Respiratory PassPoint Quiz

A home health nurse sees a client with end stage COPD. An outcome identified for this client is preventing infection. Which finding indicates this outcome has been met?

decreased oxygen requirements

A recent immigrant is diagnosed with TB. Which intervention is most importnat for the nurse to implement with this client?

developing a list of people with whom the client has had contact

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia

dyspnea and wheezing

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

encourage coughing and deep breathing

The nurse should teach the client with asthma to avoid which of the most common precipitating factors of an acute asthma attack?

exposure to cigarette smoke

A 56-year-old client on the surgical unit had a large bowel resection to resolve complications of diverticulitis. Assessment findings that require Follow-up

* Decreased breath sounds in lung bases RR 24 bpm O2 Sat 92% Shallowing respirations Smoking hx

A client with a nasotracheal tube needs to be suctioned. What is the length of time the nurse should apply the suction for each pass of the catheter?

10-15 seconds.

The client is to receive theophylline 500 mg IV in 500 mL of normal saline solution to run over 4 hours. The tubing delivers 60 gtt/mL. The nurse should set the infusion pump to administer the solution at how many milliliters per hour?

125

A nurse is assessing the injection site of a client who has had a PPD test. Which finding indicates a need for further evaluation?

15-mm induration

For a client with acute pulmonary embolism, the physician orders heparin 25,000 units in 500 mL of dectrase 5% in water at 1,100 units/hour. The nurse should administer how many ml/hour?

22

A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? ■ 1. An obstruction is present in the chest tube. ■ 2. The client is developing subcutaneous emphysema. ■ 3. The chest tube system is functioning properly. ■ 4. There is a leak in the chest tube system.

3. The chest tube system is functioning properly

A nurse is caring for a client diagnosed with pneumonia, a UTI, dehydration, a temp of 101.4 F. The HCP orders 1,000 ml of D5W to infuse over 8 hours. The available drop factor is 20 gtt/mL. The nurse would regulate the intravenous flow rate to deliver how many drops per minute.

42

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? a) 3 to 5 days b) 1 to 3 weeks c) 2 to 4 months d) 6 to 12 months

6-12 months

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

The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest x-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate?

A chest tube will be inserted into the left pleural space and attached to a pleural evacuation

A client with a hx of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 bpm, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first?

Administer bronchodilators as prescribed

A nurse is assisting a client with chronic respiratory disease to walk in the hallway. The nurse observes as the clients Spo2 drops from 94% to 88% during ambulation. Which nursing action is most appropriate?

Administer low flow supplemental O2

A nurse is caring for a client diagnosed with DVT. The client begins to experience symptoms of chest pain, dyspnea, and restlessness. Physical assessment reveals a heart rate of 140 bpm, BP of 100/60, and respiratory rate of 40 bpm. What is the nurse's priority action?

Assess the clients O2 sat level

Upon creating the plan of care for the client, the nurse would include which interventions?

Assist the client with turning while in bed Encourage the use of an IS Splint the abdomen Administer prescribed narcotic analgesic medication as needed

The client is ready for discharge after surgery for a deviated septum. Which instructions are appropriate?

Avoid activities that elicit Valsalva's maneuver.

When performing the Heimlich maneuver on a conscious adult victim, where should the nurse deliver the rescuer and upward thrusts?

Below the xiphoid process and above the umbilicus

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse record the breathing pattern?

Cheyne-Stokes respiration

Click to specify if the finding is consistent with the process of hypoventilation, hypopharyngeal obstruction, or asthma.

Choking: hypopharyngeal Decreased O2 sat: hypoventilation, hypopharyngeal obstruction, asthma Shallow respirations: hypoventilation Increased respiratory rate: hypoventilation, asthma Wheezing: asthma

A client in severe respiratory distress is admitted to the hospital. When assessing the client, the nurse should: a) Delay assessment until client's respiratory distress is resolved. b) Focus assessment on the respiratory system and distress. c) Complete a comprehensive physical examination. d) Conduct a complete health history.

Complete a focused assessment on the respiratory system

A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately follwoing the insertion of the catheter and notes a sudden onset of chest pain and SOB. WHich complication should the nurse be prepared to treat?

Pneumothorax

The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate?

Position in high fowlers position and administer an albuterol sulfate inhaler

A client diagnosed with an empysema is scheduled for a thoracentesis. The nurse should prepare the client for this procedure with which action?

Position the client sitting upright on the edge of the bed and leaning forward

The nurse teaches thhe client how to instill nose drops. Which technique is correct?

THe client blows the nose gently before instilling drops

A nurse is conducting an initial assessment on a client with possible TB. Which assessment finding indicates a risk factor for TB?

THe client had a liver transplant 2 years ago

For each potential intervention, click to specify whether the intervention is priority, nonessential, or contraindicated for the next 24 hours.

Having the client perform coughing and deep breathing exercises: Priority Initiate intubation and mechanical ventilation: contraindicated Begin smoking cessation education: Nonessential Encourage the use of IS: Priority Have the client change position: Priority Withhold narcotic analgesic meds: contraindicated

The nurse is planning to teach a client with COPD how to cough effectively. WHich instruction should be included?

Take a deep abdominal breath, bend forward, and cough three or four times on exhalation.

A client who has started therapy for drug-resistant TB demonstrates understanding of TB transmission by saying:

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

Which intervention is most appropriate for a client with an arterial blood gas of pH 7.5, PaCO2 26, O2 96%, HCO3 24, and PaO2 of 94?

Instruct the client to breathe into a paper bag

A client with lung cancer has developed an intractable, nonproductive cough that is not treated with nonopioid antitussive agents. The health care provider orders codeine, 10 mgPO every 4 hours. Which statement accurately describes codeine?

It's a centrally acting antitussive and can cause dependence

The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration show, what should the nurse do?

Lower the drainage system to maintain gravity flow

For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined.

Lungs are clear in all lobes: Improved O2 Sat is 97% On room air: Improved Client is passing flatus: Improved The dressing has 3x5 cm yellow drainage: Declined The abdomen is firm: No change Pain is rated as a 1 on a scale of 0-10: Improved The client is ambulating without assistance: Improved

The nurse is assessing the client who has recently returned from a 2 month mission to Africa. What type of respiratory protection is appropriate for staff?

N95 particulate respirator

A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a PCA system and reports having pain in the left thorax that worsens when coughing. After checking the PCA system, what should the nurse do next?

Obtain a more detailed assessment of the client's pain using a pain scale

For a client with asthma, the health care provider prescribed albuterol, two puffs a day via a metered-dose inhaler (MDI), and beclomethasone, two puffs a day via MDI. How should the nurse instruct the client to administer these drugs?

Take the albuterol first and follow with beclomethasone two times a day

A competent client requiring long-term mechanical ventilation privately tells a nurse that the want the ventilator withdrawn. Which response by the nurse is best?

Tell me more about how you are feeling

The nurse has placed the intubated client with ARDS in the prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to supine position?

The Spo2 and Po2 have decreased THe client is tachycardiac with a drop in BP the face has increased skin breakdown and edema

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen value of 90 mm Hg or higher

When attempting to check the pupils of a client scheduled to receive general anesthesia the nurse notices that the client has trouble tilting the head back. What is the primary concern about this finding?

The client is at risk for difficult intubation

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?

The client's respiratory center is so used to high carbon dioxide and low oxygen that changing these levels may eliminate his stimulus for breathing.

A nurse is helping a suspected choking victim. When should the nurse perform the Hiemlich maneuver?

The victim cannot speak due to an airway obstruction.

A nurse is assessing a client using a trach tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which action should the nurse take?

Use a sterile suction kit to suction the client

A client with COPD and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

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

Which client should the nurse most encourage to receive the pneumococcal and influenza vaccination?

a 75-year-old woman with diabetes

Which resgistered nurse should be assigned to the client who had a chest tube inserted yesterday?

a RN who use to work on the cardiovascular unit

A client with a clamped chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The nurse understands that the most likely cause is:

a tension pneumothorax

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later the physician suspects that the client has aspirated stomach contents. The nurse should monitor closely for complications that include which of the following?

acute respiratory distress syndrome (ARDS)

A client experiencing a severe asthma attach has the following ABGs, ph 7.33, PCO2 48, PO2 58, HCO3 26. Which prescription should the nurse first implement?

albuterol nebulizer

After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema?

apply cold compresses to the area

The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures adequacy of tissue oxygenation?

arterial blood gases

An anxious client is brought to the walk-in clinic following a bee sting. Physical assessment reveals BP 160/78, HR 102, and respiratory rate 32 bpm with audible wheezing. What is the nurses priority action?

assess airway

A client with chronic renal failure is being admitted with pulmonary edema. which is a priority nursing intervention?

assess lung sounds and O2 sat level

Following the 1400 assessment, which potential complication would the nurse continue to monitor for?

atelectasis paralytic ileus surgical site infection

A client has a positive reaction to the Mantoux test. How should the nurse interpret this reaction? The client has:

been exposed to Mycobacterium tuberculosis.

The nurse is instructing the client with COPD to do pursed lip breathing. What is the expected outcome?

better elimination of carbon dioxide

When evaluating the effectiveness of airway suctioning, the nurse should use which criterion?

breath sounds clear on auscultation

A nurse notices that a client admitted for exacerbation of COPD is short of breath. The client has a signed advanced directive indicating that they don't want to be resuscitated. The nurse should

check the clients oxygen saturation

A client with emphysema is at greater risk for developing what acid-base imbalance?

chronic respiratory acidosis

A client admitted with tuberculosis reports concerns about payinf for needed medications. THe nurse should:

collaborate with the social worker to investigate possibility of funds

The nurse should teach clients that the most common route of transmitting tuberle bacilli from person-to-person is through contaminated:

droplet nuclei

On admission, the client's ABG values were: pH 7.20, PaO2 64, PaCO2 60 and HCO3 22. A chest tube is inserted and o2 at 4L/min is started. 30 minutes later values are: pH 7.3, PaO2 76, PaCO2 50, and HCO3 22. This would indicate:

improving respiratory status

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?

increase in rate and depth of respirations

A client is transported to the ER with an acute respiratory infection. Vital signs are T 102, P 110 bpm, R 32 bpm. Circumoral cyanosis is noted, and the O2 sat is 86%. What should be the immediate actions by the nurse caring for this patient?

initiate oxygen at 6 L/min via nasal cannula. Place the client in high Fowler's position

A client requires long-term ventilator therapy. The client has a trach in place that requires frequent suctioning. Which technique should the nurse use?

intermittent suction while withdrawing the catheter

A nurse is administering moderate sedation to a client with COPD. The nurse's next action is based on the principle that:

it may be necessary to raise the head of this client's bed

The nurse instructs the UAP on how to care for a client with chest tubes that are connected to water-seal drainage. The nurse should instruct the UAP to:

mark the time and amount of drainage on the collection chamber

A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. 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 it:

may induce bronchospasm

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?

measuring and documenting the drainage in the collection chamber

A client has the following ABG values: pH 7.12, PaCO2 40, HCO3 15. These ABG values suggest which disorder?

metabolic acidosis

The nurse is assessing a client with a darker-skin tone in need of emergency care for acute respiratory distress. Which area would the nurse inspect when assessing for cyanosis in this client?

mucous membranes

A physician orders albuterol for a client with newly diagnosed asthma. When traching about this drug, the nurse should explain that it may cause:

nervousness

A HCP has entered orders for a client witth COPD. Which order should the nurse question?

oxygen increased to 3L/min if O2 sat is less than 94% on room air

The nurse is analyzing the ABG results of client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis?

pH 7.20, PaCO2 65, HCO3 26

Arterial blood gas analysis would reveal which finding related to acute respiratory failure?

pH 7.24

The nurse has received lab reports for several clients undergoing care. Which set of ABG results will the nurse investigate first?

pH 7.49, PaCO2 30, PaO2 75, HCO3 22

A nurse is interpreting blood gases for a client with acute respiratory distress syndrome. Which set of ABGs does the nurse expect for this client?

ph 7.25, PaCO2 48. HCO3 24

A client with Guillain-Barre syndrome develops respiratory acidosis as a result of reduced aveolar ventilation. Which combination of ABG values confirms respiratory acidosis?

ph 7.25, PaCO2 50 mm hg

A nurse is brought to the emergency department following an automobile accident. The assessment reveals tachycardia, dyspnea, and absent breath sounds over the right lung. WHich action is the nurses most appropriate action?

preparing the client for a chest tube insertion

After a total laryngetomy, the client has a feeding tube. What is the purpose of the feeding tube?

provides nutrition

An expected outcome of theophylline ethylenediamine when administered to a client with COPD is:

relax bronchial smooth muscle

A young adult is admitted for elective nasal surgery for a deviated septum/ Which sign is an important indicator of bleeding even if the nasal drip pad remained dry and intact?

repeated swallowing

A client appears flushed and has shallow respirations. The ABGs are: ph 7.24, PaCO2 49, HCO3 24. These findings are indicative of which imbalance?

respiratory acidosis

As status asthmaticus worsens, the nurse would expect which acid-base imbalance?

respiratory acidosis

A client with longstanding diagnosis of GAD presents to the ER. The triage nurse notes upon assessment that the patient is hyperventilating. THe nurse is aware that hyperventilation is the most common cause of:

respiratory alkalosis

A client's pulmonary function tests note an increased residual volume and a decreased vital capacity. Which is the best nursing diagnosis?

risk for activity intolerance

A nurse is caring for a client who recently underwent a tracheostomy. What is the nurses priority when caring for this client?

suctioning to keep the airway patent

Which is an expected outcome for a client who has been treated for bacterial pneumonia?

the ability to perform activities of daily living without dyspnea

A client has the following ABG values: pH 7.52, PaO2 50, PaCO2 28, HCO3 24. Based upon the client's PaO2, which clinical judgment should the nurse make?

the client is severely hypoxic

A nurse on the medical-surgical unit just received the client care assignment report. Which client should the nurse assess first?

the client with unilateral leg swelling who reports anxiety and shortness of breath.

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

the oxygen tubing is pinched

THe nurse instills 5 mL of normal saline before suctioning a client's trach. Which indicates the instillation is effective?

the secretions are thinned

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

the system has an air leak

a client receiving furosemide as part of the treatment for heart failure. Which finding indicates that the medication is attaining a therapeutic effect?

trace peripheral edema, previously 2+

A client recovering from a PE is receiving warfarin. To counteract a warfarin overdose, the nurse should administer

vitamin K

A nurse is caring for a client with TB. Which infection-control technique is the priority when caring for this client?

wearing an N95 respirator when caring for client