Chapter 27 Adaptive

A client has bluish buccal mucous membranes and lips. Which term will the nurse use to document this finding? 1 Central cyanosis 2 Central jaundice 3 Peripheral jaundice 4 Peripheral cyanosis

1 Central cyanosis

A client is admitted with tachypnea, absent breath sounds on the affected side, hyperresonance on the affected side, tracheal deviation, and sudden chest pain. Which primary piece of equipment should the nurse obtain to assist the primary healthcare provider in management of this condition? 1 Chest tube 2 Thermometer 3 Electrocardiograph 4 Blood pressure cuff

1 Chest tube

The client's previous medical records document a history of a reflex that helps clear the airways by an explosive expiration. What term should the nurse use to identify this respiratory behavior? 1 Cough 2 Orthopnea 3 Hypocapnia 4 Paroxysmal nocturnal dyspnea

1 Cough

Which signs and symptoms of pulmonary disease are the most common that the nurse will observe upon assessment? 1 Dyspnea and cough 2 Cyanosis and clubbing 3 Hemoptysis and chest pain 4 Abnormal sputum and hypoventilation

1 Dyspnea and cough

A client's pleural fluid contains pus and cellular debris. What term should the nurse use during report to explain this finding? 1 Empyema 2 Transudate 3 Chylothorax 4 Hemothorax

1 Empyema

A client is at rest and breathing 14 breaths per minute in a rhythmic pattern. What term should the nurse use to describe this finding? 1 Eupnea 2 Dyspnea 3 Orthopnea 4 Hypoventilation

1 Eupnea

client's radiographic report indicates that the sternum and several consecutive ribs are broken in multiple places. Which condition most likely occurred? 1 Flail chest 2 Aspiration 3 Emphysema 4 Pleural effusion

1 Flail chest

A nurse is asked how tuberculosis is spread from person to person. What is the nurse's best response? 1 From airborne droplets 2 From undercooked food 3 From contaminated water 4 From lack of handwashing

1 From airborne droplets

client is admitted to the hospital with expectoration of blood. Which term should the nurse use to document this assessment finding? 1 Hemoptysis 2 Hemoglobin 3 Hematemesis 4 Hypoventilation

1 Hemoptysis

Which assessment finding is common in a client with laryngeal cancer? 1 Hoarseness 2 Hypercalcemia 3 Pleural effusion 4 Cushing syndrome

1 Hoarseness

Which finding will cause the nurse to notify the primary healthcare provider for a client with asthma? 1 Status asthmaticus 2 Late phase response 3 Mast cell degranulation 4 Exercise-induced asthma

1 Status asthmaticus

A nurse is teaching a health and wellness class on reducing the risk for lung cancer. Which technique will the nurse suggest? 1 Stopping smoking 2 Using safe sex practices 3 Washing hands routinely 4 Cooking food thoroughly

1 Stopping smoking

Which condition will cause the nurse to use the term "dyspnea"? 1 The client has feelings of shortness of breath. 2 The client does not use accessory breathing muscles. 3 The client demonstrates decreased work of breathing. 4 The client has improvement of symptoms with exercise.

1 The client has feelings of shortness of breath.

Which client is at highest risk for aspiration? 1 A 24-year-old client who has a history of seizures 2 An 84-year-old client who is lethargic after a stroke 3 A 56-year-old client who has stomatitis from chemotherapy 4 A 16-year-old client who has trouble swallowing from a sore throat

2 An 84-year-old client who is lethargic after a stroke

Which term should the nurse use to describe the collapse of a client's previously inflated area of lung tissue? 1 Aspiration 2 Atelectasis 3 Bronchiolitis 4 Bronchiectasis

2 Atelectasis

What is the most common cause of a chronic cough in a client who smokes a pack of cigarettes a day? 1 Asthma 2 Chronic bronchitis 3 Pulmonary embolus 4 Postnasal drainage syndrome

2 Chronic bronchitis

A client presents to the primary care clinic complaining of breathlessness. The nurse also notes that the client is expending a great deal of effort to breathe. How should the nurse chart this finding? 1 Apnea present 2 Dyspnea present 3 Kussmaul present 4 Tachypnea presen

2 Dyspnea presen

A client is experiencing hypoventilation. The nurse expects which laboratory result? 1 Hypocapnia 2 Hypercapnia 3 Respiratory alkalosis 4 Elevated D-dimer levels

2 Hypercapnia

Which term should the nurse use to describe a condition that causes a client to have reduced oxygenation of cells in tissues? 1 Hilum 2 Hypoxia 3 Hypocapnia 4 Hemoptysis

2 Hypoxia

A client with asthma is exposed to inhaled allergens. While reading the laboratory report, the nurse will find that which immunoglobulin will be produced in large quantities? 1 Immunoglobulin A (IgA) 2 Immunoglobulin E (IgE) 3 Immunoglobulin G (IgG) 4 Immunoglobulin M (IgM)

2 Immunoglobulin E (IgE)

The nurse teaches a student nurse about the pathogenesis of bronchitis. Which information by the student indicates teaching was successful? 1 It causes decreased secretion of mucus. 2 It is characterized by airway inflammation. 3 Presents with occasional nonproductive cough. 4 There is decreased responsiveness to environmental stimuli.

2 It is characterized by airway inflammation.

A client with asthma is having an acute attack with no bacterial infection. Which medication should the nurse be prepared to administer? 1 Antibiotics 2 Oral corticosteroids 3 Monoclonal antibodies 4 Leukotriene antagonists

2 Oral corticosteroids

Which term will the nurse use to document the client's report that "I have to sleep sitting up"? 1 Clubbing 2 Orthopnea 3 Hyperpnea 4 Paroxysmal nocturnal dyspnea

2 Orthopnea

When the nurse takes a health history, which finding will place the client at greatest risk for lung cancer? 1 Drinking 2 Smoking 3 Drug use 4 Sedentary lifestyle

2 Smoking

Which assessment finding will place the client at the most risk for lung cancer? 1 Advanced age 2 Tobacco smoking 3 Asbestos exposure 4 Lung cancer in family

2 Tobacco smoking

Which action can the nurse take to prevent a pulmonary embolus in a client? 1 Promote venous stasis. 2 Use pneumatic calf compression. 3 Place leg in a dependent position. 4 Avoid low-dose anticoagulant therapy.

2 Use pneumatic calf compression.

A nurse is teaching about examples of chronic obstructive pulmonary disease (COPD). Which diseases should the nurse include? Select all that apply. 1 Asthma 2 Emphysema 3 Pneumonia 4 Pulmonary fibrosis 5 Chronic bronchitis

2 Emphysema 5 Chronic bronchitis

A client has hypoxemia. Which intervention is priority? 1 Give antibiotics 2 Humidify inspired air 3 Administer supplemental oxygen 4 Encourage use of incentive spirometry

3 Administer supplemental oxygen

A client has hypercapnia. What probably caused the hypercapnia? 1 Clubbing 2 Intact spinal cord 3 Decreased drive to breathe 4 Stimulation of the respiratory center

3 Decreased drive to breathe

A client reports breathlessness when exercising. Which term should the nurse use to describe this finding? 1 Orthopnea 2 Retractions 3 Dyspnea on exertion 4 Paroxysmal nocturnal dyspnea

3 Dyspnea on exertion

What information will the nurse include when educating a client regarding the diagnosis of pneumothorax? 1 It is the presence of liquid in the pleural space. 2 It is the presence of pus in the pleural space. 3 It is the presence of air in the pleural space. 4 It is the presence of blood in the pleural space.

3 It is the presence of air in the pleural space.

Which client condition most commonly results in pulmonary edema? 1 Dehydration 2 Adequate surfactant 3 Left-sided heart disease 4 Permanent enlargement of acini

3 Left-sided heart disease

A client lies flat and experiences dyspnea. Which term should the nurse use when charting? 1 Cough 2 Cyanosis 3 Orthopnea 4 Kussmaul respirations

3 Orthopnea

A client with heart failure reports orthopnea. Which action should the nurse take? 1 Encourage the client to drink fluids. 2 Administer a pain medication to the client. 3 Place the client in a forward-leaning posture. 4 Advise the client to stand slowly from a sitting position.

3 Place the client in a forward-leaning posture.

A client experiences an increased pressure in the chest cavity with resulting collapse of the right lung and is diagnosed with a secondary pneumothorax. This diagnosis is based on what criterion? 1 The exact cause of the pathosis is not known. 2 It occurred unexpectedly in a healthy individual. 3 Some type of chest trauma resulted in the symptoms. 4 The client was coughing up blood-tinged frothy sputum.

3 Some type of chest trauma resulted in the symptoms.

hich person is most at risk for developing a pulmonary embolism? 1 A 25-year-old man with asthma 2 A 42-year-old woman with a broken arm 3 A 28-year-old woman who is immobilized for 1 week 4 A 67-year-old man with a deep vein thrombosis in the femoral vein

4 A 67-year-old man with a deep vein thrombosis in the femoral vein

Which client will be most at risk for reactivation of tuberculosis (TB) infection? 1 A man 2 A woman who overused antibiotics 3 A woman who drank contaminated water 4 A man with human immunodeficiency virus (HIV)

4 A man with human immunodeficiency virus (HIV)

Which classic breathing pattern by a client is generally identified by the nurse as Cheyne-Stokes respirations? 1 Rapid ventilatory rate 2 Rhythmic and effortless breathing 3 Presence of occasional sighs during breaths 4 Alternating periods of deep and shallow breathing

4 Alternating periods of deep and shallow breathing

A client develops atelectasis from an external pressure exerted by a tumor. The nurse will report the client has which type of atelectasis? 1 Verrucous atelectasis 2 Surfactant atelectasis 3 Absorption atelectasis 4 Compression atelectasis

4 Compression atelectasis

A client has chronic bronchitis. Which assessment finding is typical? 1 No cough 2 Very thin, clear mucus 3 Dry nonproductive cough 4 Hypersecretion of thick mucus

4 Hypersecretion of thick mucus

Which information indicates the nurse has a correct understanding of the pathophysiology that caused a client's chronic productive cough from chronic bronchitis? 1 Large air spaces (bullae) with air trapping 2 Destruction of alveolar walls without obvious fibrosis 3 Permanent enlargement of gas-exchange airways (acini) 4 Increased size and number of mucous glands and goblet cells

4 Increased size and number of mucous glands and goblet cells

A client has bronchiolitis. The nurse is caring for which client? 1 One with emphysema 2 One with a bacterial infection 3 One with oxygen toxicity from too high concentrations of oxygen 4 One with a diffuse, inflammatory obstruction of the small airways

4 One with a diffuse, inflammatory obstruction of the small airways

A client reports awakening at night gasping for air and having to sit up to relieve difficult breathing. Which term should the nurse use to describe this finding? 1 Hemoptysis 2 Dyspnea on exertion 3 Kussmaul respirations 4 Paroxysmal nocturnal dyspnea

4 Paroxysmal nocturnal dyspnea

What term should the nurse use to best describe accumulation of fluid in the client's pleural space? 1 Pleurisy 2 Flail chest 3 Lung abscess 4 Pleural effusion

4 Pleural effusion

A client has pus in the pleural space from a previous pneumonia. The nurse will provide information to the client about which condition? 1 Flail chest 2 Hypercapnia 3 Pneumothorax 4 Pleural empyema

4 Pleural empyema

A client is born with an α1-antitrypsin deficiency. Which condition will most likely manifest? 1 Pneumonia 2 Lung abscess 3 Pulmonary fibrosis 4 Primary emphysema

4 Primary emphysema

Which term should the nurse use to describe a client condition of excess water in the lung? 1 Infection 2 Pneumonia 3 Pneumoconiosis 4 Pulmonary edema

4 Pulmonary edema

When a nurse is caring for a client with Mycobacterium tuberculosis. Which principle of transmission should the nurse use to guide nursing care? 1 Transmitted by contact with infected blood 2 Transmitted by contact with infected sputum 3 Transmitted by contact with infected gastric secretions 4 Transmitted by contact with infected airborne droplets

4 Transmitted by contact with infected airborne droplets

What term should the nurse use to best describe accumulation of fluid in the client's pleural space? 1 Pleurisy 2 Flail chest 3 Lung abscess 4 Pleural effusion

4. Pleural effusion