PrepU Quizzes for Test 2

A client exhibits a sudden and complete loss of voice and is coughing. The nurse states

"Do not smoke and avoid being around others who are smoking."

The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse?

"The tube will drain air from the space around the lung."

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include?

"You can use writing or a communication board to communicate."

Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia).

60; 50

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?

95%

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?

Flail chest

A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?

Fluoroscopy

A client with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. What sinus is the client referring?

Frontal

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?

Impaired gas exchange related to ventilator setting adjustments

The nurse is caring for a critically ill client in the ICU. The nurse documents the client's respiratory rate as bradypnea. The nurse recognizes that bradypnea is associated with which condition?

Increased intracranial pressure

Which measure may increase complications for a client with COPD?

Increased oxygen supply

Which clinical manifestation of hemorrhage is related to carotid artery rupture?

Increased pulse rate

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

Increased restlessness

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen?

Nonrebreather mask

Which oxygen administration device has the advantage of providing a high oxygen concentration?

Nonrebreathing mask

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Notify the physician.

The nurse is teaching a client the proper technique for diaphragmatic breathing. Place the steps for this procedure in the correct sequence.

Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. Breathe out through pursed lips while tightening the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. Repeat for 1 minute; follow with a 2-minute rest period.

During a preadmission assessment, the nurse finds increased tactile fremitus. She knows this sign is consistent with which of the following diagnoses?

Pneumonia

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

Pneumothorax

A client presents to the ED with a suspected allergic reaction. The client is experiencing laryngeal edema, which is causing obstruction, and is demonstrating retractions in the neck during inspiration. Which is the nurse's priority intervention?

Prepare to administer subcutaneous epinephrine and corticosteroids

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?

Pulmonary embolism

Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage?

Rapid, deep respirations

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway.

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure?

Sudden onset of lung impairment in a client who had normal lung function

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?

Sudden restlessness

A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by

Telling the client to sit upright with the head tilted forward

A mediastinal shift occurs in which type of chest disorder?

Tension pneumothorax

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?

The client has a funnel chest.

In relation to the structure of the larynx, which describes the cricoid cartilage?

The only complete cartilaginous ring in the larynx

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?

Water-seal chamber

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?

Wheezes

A client with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed?

With meals

The nurse advises a patient who sustained a fractured nose during an automobile accident that surgery will be necessary. Due to significant facial edema, surgery would be scheduled:

Within 1 week.

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:

Expect coughing when using the spirometer properly.

The client with a lower respiratory airway infection is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse?

Ineffective Airway Clearance

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is

Ineffective airway clearance related to excess mucus production

The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure?

Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting

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?

Pleurisy

In general, chest drainage tubes are not indicated for a client undergoing which procedure?

Pneumonectomy

Which hollow tube transports air from the laryngeal pharynx to the bronchi?

trachea

A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects?

Ineffective coping related to anxiety

The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation?

Initial washing of hands after cleaning inner cannula.

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?

Take deep breaths and cough forcefully.

The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." This assists in meeting which nursing goal?

The client will have decreased edema.

A patient comes to the clinic complaining of a possible upper respiratory infection. What should the nurse inspect that would indicate that an upper respiratory infection may be present?

The nasal mucosa

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?

The patient will have an insertion of a tracheostomy tube.

A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately?

"Client is becoming agitated and complains of pleuritic pain."

A client with chronic obstructive pulmonary disease (COPD) expresses a desire to quit smoking. The first appropriate response from the nurse is:

"Have you tried to quit smoking before?"

A physician orders metaproterenol by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication?

"I need to hold my breath as long as possible after I take a deep inhalation."

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

"I should become involved in a weight loss program."

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?

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

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says:

"I'll stop being contagious when I have a negative acid-fast bacilli test."

A nurse is transporting a client 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?

Place the chest tube in sterile water

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 compromised skin graft.

The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have

a persistent cough or sore throat"

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 possible hematologic problem.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

The tissues give a crackling sensation when palpated.

A commonly prescribed methylxanthine used as a bronchodilator is which of the following?

Theophylline

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?

They help prevent cardiac arrhythmias.

The nurse is studying for a physiology test over the respiratory system. What should the nurse know about central chemoreceptors in the medulla?

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

A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?

Tonsils

The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?

Transillumination of the sinus

A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first?

Troubleshoot to identify the malfunction.

Which comfort technique does a nurse teach to a client with pleurisy to assist with splinting the chest wall?

Turn onto the affected side

Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall?

Turn onto the affected side.

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?

Unresponsive arterial hypoxemia

A nurse is aware that the diagnostic feature of ARDS is sudden:

Unresponsive arterial hypoxemia.

Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy?

Use enteral feedings after the procedure

A patient comes to the clinic with a cold and wants something to help relieve the symptoms. What should the nurse include in educating the patient about the uncomplicated common cold? (Select all that apply.)

Inform the patient about the symptoms of secondary infection. Suggest that the patient take adequate fluids and get plenty of rest. Inform the patient that the virus is contagious for 2 days before symptoms appear and during the first part of the symptomatic phase.

When a client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the high risk for

carotid artery hemorrhage.

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should:

instruct the client to drink at least 2 L of fluid daily

A late complication of radiation therapy is

laryngeal necrosis.

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:

mucous membranes.

What does a positive Mantoux test indicate?

production of an immune response

The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing

sinus infection

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

skin test doesn't differentiate between active and dormant tuberculosis infection.

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:

synchronized intermittent mandatory ventilation (SIMV).

A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include

the importance of blood tests to monitor serum concentrations.

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he:

uses the sternocleidomastoid muscles.

A client is prescribed methylprednisolone (Solu-Medrol) 125 mg intravenously. The medication is available in a 125 mg single-dose vial containing 2 mL. The nurse will administer methylprednisolone over 2 minutes. How many mL will the nurse administer each 15 seconds? Write your answer to 2 decimal places. Starting with 0., enter the correct number ONLY.

0.25

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting?

0.5

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for:

10 seconds with 5 episodes/hour

The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.

100

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15-mm induration

Arterial blood gases should be obtained how often after initiating continuous mechanical ventilation?

20 minutes

Which is a correct endotracheal tube cuff pressure?

22 mm Hg

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:

5 g/dL

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:

5 to 20 minutes.

A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient?

A Venturi mask

The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside?

A bottle of sterile water

A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate?

A disease process is present.

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?

A partial rebreathing mask

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?

Acute respiratory distress syndrome

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?

Administer an over-the-counter decongestant.

A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority?

Administer one intramuscular injection of penicillin

A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs?

Administer the salmeterol and then administer the triamcinolone.

Which is a true statement regarding air pressure variances?

Air is drawn through the trachea and bronchi into the alveoli during inspiration.

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

Aspiration pneumonia

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:

Assess pulse and blood pressure

The nurse is to make a room assignment for a client diagnosed with an upper respiratory infection. The other clients with empty beds in the room are listed in the accompanying chart. The best room assignment for the new client would be with Client

B

The nurse is performing an assessment of a patient who arrived in the emergency department with a barbiturate overdose. The respirations are normal for 3 to 4 breaths followed by a 60-second period of apnea. How does the nurse document the respirations?

Biot's respirations

The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and would assist in the diagnosis of an occupational lung disease?

Black-streaked sputum

The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?

Blood gases

The nurse is caring for a client being weaned from a mechanical ventilator. Which findings would require the weaning process to be terminated?

Blood pressure increase of 20 mm Hg from baseline

In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?

Bradypnea

Which of the following occupy space in the thorax, but do not contribute to ventilation?

Bullae

A nurse should include what instruction for the client during postural drainage?

Change positions frequently and cough up secretions.

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply.

Check for any unusual changes in breathing during the first 48 hours. Observe for any clear drainage from either nostril. Elevate the head of the bed for sleeping during the first week. Restrict from sports activities for 6 weeks.

A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to

Check the clear fluid for glucose.

The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is

Epistaxis

A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions?

Every 2 to 4 hours

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?

Evidence of muscle weakness

The nurse has instructed the client to use a peak flow meter. The nurse evaluates client learning as satisfactory when the client

Exhales hard and fast with a single blow

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

Few early symptoms

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes

Gastroesophageal reflux disease (GERD)

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

Gastrointestinal hemorrhage

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client

Has wheezes in the right lung lobes

Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure?

Hyperbaric

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?

Hypercapnia

A client is seen in the emergency room for a case of diabetic acidosis with the presence of Kussmaul respirations. What client condition is associated with the presence of Kussmaul respirations?

Hyperventilation

In which grade of COPD is the forced expiratory volume in 1 second (FEV1) greater than 80% predicted?

I

A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 65% for a patient with COPD. What stage should the nurse document the patient is in?

II

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?

Impaired Gas Exchange

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

A client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist with mucus. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. What is a priority nursing concern?

Ineffective airway clearance

Which is the priority nursing diagnosis for a client undergoing a laryngectomy?

Ineffective airway clearance

Which of the following factors contribute to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Select all that apply.

Inflamed airways obstruct airflow. Mucus secretions block airways. Overinflated alveoli impair gas exchange.

Which of the following interventions would be helpful for a client reporting nasal congestion, sneezing, sore throat, and muscle aches? Select all that apply.

Provide warm salt-water gargles. Administer oral ibuprofen. Teach the client about handwashing. Recommend guaifenesin.

The clinical finding of pink, frothy sputum may be an indication of which condition?

Pulmonary edema

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart

Reduced cardiac output

A client has a nursing diagnosis of acute pain related to upper airway irritation. The best short-term goal for this client is for the client to

Report relief of pain to level 3 using a pain intensity scale of 0 to 10.

The nurse is caring for a patient with status asthmaticus in the intensive care unit (ICU). What does the nurse anticipate observing for the blood gas results related to hyperventilation for this patient?

Respiratory alkalosis

A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped?

Runs of ventricular tachycardia

A client who has an altered level of consciousness is receiving a tube feeding. Clients receiving tube feeding should be placed in which position?

Semi-Fowler's or higher

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:

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.

A nurse is discussing asthma complications with a client and family. What complications should the nurse include in the teaching? Select all that apply.

Status asthmaticus Respiratory failure Atelectasis

A client involved in a motor vehicle crash suffered a penetrating injury to the chest wall and was brought to the emergency department. The nurse assesses the client for which clinical manifestation that would indicate the presence of a pneumothorax?

Sucking sound at the site of injury

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?

Suction the client, withdraw residual air from the cuff, and reinflate it.

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.

Tachypnea

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?

Tachypnea

A nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). What instructions should the nurse include in the teaching? Select all that apply.

Take a slow, deep inhalation from the device. Activate the MDI once. The device may increase delivery of the MDI medication.

The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session?

Coughing

A client is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which medication is contraindicated in the treatment of asthma exacerbations?

Cromolyn sodium

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear?

Decreased breath sounds

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.

Diaphragm contracts and elongates the chest cavity.

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.

What is the reason for chest tubes after thoracic surgery?

Draining secretions, air, and blood from the thoracic cavity is necessary.

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?

Dull

For a client with pleural effusion, what does chest percussion over the involved area reveal?

Dullness over the involved area

High or increased compliance occurs in which disease process?

Emphysema

The nurse knows that what condition is associated with increased compliance of the lungs?

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?

Emphysema

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?

Encourage the patient to take approximately 10 breaths per hour, while awake.

A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?

Laryngeal cancer

The nurse is caring for a client receiving radiation therapy for laryngeal cancer. Which is a late complication of radiation therapy?

Laryngeal necrosis

Late complications of radiation therapy may include which of the following? Select all that apply.

Laryngeal necrosis Edema Fibrosis

A client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night." The nurse should suspect which of the following conditions based on the client's primary report?

Left-sided heart failure

Which community-acquired pneumonia demonstrates the highest occurrence during summer and fall?

Legionnaires disease

A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.

"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7."

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement?

"It is all right if I have a grilled cheese sandwich with American cheese."

The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?

Aortic arch, pons, and CO2 receptor sites

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?

Anemic hypoxia

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?

Angiotensin converting enzyme (ACE) inhibitors

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:

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

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?

Chemical irritation

You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate?

Chemical irritation

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?

Chest tube drainage, 190 mL/hr

The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall?

Chronic granular

Which assessment finding puts a client at increased risk for epistaxis?

Cocaine use

A young adult with cystic fibrosis is admitted to the hospital for an acute airway exacerbation. Aggressive treatment is indicated. What is the first action by the nurse?

Collects sputum for culture and sensitivity

What happens to the diaphragm during inspiration?

It contracts and flattens.

The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.

Oxygen is dissolved. Oxyhemoglobin circulates to the body tissue. Adequate red blood cells are needed for oxygen transport.

Which is a key characteristic of pleurisy?

Pain

A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:

Palpates the thyroid cartilage.

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

Using a Venturi mask to deliver oxygen as ordered

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?

Using strict hand hygiene

What is the difference between respiration and ventilation?

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

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?

Vesicular

Most cases of acute pharyngitis are caused by which of the following?

Viral infection

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply.

Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg PaO2 of 64 mm Hg

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6

A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is

amoxicillin-clavulanic acid.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis.