EAQ Gas Exchange

Which complication is prevented by coaching a client in the second stage of labor to take a breath at least every 6 seconds while pushing with each contraction? A. Fetal Hypoxia B. Perineal Lacerations C. Carpopedal Spasms D. Maternal Hypertension

A. Fetal Hypoxia

While in the post anesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? A. Initiate oxygen via a nasal cannula. B. Administer the prescribed morphine. C. Prepare the client for endotracheal intubation. D. Place a nitroglycerin tablet under the client's tongue.

A. Initiate oxygen via a nasal cannula.

The nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? A. Lips B. Sclera C. Conjunctiva D. Mucus Membrane

A. Lips

During a client's immediate postoperative period after a laryngectomy, which is a nursing priority? A. Provide emotional support. B. Observe for signs of infection. C. Keep the trachea free of secretions. D. Promote a means of communication.

C. Keep the trachea free of secretions.

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? SELECT ALL THAT APPLY. A. Mold B. Cold Air C. Pet Dander D. Air Pollution E. Cigarette Smoke

A. Mold B. Cold Air C. Pet Dander D. Air Pollution E. Cigarette Smoke

Which medication would the nurse instruct a client to avoid while taking alprazolam? SELECT ALL THAT APPLY. A. Opioids B. Alcohol C. Barbiturates D. Antidepressants E. First-Generation Antipsychotics

A. Opioids B. Alcohol C. Barbiturates

A client shows an increase in respiratory rate that is abnormally deep and regular. Which condition would the nurse expect? A. Hypoventilation B. Biot Respiration C. Kussmaul's Respiration D. Cheyne-Strokes Respiration

C. Kussmaul's Respiration

Why should the use of baby powder on an infant be avoided? A. Skin Irritation B. Skin Infection C. Lung Irritation D. Respiratory Infection

C. Lung Irritation

Which is the priority assessment for the client who has Guillain-Barre syndrome with rapidly ascending paralysis? A. Monitoring Urinary Output B. Assessing Nutritional Status C. Monitoring Respiratory Status D. Assessing Communication Needs

C. Monitoring Respiratory Status

After reviewing information about oxygenation for 4 clients with COPD, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy? A. PaO2 of 72; SpO2 of 96 B. PaO2 of 60; SpO2 of 90 C. PaO2 of 55; SpO2 of 88 D. PaO2 of 70; SpO2 of 92

C. PaO2 of 55; SpO2 of 88

Which assessment finding for a 4-hour-old newborn would be most concerning for the nurse? A. Acrocyanosis B. Irregular Heartbeat C. Paradoxical Respiration D. Apical Pulse in the 4th Intercostal Space

C. Paradoxical Respiration

Which client response is most important for the nurse in the post anesthesia care unit to monitor when caring for a client who had a thyroidectomy? A. Urinary Retention B. Signs of Restlessness C. Decreased Blood Pressure D. Signs of Respiratory Obstruction

D. Signs of Respiratory Obstruction

The nurse is teaching client with a diagnosis of pulmonary tuberculosis about recovery after discharge. Which is the most important intervention for the nurse to include in this plan? A. Ensuring Sufficient Rest B. Changing Lifestyle Routines C. Breathing Clean Outdoor Air D. Taking Medications as Prescribed

D. Taking Medications as Prescribed

A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. Which responses from the nurse would be the best? A. I don't know; however, I will ask your health care provider for a prescription as soon as possible. B. Antibiotics are used to treat viruses, and your cultures indicates the presence of a bacterial infection. C. Antibiotics are ineffective for treating the bacteria that caused your upper respiratory infections. D. Upper respiratory infections are generally caused by viruses and wold not be treated with antibiotics.

D. Upper respiratory infections are generally caused by viruses and wold not be treated with antibiotics.

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the ED to a neurological trauma unit? A. Notifying the receiving unit of the transfer. B. Having the client's records ready for the transfer. C. Verifying that the family has been notified of the transfer. D. Validating availability of a bag-value-mask during the transfer.

D. Validating availability of a bag-value-mask during the transfer.

Which technique would the nurse employ for an obstetrical client with a foreign body airway obstruction? A. Back Blows B. Chest Thrusts C. Suprapubic Thrusts D. Abdominal Thrusts

B. Chest Thrusts

Which is prevented by providing warm, humidified oxygen to a preterm infant? A. Apnea B. Cold Stress C. Respiratory Distress D. Bronchopulmonary Dysplasia

B. Cold Stress

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? A. Prevents Bronchial Spasm B. Decreases Air Trapping in Lungs C. Improves Alveolar Surface Area D. Strengthens Diaphragmatic Contraction

B. Decreases Air Trapping in Lungs

Which clinical manifestation would the nurse expect when a client experiences fat embolism syndrome (FES)? A. Nausea B. Dyspnea C. Orthopnea D. Paresthesia

B. Dyspnea

Which nursing action will help a client obtain maximum benefits after postural drainage? A. Administer Oxygen B. Encourage Coughing Deeply C. Place the Client in a Sitting Position D. Encourage the Client to Rest for 30 Minutes

B. Encourage Coughing Deeply

After a nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? A. I have abnormal platelets. B. I have abnormal hemoglobin. C. I have abnormal hematocrit. D. I have abnormal white blood cells.

B. I have abnormal hemoglobin.

The nurse provides education about self-care management to a client who was recently diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement? A. I will try to avoid smoking. B. I will maintaining complete bed rest. C. I'll control the temperature in my home. D. I'll need to clean my mouth several times a day.

B. I will maintaining complete bed rest.

The nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. The nurse would include which information in the education? A. Purpose of bronchodilators. B. Importance of meticulous oral hygiene. C. Technique used in pursed-lip breathing. D. Methods used to maintain a dust-free environment.

B. Importance of meticulous oral hygiene.

Which type of breathing pattern is manifested with hypercarbia? A. Eupnea B. Tachypnea C. Hypoventilation D. Kussmaul Respiration

C. Hypoventilation

In which position will the nurse place a client who has been transferred from the post anesthesia care unit to the intensive care unit after a radical neck dissection? A. Sims B. Lateral C. High Fowler D. Semi-Fowler

D. Semi-Fowler

Which disease is caused by coronaviruses? A. Pertussis B. Inhalation Anthrax C. Coccidioidomycosis D. Severe Acute Respiratory Syndrome

D. Severe Acute Respiratory Syndrome

At which interval are humidified oxygen systems replaced to prevent infection? A. 1 Day B. 3 Days C. 5 Days D. 7 Days

A. 1 Day

Which complication of CF is related to frequent stools and tenacious mucus? A. Anal Fissures B. Rectal Prolapse C. Intussusception D. Meconium Ileus

B. Rectal Prolapse

The nurse noticed the respiratory rate as regular and slow while assessing a client. Which would be the condition of the client? A. Apnea B. Bradypnea C. Tachypnea D. Hyperpnea

B. Bradypnea

Which findings would the nurse expect when doing a respiratory assessment on a health young adult? SELECT ALL THAT APPLY. A. A Midline Trachea B. Deep Pink Nasal Mucosa C. Deviated Nasal Septum D. Respirations of 14 Breaths Per Minute E. Anteroposterior to Lateral Chest Diameter Ratio 2:1

A. A Midline Trachea B. Deep Pink Nasal Mucosa D. Respirations of 14 Breaths Per Minute

Which assessment would the nurse perform first for a client with sever trauma? A. Airway B. Disability C. Breathing D. Circulation

A. Airway

Which manifestation is an adverse effect of intravenous lorazepam? SELECT ALL THAT APPLY. A. Anemia B. Drowsiness C. Sleep Driving D. Blurred Vision E. Respiratory Depression

A. Anemia B. Drowsiness C. Sleep Driving D. Blurred Vision E. Respiratory Depression

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. Which immediate action would the nurse implement? A. Auscultate the Lungs B. Obtain Arterial Blood Gases C. Notify the Health Care Provider D. Apply Pressure to the Abdomen

A. Auscultate the Lungs

Which life-threatening wounds are treated with hyperbaric oxygen therapy? SELECT ALL THAT APPLY. A. Burns B. Skin Cancer C. Osteomyelitis D. Diabetic Ulcers E. Myocardial Infarction

A. Burns C. Osteomyelitis D. Diabetic Ulcers

Which child is the best roommate option for child admitted in a vasoocclusive sickle cell crisis? A. Child with thalassemia. B. Child with osteomyelitis. C. Child with viral pneumonia. D. Child with acute pharyngitis.

A. Child with thalassemia.

Which symptoms are common during the fulminant stage of inhalation of anthrax? SELECT ALL THAT APPLY. A. Dyspnea B. Dry Cough C. Diaphoresis D. Mild Chest Pain E. High Temperature

A. Dyspnea C. Diaphoresis E. High Temperature

The nurse is caring for a school-aged child with CF. Which pathophysiologic factor has the greatest effect on the child's health status? A. Extremely thick mucus causing obstructed airways. B. Acute inflammation of the lung parenchyma. C. Endocrine glands secreting increased levels of hormones. D. Increased irritability of the airways resulting in obstruction.

A. Extremely thick mucus causing obstructed airways.

For a client experiencing an anaphylactic attack, which medication would the nurse initiate immediately? A. Isoproterenol B. Diphenhydramine HCl C. Hydrocortisone Sodium Succinate D. Methylprednisolone Sodium Succinate

A. Isoproterenol

Which explanation would the nurse provide to the parents of a child with spasmodic croup who ask why their child is receiving humidified oxygen? A. It helps prevent drying of membranes. B. It provides a mode of giving inhalant medications. C. It increases the surface tension of the respiratory tract. D. It provides an environment free of pathogenic organisms.

A. It helps prevent drying of membranes.

Which action will the nurse take to check from subcutaneous emphysema in a client wit ha chest tube? A. Palpate around the tube insertion sties for crepitus. B. Auscultate the breath sounds for crackles and atelectasis. C. Observe the client for the presence of a barrel-shaped chest. D. Compare the length of inspiration with the length of expiration.

A. Palpate around the tube insertion sties for crepitus.

A child in respiratory distress is admitted to the hospital and diagnosed with acute spasmodic laryngitis. At the time of discharge, the mother asks how to handle another attack at home. Which would the nurse recommend? A. Place him near a cool-mist humidifier. B. Bring him to the ED. C. Give him an over-the-counter cough syrup. D. Offer him warm tea sweetened with honey.

A. Place him near a cool-mist humidifier.

Which is a risk factor of necrotizing enterocolitis in the preterm infant? A. Polycythemia B. Hypoglycemia C. Ventilatory Support D. Antibiotic Administration

A. Polycythemia

A child with acute spasmodic bronchitis who is receiving humidified air removes the mask, and while bathing the child the nurse notes increasing respiratory distress. Which is the most appropriate nursing intervention? A. Stopping the bath and replacing the mask. B. Performing postural drainage and clapping the chest. C. Placing the child in the orthopedic position and calling the health care provider. D. Suctioning the child's nasal passages and waiting for the dyspnea to subside.

A. Stopping the bath and replacing the mask.

Which finding is indicative of abnormal newborn breathing? SELECT ALL THAT APPLY. A. Stridor B. Mottling C. Bradypnea D. Nasal Flaring E. Expiratory Grunting

A. Stridor B. Mottling C. Bradypnea D. Nasal Flaring E. Expiratory Grunting

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and would begin with which aspect of care? A. The disease process and breathing exercises. B. How to control or prevent respiratory infections. C. Using aerosol therapy, especially nebulizers. D. Priorities when performing everyday activities.

A. The disease process and breathing exercises.

A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? A. The ribcage is not compressed and released during birth. B. The sudden temperature change at birth causes aspiration. C. There is usually oxygen deprivation after a cesarean birth. D. There is no gravity during the birth to promote drainage from the lungs.

A. The ribcage is not compressed and released during birth.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? A. Their gag reflex has returned. B. They are confused due to anesthesia. C. They are nauseated and want to vomit. D. Their airway is becoming obstructed.

A. Their gag reflex has returned.

Which statement describes a client's tidal volume? A. Tidal volume is the volume of air inhaled and exhaled with each breath. B. Tidal volume is the amount of air remaining in the lungs after forces expiration. C. Tidal volume is the additional air forcefully inhaled after normal inhalation. D. Tidal volume is the additional air forcefully exhaled after normal exhalation.

A. Tidal volume is the volume of air inhaled and exhaled with each breath.

Which assessment finding is consistent with bronchospasm? A. Wheezing B. Rhonchi C. Pleural Friction Rub D. Low-Pitched Crackles

A. Wheezing

Which factor would elevate the oxygen saturation during an assessment? A. Nail Polishes B. Carbon Monoxide C. Intravascular Dyes D. Skin Pigmentation

B. Carbon Monoxide

Which would be the respiratory rate in a 2-year-old child? A. 20 breaths/min B. 30 breaths/min C. 40 breaths/min D. 50 breaths/min

B. 30 breaths/min

Pilocarpine is used as part of the diagnostic process of a toddler suspected of CF. The nurse knows that the pilocarpine would stimulate which process? A. Secretion of Mucus B. Activity of Sweat Glands C. Excretion of Pancreatic Enzymes D. Release of Bile from the Gallbladder

B. Activity of Sweat Glands

The spouse of a client with TB received a tuberculin skin test. The nurse examined the skin test and identified an area of induration greater than 10 mm. Which response to this finding would the nurse implement? A. No further action is required at this time. B. Additional tests are necessary to determine infection status. C. Immediately repeat the skin test for confirmation. D. Results are positive, indicating an active infection.

B. Additional tests are necessary to determine infection status.

Which clinical manifestations are associated with a diagnosis of tuberculosis? SELECT ALL THAT APPLY. A. Diarrhea B. Anorexia C. Weight Gain D. Hemoptysis F. Night Sweats

B. Anorexia D. Hemoptysis F. Night Sweats

The nurse is providing care to a client who is receiving internal feedings via a nasogastric tube. Which serious complication would the nurse take measures to prevent ? A. Skin Breakdown B. Aspiration Pneumonia C. Retention Ileus D. Profuse Diarrhea

B. Aspiration Pneumonia

A client with COPD is admitted to the hospital with a tentative diagnosis of pleuritic. It is important for the nurse to perform which intervention? A. Administer opioids frequently. B. Assess for signs of pneumonia. C. Give medication to suppress coughing. D. Limit fluid intake to prevent pulmonary edema.

B. Assess for signs of pneumonia.

A client's respiratory tract infection, which started wit ha common cold, has progressed to whooping cough. The client reports "coughing fits" lasting for several minutes. Which organisms is responsible for the client's condition? A. Bacillus Anthracis B. Bordetella Pertussis C. Streptococcus Pneumoniae D. Mycobacterium Tuberculosis

B. Bordetella Pertussis

A 15-year-old with CF is admitted wit ha respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. Which is the priority nursing intervention? A. Increasing Physical Activities B. Performing Postural Drainage C. Maintaining Dietary Restrictions D. Administering Prescribed Pancreatic Enzymes

B. Performing Postural Drainage

The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of COPD. Which nursing intervention is correct when the client becomes short of breath during the care? A. Obtain a pulse oximeter to determine the client's oxygen saturation level. B. Put the client in a high Fowler position. C. Darken the lights and provide a rest period of at least 15 minutes. D. Continue the hygiene activities while reassuring the client.

B. Put the client in a high Fowler position.

A client is admitted to the ED with a stab wound of the chest. Which is a priority nursing assessment? A. Level of Pain B. Quality and Depth of Respirations C. Amount of Serosanguinous Drainage D. Blood Pressure and Pupillary Response

B. Quality and Depth of Respirations

Which actions would the nurse take to obtain subjective data about a client's respiratory status? SELECT ALL THAT APPLY. A. Palpate the chest and back for masses. B. Question the client about shortness of breath. C. Check the hematocrit and hemoglobin values. D. Inspect the skin and nails for integrity and color. E. Ask the client about color and quantity of sputum.

B. Question the client about shortness of breath. E. Ask the client about color and quantity of sputum.

A client diagnosed with tuberculosis is taking isoniazid. To prevent a food and medication interaction, the nurse will advise the client to avoid which food item? A. Hot Dogs B. Red Wine C. Sour Cream D. Grapefruit Juice

B. Red Wine

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? A. Respiratory Acidosis B. Respiratory Alkalosis C. Respiratory Compensation D. Respiratory Decompensation

B. Respiratory Alkalosis

Which is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation? A. Duration of Cry B. Respiratory Distress C. Frequency of Voiding D. Poor Nutritional Intake

B. Respiratory Distress

A client is extubated in the post anesthesia care unit after surgery. For which common response would the nurse be alert when monitoring the client for acute respiratory distress? A. Bradycardia B. Restlessness C. Constricted Pupils D. Clubbing of the Fingers

B. Restlessness

Which parameter describes the maximum volume of air a client's lungs may contain? A. Vital Capacity B. Total Lung Capacity C. Inspiratory Capacity D. Functional Residual Capacity

B. Total Lung Capacity

Which complication is the priority for the nurse to assess in a child with smoke inhalation? A. Systemic Infection B. Tracheobronchial Edem C. Post-Traumatic Stress Disorder D. Generalized Adaptation to Stress

B. Tracheobronchial Edem

How would the nurse position a client to practice supraglottic swallowing after tracheostomy? A. In Bed B. Upright C. Lying Down D. Position of Comfort

B. Upright

After auscultating the chest, how will the nurse document findings of bilateral, high-pitched, continuous whistling sounds heard during each expiration? A. Crackles B. Wheezes C. Rhonchus D. Pleural Friction Rub

B. Wheezes

The nurse described a client's abnormal breath suds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear? A. Vesicular B. Bronchial C. Adventitious D. Bronchovesicular

C. Adventitious

Which complication is the nurse's main priority during the early postoperative period after a subtotal thyroidectomy? A. Hemorrhage B. Thyrotoxic Crisis C. Airway Obstruction D. Hypocalcemic Tetany

C. Airway Obstruction

The nurse is caring for a client admitted with COPD. Which laboratory test would the nurse monitor for hypoxia? A. Red Blood Cell Count B. Sputum Culture C. Arterial Blood Gas D. Total Hemoglobin

C. Arterial Blood Gas

The nurse assesses the integumentary system of four clients. Which client has the least change of a false-positive result while undergoing assessment of capillary refill time? A. Client with shock. B. Client with anemia. C. Client with epilepsy. D. Client with perisperhal vascular disease.

C. Client with epilepsy.

The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breathe sounds that are more obvious on inspiration. Which would the nurse document these sounds as? A. Vesicular B. Bronchial C. Crackles D. Rhonchi

C. Crackles

A client's breath has a sweet, fruity odor. Which condition is affecting this client? A. Gum Disease B. Uremic Acidosis C. Diabetic Acidosis D. Infection Inside a Cast

C. Diabetic Acidosis

A client arrives in the ED with multiple crushing wounds of the chest, abdomen, and legs. What are priority nursing assessments? A. Level of consciousness and pupil size. B. Characteristics of pain and blood pressure. C. Quality of respirations and presence of pulses. D. Observation of abdominal contusions and other wounds.

C. Quality of respirations and presence of pulses.

A client has a closed chest drainage system in place. How would the nurse determine the amount of chest tube drainage? A. Aspirate the drainage from the collection chamber. B. Clamp the chest tube and empty the fluid from the collection chamber. C. Refer to the date and time markings on the outside of the collection chamber. D. Replace the existing system with a new one to access the drainage in the existing system.

C. Refer to the date and time markings on the outside of the collection chamber.

A client with the diagnosis of inhalation anthrax is admitted to the intensive care unit. It is most important for the nurse to make a focused assessment of which body system? A. Mental B. Hydration C. Respiratory D. Neurological

C. Respiratory

Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis? A. Repositioning B. Humidified Air C. Saline Irrigation D. Frequent Suctioning

C. Saline Irrigation

An older client with a history of congestive heart failure expresses concern about potential exposure to TB from his or her roommate at the extended care facility. The roommate coughs a great deal and sometimes spits up blood. Which is the primary reason that the nurse pursues more information about the roommate? A. Death from TB is on the increase in older populations. B. The roommate is causing increased anxiety and stress in the client. C. TB adversely affects older adults with chronic illness. D. Most likely, the roommate prevents the client from getting proper sleep.

C. TB adversely affects older adults with chronic illness.

A child with CF has recurrent episodes of bronchitis, and the parents ask why this happens. Which reason would the nurse include in the reply? A. Associated heart defects cause heart failure and respiratory depression. B. Neuromuscular irritability causes spasms and constriction of the bronchi. C. Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria. D. The increased salt content in saliva irritates the mucous membranes, resulting in inflammation of the nasopharynx.

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

Parents whose child has CF has no history of CF in their family and ask how their child inherited this disorder. How would the nurse clarify the way in which the disease was inherited? A. It is a mutated gene. B. It involves an X-linked gene. C. The inheritance is autosomal recessive. D. The inheritance is autosomal dominant.

C. The inheritance is autosomal recessive.

A client presents with hemoptysis. The nurse recalls that the clinical manifestation is associated with which disease? A. Anemia B. Pneumonia C. Tuberculosis D. Leukocytosis

C. Tuberculosis

How would the nurse position a client with epistaxis? A. Supine B. Side-Lying C. Upright Leaning Forward D. Sitting with the Head Tipped Backward

C. Upright Leaning Forward

Which amount is the normal value of a client's inspiratory reserve volume? A. 0.5 L B. 1.0 L C. 1.5 L D. 3.0 L

D. 3.0 L

The nurse is assessing a newborn in the well-baby nursery. Which type of respirations would the nurse expect to identify in a healthy newborn? A. Deep and Retracting B. Shallow and Thoracic C. Stertorous and Regular D. Abdominal and Irregular

D. Abdominal and Irregular

A client reports left-sided chest pain after playin racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? A. Dull sound on percussion B. Vocal fremitus on palpation C. Rales w/ rhonchi on auscultation D. Absence of breath sounds on auscultation

D. Absence of breath sounds on auscultation

During administration of an antibiotic, the client becomes restless and flushed, and begins to wheeze. Which action will the nurse take after stopping the antibiotic infusion? A. Check the client's temperature B. Take the client's blood pressure C. Obtain the client's pulse oximetry D. Assess the client's respiratory status

D. Assess the client's respiratory status

Nursing action after a client has had general anesthesia are directed at preventing which postoperative respiratory complication? A. Pleural Effusion B. Empyema C. Pneumothorax D. Atelectasis

D. Atelectasis

The nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. Which aspect of counseling would the nurse focus on? A. Teaching how to make a room allergy-free. B. Referring to a support group for individuals with asthma. C. Arranging with the college to ensure a speedy return to classes. D. Evaluating whether the necessary lifestyle changes are understood.

D. Evaluating whether the necessary lifestyle changes are understood.

Which insect or arthropod is the most common allergen for children with asthma? A. Spider B. Centipede C. Carpenter Ant D. Household Cockroach

D. Household Cockroach

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? SELECT ALL THAT APPLY. A. Emptying the drainage system when full. B. Keeping the drainage system at heart level. C. Notifying the health care provider of drainage greater than 50 mL/h. D. Marking the time on the drainage unit every shift. E. Laying the drainage system on its side during transport.

D. Marking the time on the drainage unit every shift.

Which action will the nurse take to support safe oral intake after tracheostomy? A. Include thin liquids. B. Provide large meals. C. Inflate the tracheostomy cuff fully. D. Position client as upright as possible.

D. Position client as upright as possible.

The nurse provides education to a group of student nurses about purse-lip breathing. The nurse would include which primary purpose of the respiratory exercise? A. Decreases Chest Pain B. Conserves Energy C. Increases Oxygen Saturation D. Promotes Elimination of CO2

D. Promotes Elimination of CO2

After percussing a client's posterior chest and hearing low-pitched hollow sounds over the whole chest, how will the nurse document the findings? A. Dull B. Flat C. Tympanic D. Resonance

D. Resonance

A client is admitted to the hospital with a diagnosis of acute Guillain-Barre syndrome. Which assessment is the priority? A. Urinary Output B. Sensation to Touch C. Neurological Status D. Respiratory Exchange

D. Respiratory Exchange

A client sustains crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects to react to which clinical manifestation? A. Ventricular fibrillation and decreased perfusion. B. Dysfunction of the vagus nerve with hiccups. C. Retention of sensation but paralysis of the lower extremities. D. Respiratory paralysis and cessation of diaphragmatic contractions.

D. Respiratory paralysis and cessation of diaphragmatic contractions.

When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. What complication do these adjustments attempt to prevent? A. Cataracts B. Strabismus C. Ophthalmia Neonatorum D. Retionopathy of Prematurity

D. Retionopathy of Prematurity

When a client with a health care acquired respiratory tract infection asks the nurse what this means, which response will the nurse give? A. You developed an infection that requires antibiotics. B. This is a highly contagious infection requiring isolation. C. An infection you had before beginning treatment has flared up. D. Your infection occurred because of exposure to a health care facility.

D. Your infection occurred because of exposure to a health care facility.