NSG-1523 PrepU Respiratory 2

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order: 1) Hold breath for about 3 seconds. 2) Sit in an upright position. 3) Place the mouthpiece of the spirometer in the mouth. 4) Breathe air in through the mouth. 5) Exhale air slowly through the mouth.

2, 3, 4, 1, 5

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

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? a) Suction the client, withdraw residual air from the cuff, and reinflate it. b) Call the physician. c) Add more air to the cuff. d) Remove the malfunctioning cuff.

A

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

A

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? a) Measuring and documenting the drainage in the collection chamber b) Stripping the chest tube every hour c) Maintaining continuous bubbling in the water-seal chamber d) Keeping the collection chamber at chest level

A

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: a) Symmetry of the client's chest expansion b) Cool air humidified through the tube c) A scheduled time for deflation of the tracheal cuff d) Tracheal cuff pressure set at 30 mm Hg

A

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) "When the tube is being removed, take a deep breath, exhale, and bear down." b) "While the chest tube is being removed, raise your arms above your head." c) "Exhale forcefully while the chest tube is being removed." d) "During the removal of the chest tube, do not move because it will make the removal more painful."

A

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

A

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 adequate transport of oxygen in the blood b) To provide visual feedback to encourage the client to inhale slowly and deeply c) To decrease the work of breathing d) To clear respiratory secretions e) To reduce stress on the myocardium

A, C, E

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.) a) Pressure necrosis b) Tracheal aspiration c) Tracheal bleeding d) Hypoxia e) Tracheal ischemia

A, C, E

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations? a) Nasal cannula b) Nonrebreather mask c) Face tent d) Simple mask

B

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) Regularly assess the client's vital signs every 2 to 4 hours. d) Encourage deep breathing exercises. e) Monitor and record hourly intake and output.

B, C, D

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) Bradycardia b) Dyspnea c) Mood swings d) Substernal pain e) Fatigue

B, D, E

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: a) 30 to 40 minutes. b) 15 to 60 seconds. c) 5 to 20 minutes. d) 45 to 60 minutes.

C

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? a) Have the patient lie in a supine position during the use of the spirometer. b) Encourage the patient to try to stop coughing during and after using the spirometer. c) Encourage the patient to take approximately 10 breaths per hour, while awake. d) Inform the patient that using the spirometer is not necessary if the patient is experiencing pain.

C

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) Providing frequent oral hygiene c) Auscultating the lungs for bilateral breath sounds d) Turning the client from side to side every 2 hours

C

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? a) Perform this measure with the client once a day. b) Use aerosol sprays to deodorize the client's environment after postural drainage. c) Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. d) Administer bronchodilators and mucolytic agents following the sequence.

C

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) Moderate amounts of colorless sputum c) Chest tube drainage of 190 mL/hr d) Pain of 5 on a 1 to 10 pain scale

C

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

D

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) Consults with the physician about removing the client from the ventilator b) Contacts the respiratory therapy department to report the ventilator is malfunctioning c) Changes the setting on the ventilator to increase breaths to 14 per minute d) Continues assessing the client's respiratory status frequently

D

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

D

Which of the following is a correct endotracheal tube cuff pressure? a) 13 mm Hg b) 17 mm Hg c) 21 mm Hg d) 25 mm Hg

B

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator? a) Heart rate less than 100 b) Blood pressure increase of 20 mm Hg c) PaOgreater than 60 mmHg with a FiO less than 40% d) Vital capacity of 12 mL/kg

B

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for a) A cut or slice in the tubing from the ventilator b) Malfunction of the alarm button c) Higher than normal endotracheal cuff pressure d) A kink in the ventilator tubing

D

Constant bubbling in the water seal of a chest drainage system indicates which of the following problems? a) Increased drainage b) Tidaling c) Tension pneumothorax d) Air leak

D

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) continuous positive airway pressure (CPAP). c) pressure support ventilation (PSV). d) assist-control (AC) ventilation.

A

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) Place the end of the chest tube in a container of sterile saline. b) Apply an occlusive dressing and notify the physician. c) Clamp the chest tube immediately. d) Secure the chest tube with tape.

A

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? a) "Before you do the exercise, I'll give you pain medication if you need it." b) "You need to start using the incentive spirometer 2 days after surgery." c) "Breathe in and out quickly." d) "Don't use the incentive spirometer more than 5 times every hour."

A

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? a) The patient will have an insertion of a tracheostomy tube. b) The patient will be extubated and a nasotracheal tube will be inserted. c) The patient will begin the weaning process. d) The patient will be extubated and another endotracheal tube will be inserted.

A

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) Negative-pressure ventilator b) Continuous positive airway pressure (CPAP) c) Positive-pressure ventilator d) Bilevel positive airway pressure (Bi-PAP)

A

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) Water-seal chamber b) Air-leak chamber c) Suction control chamber d) Collection chamber

A

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: a) Administer prescribed pain medication. b) Assess pulse and blood pressure. c) Notify the physician. d) Lay the client's head to a flat position.

B

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

B

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

B

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 just changed into my running suit; we can do my CPT now." b) "I received my pain medication 10 minutes ago, let's do my CPT now." c) "I just finished eating my lunch, I'm ready for my CPT now." d) "I have been coughing all morning and am barely bringing anything up.

C

The nurse should monitor a client receiving mechanical ventilation for which of the following complications? a) Pulmonary emboli b) Immunosuppression c) Gastrointestinal hemorrhage d) Increased cardiac output

C

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) Semiconsciousness b) Delirium c) Hyperventilation d) Hypoxia

D

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: a) suctioning the tracheostomy tube frequently. b) using a cuffed tracheostomy tube. c) keeping the tracheostomy tube plugged. d) using the minimal-leak technique with cuff pressure less than 25 cm H2O.

D

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

D

In general, chest drainage tubes are not used for the patient undergoing a) wedge resection. b) lobectomy. c) segmentectomy. d) pneumonectomy.

D

Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration? a) Venturi mask b) Face tent c) Catheter d) Non-rebreather mask

D

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

D

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) Hypoxic hypoxia b) Histotoxic hypoxia c) Anemic hypoxia d) Circulatory hypoxia

D

A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient? a) Continuous positive airway pressure b) Bi-level positive airway pressure c) Surgery to remove the tonsils and adenoids d) Medications to assist the patient with sleep at night

A

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) pH b) Partial pressure of arterial oxygen (PaO2) c) Bicarbonate (HCO3-) d) Partial pressure of arterial carbon dioxide (PaCO2)

B

A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? a) Make sure that a thoracotomy tube is linked to open chest drainage. b) Encourage coughing to mobilize secretions. c) Assist with positioning the client on the right side. d) Restrict intravenous fluids for at least 24 hours.

B

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) A disconnected ventilator tube b) Kinking of the ventilator tubing c) An ET cuff leak d) A change in the oxygen concentration without resetting the oxygen level alarm

B

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) 58 mm Hg b) 84 mm Hg c) 45 mm Hg d) 120 mm Hg

B

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? a) Tracheostomy cleaning kit b) Manual resuscitation bag c) Water-seal chest drainage set-up d) Oxygen analyzer

B

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) Check for an apical pulse. b) Suction the client's artificial airway. c) Increase the oxygen percentage. d) Ventilate the client with a handheld mechanical ventilator.

B

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) Have the patient cough. b) Auscultate the lung for adventitious sounds. c) Assess the CO2 level to determine if the patient requires suctioning. d) Have the patient inform the nurse of the need to be suctioned.

B

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

B

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) Risk for trauma related to endotracheal intubation and cuff pressure b) Impaired gas exchange related to ventilator setting adjustments c) Risk for infection related to endotracheal intubation and suctioning d) Impaired physical mobility related to being on a ventilator

B

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

B

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) Use of a cooling blanket b) Endotracheal suctioning c) Incentive spirometry d) Encouragement of coughing

B

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: a) hyperthermia. b) a compromised skin graft. c) pneumonia. d) a malignant tumor.

B

The nurse is preparing to perform tracheostomy care on a patient with a newly inserted tracheostomy tube. Which of the following actions, if preformed by the nurse, indicates the need for further review of the procedure? a) Cleans the wound and the plate with a sterile cotton tip moistened with hydrogen peroxide b) Places clean tracheostomy ties, and removes soiled ties after the new ties are in place c) Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula d) Puts on clean gloves; removes and discards the soiled dressing in a biohazard container

B

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

B

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 myocardial infarction. b) The patient is having a stress reaction. c) The patient is hypoxic from suctioning. d) The patient is in a hypermetabolic state.

C

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 20 to 25 seconds b) 0 to 5 seconds c) 10 to 15 seconds d) 30 to 35 seconds

C

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? a) The patient will begin the weaning process. b) The patient will be extubated and a nasotracheal tube will be inserted. c) The patient will be extubated and another endotracheal tube will be inserted. d) The patient will have an insertion of a tracheostomy tube.

D

A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors? a) Oxygen is explosive. b) Oxygen prevents the dispersion of smoke particles. c) Oxygen is combustible. d) Oxygen supports combustion.

D

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

D

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? a) Prior outcomes of weaning b) Electrocardiogram (ECG) results c) Fluid intake for the past 24 hours d) Baseline arterial blood gas (ABG) levels

D

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) Promote a more efficient and controlled ventilation and to decrease the work of breathing b) Promote the strengthening of the patient's diaphragm c) Promote the patient's ability to intake oxygen d) Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing

D

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 sedation until the chest tube (s) are removed. b) The patient will return from surgery with no drainage tubes. c) The patient will require mechanical ventilation following surgery. d) The patient will return to the nursing unit with two chest tubes.

D