Evolve Gas Exchange

A healthcare provider prescribes oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning? 1. Gurgling sounds with each breath 2. Fine crackles at the base of the lungs 3. Cyanosis in the nail beds of the fingers 4. Dry cough at increasingly frequent intervals

1. Gurgling sounds with each breath

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse conclude is causing these clinical findings? 1. Hypokalemia 2. Hyponatremia 3. Hyperglycemia 4. Hypercalcemia

1. Hypokalemia

A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level? 1. Cannula 2. Catheter 3. Venturi mask 4. Rebreather mask

1. Cannula

The nurse is assessing a client with a laryngeal trauma. This client presents with hemoptysis, aphonia, hoarseness, dyspnea, and subcutaneous emphysema. Which condition of the client stands first in the priority list? 1. Dyspnea 2. Aphonia 3. Hoarseness 4. Subcutaneous emphysema

1. Dyspnea

During the assessment of a client who was admitted to the hospital because of a productive cough, fever, and chills, the nurse percusses an area of dullness over the right posterior lower lobe of the lung. Which medical diagnosis will the nurse most likely observe documented in the client's electronic records? 1. Pleurisy 2. Bronchitis 3. Pneumonia 4. Emphysema

3. Pneumonia

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" The nurse's response is based on what likely cause of the spontaneous pneumothorax? 1. Pleural friction rub 2. Tracheoesophageal fistula 3. Rupture of subpleural bleb 4. Puncture wound of the chest wall

3. Rupture of a subpleural bleb

Following assessment, a nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. What would be the cause of these sounds? 1. Parietal pleura rubbing against visceral pleura 2. Random, sudden reinflation of groups of alveoli 3. Turbulence due to muscular spasm and fluid or mucus in the larger airways 4. High-velocity airflow through severely narrowed or an obstructed airway

3. Turbulence due to muscular spasm and fluid or mucus in the larger airways

A client with a tentative diagnosis of lung cancer is scheduled for a mediastinoscopy with biopsy. Which is a priority nursing action? 1. Tell the client that chest tubes will be present after the procedure. 2. Explain that the procedure will allow visualization of lungs and chest cavity. 3. Inform the client that some pleural fluid will be removed during this procedure. 4. Advise the client to avoid eating or drinking anything for several hours before the test.

4. Advise the client to avoid eating or drinking anything for several hours before the test.

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)? 1. Chest tube insertion 2. Aggressive diuretic therapy 3. Administration of beta-blockers 4. Positive end-expiratory pressure

4. Positive end-expiratory pressure

A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food? 1. Offer three large meals a day. 2. Assess the client's respiratory status before and after meals. 3. Seek a change in the diet prescription from soft foods to clear liquids 4. Schedule meals with the peak effect of an anticholinesterase muscle stimulant

4. Schedule meals with the peak effect of an anticholinesterase muscle stimulant

A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube should the nurse anticipate will most likely be used to meet the needs of this client? 1. Levin 2. Salem Sump 3. Miller-Abbott 4. Sengstaken-Blakemore

4. Sengstaken-blakemore Sengstaken-Blakemore includes an esophageal balloon that exerts pressure on inflation, which retards hemorrhage.

The nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider? 1. Flaring nares 2. Acrocyanosis 3. Heartbeat of 140 beats/min 4. Respirations of 40 breaths/min

1. Flaring nares

A client has chronic obstructive pulmonary disease (COPD) and cor pulmonale. When teaching about nutrition, what does the nurse instruct the client? 1. Eat small meals six times a day to limit oxygen needs. 2. Drink large amounts of fluid to help liquefy secretions. 3. Lie down after eating to conserve energy needed for digestion. 4. Increase the intake of protein to decrease intravascular hydrostatic pressure.

1. Eat small meals six times a day to limit oxygen needs.

A client is admitted for dehydration and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" What is the nurse's priority action? 1. Elevate the head of the bed and obtain vital signs. 2. Discontinue the IV site and contact the primary healthcare provider. 3. Change the IV to an intermittent infusion device. 4. Contact the primary healthcare provider to obtain a prescription for a sedative.

1. Elevate the head of the bed and obtain vital signs.

The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema? 1. Palpate around the tube insertion sites for crepitus. 2. Auscultate the breath sounds for crackles and atelectasis 3. Observe the client for the presence of a barrel-shaped chest. 4. Compare the length of inspiration with the length of expiration

1. Palpate around the tube insertion sites for crepitus.

What are the potential life-threatening conditions that should be considered during the primary survey for a client admitted after a fire accident? Select all that apply. 1. Shock 2. Ecchymosis 3. Inhalation injury 4. Direct cardiac injury 5. Subcutaneous emphysema

1. Shock 3. Inhalation injury 4. Direct cardiac injury

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum? 1. Sooty 2. Frothy 3. Yellow 4. Tenacious

1. Sooty

A client is diagnosed with emphysema. For what long-term problem should the nurse monitor this client? 1.Localized tissue necrosis 2.Carbon dioxide retention 3.Increased respiratory rate 4.Saturated hemoglobin molecules

2. Carbon dioxide retention

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? 1. Apply a thoracic binder for support 2. Encourage coughing and deep breathing 3. Defer pain medication the first day after injury 4. Position the client face-down on a soft mattress.

2. Encourage coughing and deep breathing

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? 1. Supine 2. Orthopneic 3. Low-Fowler 4. Semi-Fowler

2. Orthopneic

After a subtotal gastrectomy a client is returned to the surgical unit. Which is the best nursing action to prevent pulmonary complications? 1. Ambulating the client to increase respiratory exchange. 2. Promoting frequent turning and deep breathing to mobilize secretions. 3. Maintaining a consistent oxygen flow rate to increase oxygen saturation. 4. Keeping a plastic airway in place to ensure patency of the client's airway

2. Promoting frequent turning and deep breathing to mobilize secretions.

While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs? 1. Seizure activity is imminent. 2. Pulmonary edema has developed. 3. Bronchial constriction was precipitated by the stress of pregnancy. 4. Impaired diaphragmatic function was caused by the enlarged uterus.

2. Pulmonary edema has developed.

The nurse is studying the stages that characterize the progression of chemical pneumonia in young children following ingestion of a hydrocarbon. Which symptoms does the nurse correctly list as occurring in the third stage postingestion, between 72 to 96 hours? Select all that apply. 1. Sweating 2. Stupor 3. Multiple organ failure 4. Coagulation abnormalities 5. Pain in right upper quadrant

2. Stupor 4. Coagulation abnormalities 5. Pain in right upper quadrant

A nurse plans to set up emergency equipment at the bedside of a client in the immediate postoperative period after a thyroidectomy. What should the nurse include in the bedside setup? 1. Crash cart with bed board 2. Tracheostomy set and oxygen 3. Ampule of sodium bicarbonate 4. Airway and nonrebreather mask

2. Tracheostomy set and oxygen

A nurse is caring for a client who had a pneumonectomy. Which is the priority nursing assessment? 1. Pulse oximetry 2. Ventilatory exchange 3. Closed chest drainage 4. Approximation of the incision

2. Ventilatory exchange