Respiratory Disorders NCLEX 3000

A client has a sucking stab wound to the chest. Which action should the nurse take first?

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

A client, confused and short of breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the client's current respiratory problem, the physician orders a chest X-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurse sees many abbreviations. What does a lowercase "a" in an ABG value represent?

2. Arterial blood

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?

2. At least 2 hours after a meal

After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately?

2. Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.

During inspiration, which of the following occurs?

2. Diaphragm descends.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

2. Expect protamine sulfate to be ordered.

Which of the following would be appropriate for a client with arterial blood gas (ABG) values of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3- 24 mEq/L, and PaO2 94 mm Hg?

2. Instruct the client to breathe into a paper bag.

A client reports difficulty breathing and a sharp pain in the right side of the chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which goal of care?

2. Maintaining effective respirations

An elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza?

2. Pneumonia

A client admitted to the health care facility with acute bronchitis is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the likely cause of this sound?

2. The oxygen tubing is pinched.

A nurse detects bilateral crackles when auscultating a client's lungs. Which statement about crackles is true?

2. They're usually heard on inspiration and don't clear with a cough.

The nurse assesses a client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing?

2. Use of accessory muscles

A client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:

2. acute adrenocortical insufficiency.

The nurse formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include:

2. being overweight.

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

3. "Weigh yourself daily and report a gain of 2 lb in 1 day."

The oxygen saturation level of a 48-year-old client admitted to the hospital with bronchial pneumonia decreases, and his breathing is shallow. He refuses to perform coughing and deep-breathing exercises, or use an incentive spirometer. Which measures can the nurse take to help improve the client's respiratory status?

3. Elevate the head of the bed, and demonstrate and reinforce the importance of incentive spirometry, turning, coughing, and deep breathing.

A 59-year-old client has been in the intensive care unit for 10 days without signs of recovery after sustaining respiratory arrest. His wife requests that life support be withdrawn despite the client's advance directive that expresses his desire for life support. Which action should the nurse take?

3. Explain that the client's advance directive must be followed because it outlines his wishes for treatment.

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?

3. Manual resuscitation bag

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation?

3. Measles

A 69-year-old client comes to the emergency department with a history of productive cough, night sweats, and a 30-lb weight loss over the past 8 months. A diagnosis of tuberculosis is suspected. Which intervention is necessary for this client?

3. Place the client in a private room with negative air pressure, and implement airborne precautions.

Which of the following is the hallmark of adult respiratory distress syndrome (ARDS)?

3. Progressive hypoxemia despite oxygen therapy

A client with myasthenia gravis is having difficulty swallowing his saliva. What should the nurse do?

3. Suction the client's airway.

A 72-year-old client with end-stage chronic obstructive pulmonary disease (COPD) is admitted to the hospital in acute respiratory distress. He refuses endotracheal intubation but requests less invasive treatment interventions. A nurse notes that the client's oxygen saturation is 82%, his pulse is rapid and thready, and his respirations are shallow. How should the nurse intervene?

3. Support the client's treatment decision and provide care as prescribed.

For a client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?

3. Teaching the client how to perform controlled coughing

The nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

3. The system has an air leak.

A client is brought to the emergency department in acute respiratory distress. 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?

3. They help prevent cardiac arrhythmias.

Which phrase is used to describe the volume of air inspired and expired with a normal breath?

3. Tidal volume

The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?

3. Use diaphragmatic breathing.

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

3. Using a high-flow Venturi mask to deliver oxygen as prescribed

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure?

3. Withhold food and fluids until the client's gag reflex returns., 4. Assess for hemoptysis and frank bleeding., 6. Monitor the client's vital signs.

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

3. adult respiratory distress syndrome (ARDS).

A 21-year-old client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician prescribes acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because:

3. it may induce bronchospasm.

The nurse is caring for a client who is scheduled for a bronchoscopy. Which interventions should the nurse perform to prepare the client for this procedure?

1. Explain the procedure., 4. Confirm that a signed informed consent form has been obtained., 5. Ask the client to remove his dentures., 6. Administer atropine and a sedative.

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 him closely for:

3. atelectasis.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse should:

3. encourage coughing and deep breathing.

Inspiratory and expiratory stridor may be found in a client who:

3. has aspirated a piece of meat.

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?

1. Hypoxia

After receiving an oral dose of codeine for an intractable cough, the client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond?

1. In 30 minutes

A client's chest X-ray reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from:

3. increased pulmonary capillary permeability.

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing acute respiratory distress syndrome from acute respiratory failure?

1. Partial pressure of arterial oxygen (PaO2)

The 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?

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

The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

1. Respiratory rate of 22 breaths/minute

The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client?

1. Wear gloves when handling tissues containing sputum., 2. Wear a face mask at all times., 6. Wash hands after direct contact with the client or contaminated articles.

The amount of air inspired and expired with each breath is called:

1. tidal volume.

The nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. The reason for this change is that:

2. the airways are so swollen that no air can get through.

A competent client who requires long-term mechanical ventilation privately tells a nurse that she wants the ventilator withdrawn. Which response by the nurse is best?

1. "Tell me how you are feeling."

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

1. 15-mm induration

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is likely to include which nursing diagnosis?

1. Anxiety

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom?

1. Bleeding

A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects Legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What is the drug of choice for treating Legionnaires' disease?

1. Erythromycin (Erythrocin)

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

2. "Family members should continue to talk to the client."

A home health care nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

2. "I make sure my oxygen mask is on tightly, so it won't fall off while I nap."

What is the normal pH range for arterial blood?

2. 7.35 to 7.45

The nurse is about to perform nasopharyngeal suctioning on a client who recently had a cerebrovascular accident. Identify the area where the tip of the suction catheter should be placed.

When performing nasopharyngeal suctioning, the tip of the catheter is introduced into the naris and advanced to the pharynx. The tip remains above the posterior wall of the mouth.

The nurse is caring for a client who has a chest tube connected to a three-chamber drainage system without suction. Identify the chamber that collects drainage from the client.

The drainage chamber is on the right. It has three calibrated columns that show the amount of drainage collected. When the first column fills, drainage empties into the second; when the second column fills, drainage flows into the third. The water-seal chamber is located in the center. The suction-control chamber is on the left.

The nurse is collecting data on a client with left lower lobe atelectasis. Identify the area where she may hear fine crackles associated with this condition.

To auscultate the left lower lobe from the anterior chest, use the landmarks of the left anterior axillary line, between the fifth and sixth intercostal spaces.

A client is scheduled to undergo a bronchoscopy. Which nursing interventions would be included on the care plan?

2. Keep suction equipment available., 4. Assess cough and gag reflexes after the procedure., 6. Report hemoptysis, stridor, or dyspnea immediately.

A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcome indicates that the client has adequate respiratory function?

2. The client breathes at a rate of 16 to 20 breaths/minute.

A 47-year-old male client with an unresolved hemothorax is febrile, with chills and diaphoresis. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

2. empyema.

A positive Mantoux test indicates that the client:

2. has produced an immune response.

The nurse is caring for a client with pneumonia. The physician orders 600 mg of ceftriaxone (Rocephin) oral suspension to be given once per day. The medication label indicates that the strength is 125 mg/5ml. How many milliliters of medication should the nurse pour to administer the correct dose?

24

A recent immigrant from Vietnam is diagnosed with pulmonary tuberculosis (TB). Which intervention is most important for the nurse to implement with this client?

3. Developing a list of people with whom the client has had contact

The nurse is caring for a client with pneumonia. The nurse should expect to observe which signs and symptoms?

2. Fever, 5. Use of accessory muscles during respiration, 6. Crackles or rhonchi.

For a client with impaired gas exchange, which position is best?

2. High Fowler's

A client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature?

1. Inflamed lung tissue

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should a nurse take first?

1. Initiate oxygen therapy.

The nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

1. It helps prevent early airway collapse.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care?

1. Measuring and documenting the drainage in the collection chamber

A client with pneumonia caused by group A streptococci is admitted to an acute care facility for I.V. penicillin G therapy. Because the client can receive penicillin G only by the I.V. route, the nurse expects to administer:

1. penicillin G aqueous.

On auscultation, which finding suggests a right pneumothorax?

2. Absence of breath sounds in the right thorax

The nurse is caring for a client with pneumonia. As part of prescribed therapy, the client must use a bedside incentive spirometer to promote maximal deep breathing. The nurse checks to make sure the client is using the spirometer properly. During each waking hour, the client should perform a minimum of how many sustained, voluntary inflation maneuvers?

4. 8 to 10

The nurse prepares to perform postural drainage. How would the nurse determine the best position for facilitating drainage of the lungs?

4. Auscultation

A client with end-stage pulmonary hypertension tells his physician that he doesn't want any heroic measures should his heart stop and that he doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is a nurse upholding by supporting the client's decision?

4. Autonomy

The nurse is teaching a client about theophylline toxicity. Which of the following is a sign or symptom of theophylline toxicity?

3. Nausea

After undergoing a thoracotomy, a client is receiving epidural analgesia. Which data collection finding indicates that the client has developed the most serious complication of epidural analgesia?

4. Respiratory depression

A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician prescribes codeine, 10 mg by mouth every 4 hours. Which statement accurately describes codeine?

3. It's a centrally acting antitussive and can cause dependence.

A client is prescribed rifampin (Rifadin), 600 mg by mouth daily. Which statement about rifampin is true?

3. It's tuberculocidal, destroying the offending bacteria.

A client is to receive I.V. vancomycin (Vancocin). When preparing to administer this drug, the nurse should keep in mind that vancomycin:

1. should be infused over 60 to 90 minutes in a large volume of fluid.

A client with colorectal carcinoma is devastated after learning that the cancer has spread to his liver and lungs and that he has only a 5% chance of surviving for 5 years. Which comment by the nurse would best help the client cope with this news?

2. "It must be hard to hear that prognosis. Would it help you to talk to me or the chaplain?"

When a client's ventilation is impaired, the body retains which substance?

2. Carbon dioxide

A client with a nursing diagnosis of Impaired spontaneous ventilation undergoes a tracheostomy after many failed attempts at weaning from a mechanical ventilator. The nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

4. Withdraw residual air from the cuff and then reinflate it.

A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter but doesn't show signs of active tuberculosis. Management of her care would include:

4. advising her to begin prophylactic therapy with isoniazid (INH).

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) by I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer:

4. albuterol (Proventil).

The nurse assessing a client for tracheal displacement should know that the trachea will deviate toward the:

4. contralateral side in a hemothorax.

The nurse must administer theophylline (Theo-Dur) to a client. This drug treats asthma by:

4. relaxing bronchial smooth muscle.

A client has allergy-induced asthma. During assessment of breath sounds the nurse would expect:

4. wheezing and shortness of breath

A client with pneumonia has just finished dinner. The nurse must calculate the client's fluid intake before taking the tray from his room. The client had 6 ounces of soup, 4 ounces of milk, and 8 ounces of juice. How many milliliters of fluid should the nurse record on the client's intake record?

540

A client with bronchitis is ordered 300 mg of liquid guaifenesin (Robitussin) every 4 hours. The container indicates that there is 200 mg/5 ml. How many milliliters should the nurse administer per dose?

7.5

A client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

4. 10 to 20 mcg/ml

A client undergoes a purified protein derivative (PPD) test for tuberculosis. After injecting PPD, the nurse should plan to read the test results after waiting:

4. 48 hours.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's teenage daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

4. 6 to 12 months

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?

4. Chest pain and dyspnea

The physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which of the following?

4. Daily doses of isoniazid, 300 mg for 6 months to 1 year

The nurse is collecting data on a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

4. Dyspnea and wheezing

A client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

4. Impaired gas exchange related to airflow obstruction

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

4. Light-headedness or paresthesia

The nurse is performing a painless, noninvasive procedure to measure SaO2. What procedure is it?

4. Pulse oximetry

A 68-year-old client with end-stage chronic obstructive pulmonary disease (COPD) has discharge orders that include home oxygen therapy. The client exhibits anxiety about becoming dependent on supplemental oxygen. How can a nurse help allay the client's anxiety?

4. Remain with the client during an education session taught by the respiratory therapist, and reinforce teaching after the session.

The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which statement concerning PPD testing is true?

2. A positive reaction indicates that the client has been exposed to the disease.

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction?

3. "I will stay in isolation for at least 6 weeks."