NCLEX Respiratory system

A client is admitted to the hospital with a diagnosis of pneumonia. List the following nursing actions in the order they should be accomplished. 1. Insert an intravenous (IV) catheter to establish venous access. 2. Check peak and trough levels of the antibiotic. 3. Administer prescribed antibiotic intravenous piggyback. 4. Collect a sputum sample for culture and sensitivity. 5. Obtain data about the client's history and physical status.

5. Obtain data about the client's history and physical status. 1. Insert an intravenous (IV) catheter to establish venous access. 4. Collect a sputum sample for culture and sensitivity. 3. Administer prescribed antibiotic intravenous piggyback. 2. Check peak and trough levels of the antibiotic.

A patient receiving medical treatment for an active tuberculosis infection asks when she can starting going out in public again. You respond that she is no longer contagious when: A. She has 3 negative sputum cultures B. Her signs and symptoms improve C. She has completed the full medication regime D. Her chest x-ray is normal E. She has been on tuberculosis medications for about 3 weeks

A. She has 3 negative sputum cultures B. Her signs and symptoms improve E. She has been on tuberculosis medications for about 3 weeks

What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Select all that apply. A. The test involves the administration of a contrast medium. B. Clients should have their hydration levels assessed. C. Clients are instructed to lie still on a hard table. D. Clients are served shellfish before the test. E. A client's serum creatinine level is evaluated after the test.

A. The test involves the administration of a contrast medium. B. Clients should have their hydration levels assessed. C. Clients are instructed to lie still on a hard table.

After a gastroscopy, how does the nurse assess the client for the return of the gag reflex? A. Touching the pharynx with a tongue depressor B. Giving a small amount of water using an oral syringe C. Observing the client's swallowing ability D. Instructing the client to breathe deeply and cough gently

A. Touching the pharynx with a tongue depressor

A client is admitted with a sudden onset of dyspnea and chest pain. What are the interventions in the order in which the nurse will perform them to provide comfort to the client? 1. Elevating the head of the bed 2. Notifying the Rapid Response Team 3. Reassuring the client and family members 4. Monitoring and assessing for other changes 5. Preparing for oxygen therapy and blood gas analysis

2. Notifying the Rapid Response Team 3. Reassuring the client and family members 1. Elevating the head of the bed 5. Preparing for oxygen therapy and blood gas analysis 4. Monitoring and assessing for other changes

Your patient is diagnosed with a latent tuberculosis infection. Select all the correct statements that reflect this condition: A. "The patient will not need treatment unless it progresses to an active tuberculosis infection." B. "The patient is not contagious and will have no signs and symptoms." C. "The patient will have a positive tuberculin skin test or IGRA test." D. "The patient will have an abnormal chest x-ray." E. "The patient's sputum will test positive for mycobacterium tuberculosis."

B. "The patient is not contagious and will have no signs and symptoms." C. "The patient will have a positive tuberculin skin test or IGRA test."

A client with a puncture wound of the chest wall is brought to the emergency department. What should be the nurse's first action? A. Prepare for a thoracentesis. B. Apply a wound dressing. C. Obtain baseline vital signs. D. Suction fluid from the wound.

B. Apply a wound dressing.

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, what should the nurse do? A. Notify a respiratory therapist. B. Drain the fluid from the tubing. C. Decrease the amount of humidity. D. Record the amount of fluid removed from the tubing.

B. Drain the fluid from the tubing.

A nurse is caring for several postoperative clients. For which clinical manifestations of a pulmonary embolus should the nurse monitor these clients? Select all that apply. A. Apathy B. Dyspnea C. Hemoptysis D. Bronchial wheezes E. Feeling of impending doom

B. Dyspnea C. Hemoptysis E. Feeling of impending doom

A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention? A. Administer oral fluids. B. Encourage deep breathing. C. Increase the oxygen flow rate. D. Perform nasotracheal suctioning.

B. Encourage deep breathing.

You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education? A. Cough for a minimum of 6 weeks B. Night sweats C. Weight gain D. Hemoptysis E. Chills F. Fever G. Chest pain

B. Night sweats D. Hemoptysis E. Chills F. Fever G. Chest pain

A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client's response to this injury? A. Level of pain B. Quality and depth of respirations C. Amount of serosanguineous drainage D. Blood pressure and pupillary response

B. Quality and depth of respirations

A nurse uses abdominal-thoracic thrusts (Heimlich maneuver) when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts to expel a foreign object in the larynx? A. Tidal B. Residual C. Vital capacity D. Inspiratory reserve

B. Residual

During a follow-up visit, a nurse finds that the client has a slow rate of healing after laryngeal cancer surgery. The nurse also finds that the client is at risk of developing lung cancer. What would be the reason behind the nurse's suspicion? A. The client leans forward while coughing. B. The client smokes four cigarettes per day. C. The client avoids showering and swimming. D. The client uses a non-oil-based ointment to lubricate the stoma.

B. The client smokes four cigarettes per day.

A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that: A. The patient will need to immediately be placed in droplet precautions and started on a medication regime. B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided. C. The patient will need an IGRA test to help differentiate between a latent tuberculosis infection versus an active tuberculosis infection. D. The patient will need to repeat the skin test in 48-72 hours to confirm the results.

B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided.

While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing? A. Lung biopsy B. Thoracentesis C. Mediastinoscopy D. Ventilation-perfusion scan

B. Thoracentesis

A nurse is caring for a client who had a pneumonectomy. Which is the priority nursing assessment? A. Pulse oximetry B. Ventilatory exchange C. Closed chest drainage D. Approximation of the incision

B. Ventilatory exchange

You're discussing nutrition with your patient who has cystic fibrosis. You explain that it is very important the patient regularly takes fat-soluble vitamins. This includes: A. Vitamin B B. Vitamin D C. Vitamin C D. Vitamin K E. Vitamin E F. Vitamin A

B. Vitamin D D. Vitamin K E. Vitamin E F. Vitamin A

A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in ___________________ precautions and will always wear _____________________ when providing patient care? A. droplet, respirator B. airborne, respirator C. contact and airborne, surgical mask D. droplet, surgical mask

B. airborne, respirator

You're educating the parents of an 8-month-old, who was recently diagnosed with cystic fibrosis, about the disease. You explain to the parents that the child has a gene mutation on the ____________. The gene that is specifically mutated is called? A. endocrine glands; Hbg S gene B. exocrine glands; CFTR gene C. endocrine glands; Chromosome 21 D. exocrine glands; HTT gene

B. exocrine glands; CFTR gene

Which statement is correct regarding mycobacterium tuberculosis? A. This bacterium is an anaerobic type of bacteria. B. It is an alkali bacterium that stains bright red during an acid-fast smear test. C. It is known as being an aerobic type of bacteria. D. It's an acid-fact bacterium that stains bright green during an acid-fast smear test.

C. It is known as being an aerobic type of bacteria.

You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis: A. Diabetes B. Liver failure C. Long-term care resident D. Inmate E. IV drug user F. HIV G. U.S. resident

C. Long-term care resident D. Inmate E. IV drug user F. HIV

What is the underlying rationale for why a nurse assesses a client with emphysema for clinical indicators of hypoxia? A. Pleural effusion B. Infectious obstructions C. Loss of aerating surface D. Respiratory muscle paralysis

C. Loss of aerating surface

A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information? A. The client's pneumonia is continually improving. B. Oxygen concentrations up to 44% can be obtained. C. Mechanical ventilation may be required next. D. Nasal cannula may be used while the client is eating.

C. Mechanical ventilation may be required next.

Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear? A. N95 mask B. Surgical mask C. No special PPE is needed D. Face mask with shield

C. No special PPE is needed

An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which condition may the client have? A. Laryngeal trauma B. Vocal cord paralysis C. Obstructive sleep apnea D. Subcutaneous emphysema

C. Obstructive sleep apnea

About one hour after eating a meal, your patient, who has cystic fibrosis, starts to experience abdominal pain and bloating. Then two hours later the patient has a bowel movement. The patient's stool appears to be greasy and have a foul odor. Which medication below that is being taken by the patient is not providing a desirable outcome for this patient and needs to be re-addressed by the physician? A. Guaifenesin B. Triamcinolone C. Pancrelipase D. Polyethylene Glycol

C. Pancrelipase

Which disorder would the nurse state is related to the tonsils? A. Rhinitis B. Sinusitis C. Pharyngitis D. Pneumonia

C. Pharyngitis

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis

A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? A. Client no longer is infected. B. Tuberculin skin test is negative. C. Sputum is free of acid-fast bacteria. D. Client's temperature has returned to normal.

C. Sputum is free of acid-fast bacteria.

A patient is taking Streptomycin. Which finding below requires the nurse to notify the physician? A. Patient reports a change in vision. B. Patient reports a metallic taste in the mouth. C. The patient has ringing in their ears. D. The patient has a persistent dry cough.

C. The patient has ringing in their ears.

A patient completed a sweat test yesterday. The results are back and are 45 mmol/L. As the nurse you know this means: A. The patient tested positive for cystic fibrosis. B. The patient tested negative for cystic fibrosis. C. The patient needs further testing because results are not conclusive.

C. The patient needs further testing because results are not conclusive.

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? A. Bradycardia B. Flushed face C. Unilateral chest pain D. Decreased blood pressure

C. Unilateral chest pain

Your patient, who is receiving Pyrazinamide, report stiffness and extreme pain in the right big toe. The site is extremely red, swollen, and warm. You notify the physician and as the nurse you anticipated the doctor will order? A. Calcium level B. Vitamin B6 level C. Uric acid level D. Amylase level

C. Uric acid level

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How should the nurse document this finding? A. Adventitious sounds B. Fine crackling sounds C. Vesicular breath sounds D. Diminished breath sounds

C. Vesicular breath sounds

A patient taking Isoniazid (INH) should be monitored for what deficiency? A. Vitamin C B. Calcium C. Vitamin B6 D. Potassium

C. Vitamin B6

A client who is a heavy smoker has been prescribed a high-calorie, high-protein diet. The nurse should encourage the client to eat foods that are high in which vitamin? A. Niacin B. Thiamine C. Vitamin C (ascorbic acid) D. Vitamin B12

C. Vitamin C (ascorbic acid)

You're assisting a patient with performing chest physiotherapy. It is very important you have the patient ___________ during the therapy sessions. A. bear down B. use the incentive spirometer C. huff cough D. use a peak flow meter

C. huff cough

A 2 year-old patient with cystic fibrosis is scheduled to take Pancrelipase. How will you administer this medication? A. orally with yogurt B. orally with pudding C. orally with applesauce D. orally with ice cream

C. orally with applesauce

As the nurse you know that one of the reasons for an increase in multi-drug-resistant tuberculosis is: A. Incorrect medication ordered B. Increase in tuberculosis cases nationwide C. Incorrect route of drug ordered D. Noncompliance due to duration of medication treatment needed

D. Noncompliance due to duration of medication treatment needed

The nurse is providing postoperative care for an obese adult who had major abdominal surgery. The client has a history of smoking three packs of cigarettes daily. Which lab/diagnostic finding will the nurse check for the most accurate measurement of the client's respiratory status? A. PaO2 B. PaCO2 C. Hemoglobin D. Oxygen saturation

D. Oxygen saturation

A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? A. Tetany B. Hypercapnia C. Metabolic acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

A client returns from a radical neck dissection with a tracheotomy and two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? A. Cloudy wound drainage B. Poor gag reflex C. Decreased urinary output D. Restlessness with dyspnea

D. Restlessness with dyspnea

You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding? A. Ethambutol B. Streptomycin C. Isoniazid D. Rifampin

D. Rifampin

Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly? A. Remains constant in the chest drainage chamber. B. Is bubbling gently in the chest drainage chamber. C. Is bubbling vigorously in the suction control chamber. D. Rises in the tube of the water-seal chamber during inspiration.

D. Rises in the tube of the water-seal chamber during inspiration.

A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? A. Ensuring sufficient rest B. Changing lifestyle routines C. Breathing clean outdoor air D. Taking medications as prescribed

D. Taking medications as prescribed

A patient with active tuberculosis is taking Ethambutol. As the nurse you make it priority to assess the patient's? A. hearing B. mental status C. vitamin B6 level D. vision

D. vision

True or False: Tuberculosis is a contagious bacterial infection caused by mycobacterium tuberculosis and it only affects the lungs.

False

A nurse is caring for a client in postoperative recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment, the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do first? A. Administer oxygen as prescribed. B. Notify the healthcare provider. C. Assist with insertion of chest tube. D. Continue to assess client's respiratory status.

A. Administer oxygen as prescribed.

A patient with cystic fibrosis is diagnosed with pancreatic insufficiency. As the nurse you know that the patient will be lacking: A. Amylase B. Pepsin C. Protease D. Maltase E. Lipase

A. Amylase C. Protease E. Lipase

The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. What should the nurse do? A. Assess for obstructions in the chest tube B. Increase the amount of continuous suction C. Add sterile water to the water-seal chamber D. Make preparations to remove the chest tube

A. Assess for obstructions in the chest tube

You're providing care to an 18-year-old male who has cystic fibrosis. Select all the possible complications this patient can experience due to cystic fibrosis: A. Blood glucose 255 mg/dL B. Hearing disturbances C. Hemoptysis D. Greasy, foul smelling stools E. Weight gain F. Meconium ileus G. Excessive mucus production H. Dyspnea I. Coughing J. Hyperoxemia K. Infertility

A. Blood glucose 255 mg/dL C. Hemoptysis D. Greasy, foul smelling stools G. Excessive mucus production H. Dyspnea I. Coughing K. Infertility

A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level? A. Cannula B. Catheter C. Venturi mask D. Rebreather mask

A. Cannula

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. A. Confusion B. Hypocapnia C. Tachycardia D. Constricted pupils E. Slow respiratory rate

A. Confusion B. Hypocapnia C. Tachycardia

A 52-year old female patient is receiving medical treatment for a possible tuberculosis infection. The patient is a U.S. resident but grew-up in a foreign country. She reports that as a child she received the BCG vaccine (bacille Calmette-Guerin vaccine). Which physician's order below would require the nurse to ask the doctor for an order clarification? A. PPD (Mantoux test) B. Chest X-ray C. QuantiFERON-TB Gold (QFT) D. Sputum culture

A. PPD (Mantoux test)

A client with terminal cancer signs a do-not-resuscitate (DNR) order upon admission to the hospital. When the client goes into respiratory arrest a week later, the client is not resuscitated. Which factor does the nurse determine is most relevant to the legal aspects of a DNR order? A. Policies of the agency establish the status of DNR orders. B. Age is an important factor in the decision not to resuscitate. C. Decisions regarding resuscitation reside with the client's primary healthcare provider. D. Once a DNR order is signed, it remains in force for the entire hospitalization.

A. Policies of the agency establish the status of DNR orders.

A nurse is caring for a client with a tracheostomy. Which action should the nurse implement when performing tracheal suctioning? A. Preoxygenate the client before suctioning. B. Employ gentle suctioning as the catheter is being inserted. C. Be sure the cuff of the tracheostomy is inflated during suctioning. D. Loosen the client's secretions before suctioning by instilling saline.

A. Preoxygenate the client before suctioning.

The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB). What is the rationale for the nurse's teaching? A. Prolonged exhalation to decrease air trapping B. Shortened inhalation to reduce bronchial swelling C. Increased respiratory rate to improve arterial oxygenation D. Decreased use of diaphragm to increase amount of inspired air

A. Prolonged exhalation to decrease air trapping

Select the systems below that are affected by cystic fibrosis: A. Reproductive B. Lymphatic C. Respiratory D. Gastrointestinal E. Neuro F. Integumentary

A. Reproductive C. Respiratory D. Gastrointestinal F. Integumentary

A patient is scheduled to take Pancreatin. When will you administer this medication to the patient? A. Right before all meals and snacks B. Right before meals only C. Immediately after meals and snacks D. Immediately after meals only

A. Right before all meals and snacks

The physician orders chest physiotherapy on your patient with cystic fibrosis. This is best performed: A. immediately after a meal B. right before a meal C. 1-2 hours after a meal D. only at bedtime

C. 1-2 hours after a meal

A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in _________ so the results can be interpreted? A. 24-48 hours B. 12-24 hours C. 48-72 hours D. 24-72 hours

C. 48-72 hours

The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this? A. Collect 2 different sputum specimens 12 hours apart B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night) C. Collect 3 different sputum specimens on 3 different days D. Collect 2 different sputum specimens on 2 different days

C. Collect 3 different sputum specimens on 3 different days

A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? A. Decrease in red cell formation B. Rupture of emphysematous bullae C. Depression in the respiratory center D. Excessive drying of the respiratory mucosa

C. Depression in the respiratory center

Polycythemia is frequently associated with chronic obstructive pulmonary disease (COPD). Which should the nurse monitor for when assessing for this complication? A. Pallor and cyanosis B. Dyspnea on exertion C. Elevated hemoglobin D. Decreased hematocrit

C. Elevated hemoglobin

A client responds well after extensive pulmonary surgery for lung cancer and is discharged. A week after discharge the home care nurse observes the client's downcast eyes and lack of interest in the environment. The client's family states that this behavior started a few days after discharge. How should the nurse interpret these findings? A. Unusual, indicating mental illness B. Normal, and no follow-up is required C. Expected, but needs to be addressed D. Serious, needing immediate acute care

C. Expected, but needs to be addressed

A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have? A. Crepitus B. Sinusitis C. Fracture of the nose D. Upper respiratory tract infection

C. Fracture of the nose

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? A. Productive cough B. Clubbing of the fingertips C. Crackles at the height of inhalation D. Diminished breath sounds on auscultation

D. Diminished breath sounds on auscultation

Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation? A. Late cyanosis B. Early tachypnea C. Late use of accessory muscles D. Early unexplained restlessness

D. Early unexplained restlessness

The physician gives an order for a patient with cystic fibrosis to use a positive expiratory pressure (PEP) device to help with airway clearance. As the nurse you will order which device from supply: A. Incentive spirometer B. Bipap C. Peak flow meter D. Flutter valve

D. Flutter valve

A client with a sucking chest wound has a large, tight dressing over the site. Which purpose of the dressing does the nurse consider when planning care for this client? A. Protects the lung B. Seals off major vessels C. Prevents additional contamination of the wound D. Maintains the appropriate pressure within the chest cavity

D. Maintains the appropriate pressure within the chest cavity

A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result? A. 5 mm induration B. 15 mm induration C. 9 mm induration D. 10 mm induration

D. 10 mm induration

On a client's admission to a rehabilitation unit, the nurse gives the client, who is not immunocompromised, a purified protein derivative (PPD) of tuberculin to test for tuberculosis. Which client reaction indicates a positive response? A. 5-mm erythema with no induration B. No erythema with 3-mm induration C. 7-mm erythema with 5-mm induration D. 5-mm erythema with 10-mm induration

D. 5-mm erythema with 10-mm induration

Which client would have relatively smaller tidal volumes due to limited chest wall movement? A. A client with asthma B. A client with pneumonia C. A client with pulmonary fibrosis D. A client with phrenic nerve paralysis

D. A client with phrenic nerve paralysis

On the first day after a right pneumonectomy, a client suddenly sits straight up in bed. The client's respirations are labored, and a crowing sound is audible. The client's skin is pale, cool, and moist. Which action is priority? A. Notify the primary healthcare provider B. Check the chest tube for patency C. Inspect the incision for bleeding D. Auscultate the left lung

D. Auscultate the left lung

Cystic fibrosis is an autosomal recessive genetic disorder. Which option below best describes what most likely happens for a child to develop this condition? A. One parent, who is a carrier of the mutated gene, has to pass it to the child B. One of the parents has to have cystic fibrosis in order to pass it to their offspring C. Both of the parents must have cystic fibrosis in order for the child to develop it D. Both parents, who are carriers of the mutated gene, each pass one mutated gene to the child

D. Both parents, who are carriers of the mutated gene, each pass one mutated gene to the child