distal pulses b) Flushed feeling in the client c) Raised temperature in the affected limb d) Excessive capillary refill

a) Warm and humidify inspired air

The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? a) Warm and humidify inspired air b) Moisten and filter expired air c) Move mucus to the back of the throat d) Cool and dry expired air

a) How these issues affect the client's quality of life

You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess in addition to the physical and functional issues related to breathing? a) How these issues affect the client's quality of life b) How these issues affect the relationships in the client's life c) How these issues affect the client's effort to breathe d) How these issues affect the client's ability to function

a) Ventilation is breathing air in and out of the lungs.

You are caring for a 65-year-old client who has been newly diagnosed with emphysema. The client is confused by the new terms and wants to know what ventilation means. Which of the following can instruct this client? a) Ventilation is breathing air in and out of the lungs. b) Ventilation is when the body changes oxygen into CO2. c) Ventilation provides a blood supply to the lungs. d) Ventilation helps clients who cannot breathe on their own.

c) They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.

You are studying for a physiology test about the respiratory system. What should you know about central chemoreceptors in the medulla? a) They respond to changes in the O2 levels in the brain. b) They respond to changes in O2 levels and bicarbonate levels in the atmosphere. c) They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. d) They respond to changes in CO2 levels in the brain.

b) "It sounds like the different drugs will make this much easier to stand."

Your client is anxious about his upcoming bronchoscopy to obtain a tissue sample. Which of the following statements shows that the client understands the procedure? a) "If I cough up bloody mucus the next day, I need to call 911." b) "It sounds like the different drugs will make this much easier to stand." c) "If the tube goes through my nose, why will my throat hurt?" d) "At least I can eat normally again as soon as this is over."