CHA Exam 4 Review

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority?

Apply a petroleum gauze dressing over the site.

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement?

"I get a sharp, stabbing pain when I take a deep breath."

The school nurse recommends suitable physical activity for a child with exercise-induced asthma. Which statement by a parent indicates the need for additional teaching?

"I'll encourage him to join a youth running club."

The nurse is assigned a group of pediatric clients. After receiving shift report, which client should the nurse assess first?

A 6-month-old with a croupy cough and inspiratory stridor with exertion

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator?

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

A client with chronic obstructive pulmonary disease (COPD) reports a 5-pound (2.3 kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain?

Cor pulmonale

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side?

Decreased sounds

A nurse is caring for several postoperative clients. For which clinical manifestations of a pulmonary embolus should the nurse monitor these clients? Select all that apply.

Dyspnea Hemoptysis Feeling of impending doom

When caring for a client with pneumonia, which nursing intervention is the highest priority?

Employ breathing exercises and controlled coughing.

The nurse is caring for a school-aged child with cystic fibrosis. Which pathophysiologic factor has the greatest impact on the child's health status and is of priority in the care plan?

Extremely thick mucus causes obstructed airways.

What clinical findings does a nurse expect when assessing a child with acute laryngotracheobronchitis? Select all that apply.

Fever Hoarseness Barking cough Inspiratory stridor

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?

Give prescribed drugs to promote bronchiolar dilation.

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client?

Imbalanced nutrition: less than body requirements, related to fatigue

The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction?

Inhaling air fully before inserting the mouthpiece

When preparing a child with asthma for discharge, what instructions must the nurse emphasize to the family? Select all that apply.

Limit allergens in the home. Continue the medications even if the child is asymptomatic.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?

Positive end-expiratory pressure (PEEP)

During a follow-up visit, a nurse finds that the client has a slow rate of healing after laryngeal cancer surgery. The nurse also finds that the client is at risk of developing lung cancer. What would be the reason behind the nurse's suspicion?

The client smokes four cigarettes per day.

A nurse is caring for several school-aged children with cystic fibrosis. Why does the nurse anticipate that these children will probably be small and underdeveloped for their age?

These children digest little food because pancreatic enzymes are blocked.

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply.

Wheezing Tachycardia

What is the priority goal for a client with asthma who is being discharged from the hospital with prescriptions for inhaled bronchodilators?

Demonstrates use of a metered-dose inhaler

A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response?

Depression in the respiratory center

The nurse is caring for a 4-year-old child who has been hospitalized with an acute asthma exacerbation. Which assessment finding requires action by the nurse?

Diminished breath sounds

A nurse manager is providing a class on cystic fibrosis for the pediatric staff nurses. Physiologic adaptations to cystic fibrosis are a result of which problem?

Pathology of mucus-secreting glands

A nurse is caring for a client with a tracheostomy. Which action should the nurse implement when performing tracheal suctioning?

Preoxygenate the client before suctioning.

What are the uses of pulmonary function tests (PFT)? Select all that apply.

Pulmonary function tests (PFT) can measure lung volume. Pulmonary function tests (PFT) can assess responses to bronchodilators. Pulmonary function tests Pulmonary function tests (PFT) can diagnose pulmonary disease.

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take?

Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula.

A school-aged child with cystic fibrosis has recurrent episodes of bronchitis, and the parents ask the nurse why this happens. What reason should the nurse include in the reply?

Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.

During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response?

"You seem concerned about your diagnosis."

A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates?

A previous exposure to the organism

While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)?

Barrel chest