MED SURG RESP NCLEx Ques

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location? 1. Just under the left clavicle 2. Midsternum, 1 inch to the left 3. Over the fifth intercostal space 4. Midsternum, 1 inch to the right

1. Just under the left clavicle

The nurse is assisting a respiratory therapist to position a client for postural drainage. The nurse understands that a position is chosen that will use gravity to help drain which areas? 1. Lobes 2. Alveoli 3. Trachea 4. Main bronchi

1. Lobes

A client with uncomplicated or simple silicosis is being monitored yearly at the health care clinic. In this type of silicosis, which symptom should the nurse expect that the client will exhibit? 1. No symptoms 2. Severe dyspnea 3. Anorexia and weight loss 4. Malaise and extreme fatigue

1. No symptoms

A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. Which is the bestnursing action? 1. Notify the health care provider (HCP). 2. Increase the frequency of suctioning. 3. Add moisture to the oxygen delivery system. 4. Document the character and amount of drainage.

1. Notify the health care provider (HCP).

A nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment should the nurse plan to have at the bedside when the client returns from surgery? 1. Obturator 2. Oral airway 3. Epinephrine (Adrenalin) 4. Tracheostomy set with the next larger size

1. Obturator

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem? 1. Pleural pain and fever 2. Decreased respiratory rate 3. Diaphoresis during the day 4. Hyperresonant breath sounds over the left thorax

1. Pleural pain and fever

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? 1. Rhonchi are auscultated. 2. Pleural friction rub is heard. 3. Fine crackles are auscultated. 4. Pulse oximetry reading is 96%.

1. Rhonchi are auscultated.

A nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. The nurse interprets this occurrence correctly as the presence of which physical response? 1. Shunt unit 2. Anatomical dead space 3. Physiological dead space 4. Ventilation-perfusion matching

1. Shunt unit

A nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? Select all that apply. 1. Sit upright in the bed or in a chair. 2. Inhale deeply and quickly as possible. 3. Hold the device in a downward position. 4. Place the mouthpiece in your mouth and seal your lips tightly around it. 5. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

1. Sit upright in the bed or in a chair. 4. Place the mouthpiece in your mouth and seal your lips tightly around it. 5 . After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

A nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding should be reported to the health care health care provider (HCP) immediately? 1. Stridor 2. Lung congestion 3. Occasional pink-tinged sputum 4. Respiratory rate of 26 breaths/min

1. Stridor

A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse should plan to perform which action? 1. Suction the client. 2. Evaluate the cuff for a leak. 3. Assess for a disconnection. 4. Notify the respiratory therapist.

1. Suction the client.

A client tells the nurse that a health care provider has stated a diagnosis of uncomplicated or simple silicosis and asks the nurse exactly what this means. What knowledge should the nurse use in formulating a response? 1. The client has mild ventilation restriction and fibrosis on chest x-ray. 2. There is evidence of silica in the bloodstream but no clinical symptoms. 3. The client has normal pulmonary function studies but has shortness of breath. 4. Massive pulmonary fibrosis is visible on chest x-ray, but no extrapulmonary symptoms are apparent.

1. The client has mild ventilation restriction and fibrosis on chest x-ray.

A nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse plans care, anticipating that which physical response will initially occur? 1. The client's pH will fall. 2. The client will lose consciousness. 3. The client's sodium and chloride level will rise. 4. The client will complain of facial numbness and tingling.

1. The client's pH will fall.

The nurse is doing volunteer work in a homeless shelter. The nurse should monitor the individuals for which initialsigns/symptoms of tuberculosis (TB)? Select all that apply. 1. Fatigue 2. Lethargy 3. Chest pain 4. Morning cough 5. Low-grade fever 6. Labored breathing

1. Fatigue 2. Lethargy 4. Morning cough 5. Low-grade fever

A nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement? 1. "I will discard used tissues in a plastic bag." 2. "I need to wash my hands at least four times a day." 3. "I will brush my teeth and rinse my mouth once a day." 4. "I will turn my head to the side if I need to cough or sneeze."

1. "I will discard used tissues in a plastic bag."

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client toward this goal. Which client statement indicates that further instruction is needed? 1. "I will lie on the affected side for an hour." 2. "I can expect a chest x-ray exam to be done shortly." 3. "I will let you know at once if I have trouble breathing." 4. "I will notify you if I feel a crackling sensation in my chest."

1. "I will lie on the affected side for an hour."

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? 1. Absence of dyspnea 2. Increased severity of cough 3. Dull percussion notes over lung tissue 4. Decreased tactile fremitus over lung tissue

1. Absence of dyspnea

A clinic nurse notes that large numbers of clients present with flu-like symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply. 1. Get plenty of rest. 2. Increase intake of liquids. 3. Take antipyretics for fever. 4. Get a flu shot immediately. 5. Eat fruits and vegetables high in vitamin C.

1. Get plenty of rest. 2. Increase intake of liquids. 3. Take antipyretics for fever. 5. Eat fruits and vegetables high in vitamin C.

The nurse should provide which home care instructions to a client who had a laryngectomy and has a stoma? Select all that apply. 1. Increase the humidity in the home. 2. Obtain and wear a Medic-Alert bracelet. 3. Wear clothing that does not cover the stoma. 4. Stay away from people who have a respiratory infection. 5. Be careful with showering to avoid water from entering the stoma. 6. Decrease fluid intake to prevent excessive secretions from the stoma.

1. Increase the humidity in the home. 2. Obtain and wear a Medic-Alert bracelet. 4. Stay away from people who have a respiratory infection. 5. Be careful with showering to avoid water from entering the stoma.

An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all that apply. 1. Anosmia 2. Chronic cough 3. Purulent nasal discharge 4. Intolerance to strong aromas

1. Anosmia 2. Chronic cough 3. Purulent nasal discharge

The nurse is performing a cardiovascular assessment on a client. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function? 1. Breath sounds 2. Peripheral edema 3. Hepatojugular reflux 4. Jugular vein distention

1. Breath sounds

A nurse is caring for a client experiencing dyspnea. The nurse plans care, knowing that which factor will decrease the work of breathing? 1. Bronchodilation 2. Increased airway resistance 3. Interstitial pulmonary edema 4. Increased mucus production

1. Bronchodilation

A nurse is monitoring the status of a client who is being treated for dyspnea. The nurse is aware that which factor will decrease the work of breathing for this client? 1. Bronchodilation 2. Increased airway resistance 3. Increased mucus production 4. Interstitial pulmonary edema

1. Bronchodilation

A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1. Call the health care provider. 2. Replace the chest tube system. 3. Obtain a pulse oximetry reading. 4. Place the client in a Trendelenburg position.

1. Call the health care provider.

A client is returning from surgery after a pulmonary lobectomy. Which pieces of equipment should the nurse have at the bedside? Select all that apply. 1. Clamp 2. Code cart 3. Central line kit 4. Vaseline gauze 5. Tracheotomy set 6. Suction equipment

1. Clamp 4. Vaseline gauze 6. Suction equipment

A nurse is caring for a client who had tuberculin skin testing (Mantoux test) 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority? 1. Contact the health care provider (HCP). 2. Document the finding in the client's record. 3. Call the employee health service department. 4. Call the radiology department for a chest radiographic study to be done.

1. Contact the health care provider (HCP).

A nurse is caring for the client who is suspected of having lung cancer. The nurse should assess the client for which most frequent early symptom of lung cancer? 1. Cough 2. Hoarseness 3. Hemoptysis 4. Pleuritic pain

1. Cough

A nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. 1. Cough 2. Dyspnea 3. Weight gain 4. High-grade fever 5. Chills and night sweats

1. Cough 2. Dyspnea 5. Chills and night sweats

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? 1. Dyspnea 2. Bradypnea 3. Bradycardia 4. Decreased respirations

1. Dyspnea

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. 1. Dyspnea at rest 2. Clubbed fingers 3. Muscle retractions 4. Decreased respiratory rate 5. Increased body temperature 6. Prolonged expiratory breathing phase

1. Dyspnea at rest 2. Clubbed fingers 3. Muscle retractions 6. Prolonged expiratory breathing phase

A nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process? 1. Osmosis 2. Diffusion 3. Ionization 4. Active transport

2. Diffusion

A nurse is caring for a client with emphysema who has chronic hypercarbia and is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed which value? 1. 1 L/min 2. 2 L/min 3. 6 L/min 4. 10 L/min

2. 2 L/min

A nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure? 1. 16% 2. 21% 3. 30% 4. 40%

2. 21%

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. In formulating a response, the nurse understands that this effect is caused by which problem? 1. Anorexia is triggered by the infectious organism. 2. Blocked nasal passages impair the senses of smell and taste. 3. Infection blocks sensation from the taste buds of the tongue. 4. The client does not have enough energy to cook wholesome meals.

2. Blocked nasal passages impair the senses of smell and taste.

A client with frequent upper respiratory infections (URIs) asks the nurse why food doesn't seem to have any taste during illness. The nurse understands that this occurs as a result of which factor? 1. Anorexia, triggered by the infectious organism 2. Blocked nasal passages that impair the senses of smell and taste 3. The infection, which blocks sensation from the taste buds of the tongue 4. The client's medication therapy, which causes changes in the normal flora of the mouth

2. Blocked nasal passages that impair the senses of smell and taste

A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action? 1. Make sure that the client is not lying on the ventilator tubing. 2. Determine if there are any disconnections in the ventilator tubing. 3. Check to see if the client is biting on the endotracheal tube (ETT). 4. Auscultate the lungs to determine if the client needs to be suctioned.

2. Determine if there are any disconnections in the ventilator tubing.

A nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action? 1. Check for an air leak. 2. Document the findings. 3. Notify the health care provider. 4. Change the chest tube drainage system.

2. Document the findings. 3.Notify the health care provider

Which should the nurse do when caring for a client with chest tubes attached to a chest drainage system? 1. Empty the drainage collection chamber every shift. 2. Ensure the water level in the water seal chamber is at the 2-cm level. 3. Maintain the drainage collection device at the level of the client's chest. 4. Clamp the chest tube before moving the client from the bed to the chair.

2. Ensure the water level in the water seal chamber is at the 2-cm level.

A nurse is auscultating breath sounds in a hospitalized client with emphysema and hears these sounds. The nurse should document this finding as which sound? 1. Crackles 2. High-pitched wheezes 3. Bronchial breath sounds 4. Bronchovesicular breath sounds

2. High-pitched wheezes

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) should the nurse place at the client's bedside? 1. Code cart 2. Intubation tray 3. Thoracentesis tray 4. Chest tube and drainage system

2. Intubation tray

The nurse assesses for one-sided chest movement on the right while a client is being intubated by the health care provider. The nurse's action is based on the possibility that which could occur with the endotracheal tube? 1. It could enter the left main bronchus if inserted too far. 2. It could enter the right main bronchus if inserted too far. 3. It could enter the left main bronchus if not inserted far enough. 4. It could enter the right main bronchus if not inserted far enough.

2. It could enter the right main bronchus if inserted too far.

A nurse is caring for a client with acute respiratory distress syndrome. What should the nurse expect to note in the client? 1. Pallor 2. Low arterial Pao2 3. Elevated arterial Pao2 4. Decreased respiratory rate

2. Low arterial Pao2

A nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result? 1. Positive 2. Negative 3. Uncertain 4. Borderline

2. Negative

A nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate? 1. Reposition the client. 2. Notify the health care provider (HCP). 3. Change the chest tube drainage system. 4. No action is necessary because this is a normal expected finding.

2. Notify the health care provider (HCP).

An emergency department nurse is performing a respiratory assessment on a client who is complaining of painful breathing. On palpation the nurse notes a coarse grating sensation during inspiration, and on auscultation the nurse hears this breath sound. The nurse interprets these findings as characteristic of which condition? 1. Asthma 2. Pleurisy 3. Emphysema 4. Pulmonary edema

2. Pleurisy

A nurse is caring for a client who is receiving feedings by nasogastric tube. The client suddenly begins to vomit, and the nurse quickly repositions the client. The client is coughing and having difficulty breathing, and the nurse suspects that the client has aspirated the feeding. What is the nurse's priority action? 1. Call a code. 2. Suction the client. 3. Check the client's vital signs. 4. Call the health care provider (HCP).

2. Suction the client.

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. 1. Reduce fluid intake to less than 1500 mL/day. 2. Teach diaphragmatic and pursed-lip breathing. 3. Encourage alternating activity with rest periods. 4. Teach the client techniques of chest physiotherapy. 5. Keep the client in a supine position as much as possible.

2. Teach diaphragmatic and pursed-lip breathing. 3. Encourage alternating activity with rest periods. 4. Teach the client techniques of chest physiotherapy.

A nurse is reading the chest x-ray report for a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. What should the nurse interpret that the tube is positioned above? 1. The first tracheal cartilaginous ring 2. The bifurcation of the right and left main bronchi 3. The point at which the larynx connects to the trachea 4. The area connecting the oropharynx to the laryngopharynx

2. The bifurcation of the right and left main bronchi

A nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse determines that the tube is positioned above which area of the respiratory system? 1. The first tracheal cartilaginous ring 2. The bifurcation of the right and left main bronchi 3. The point at which the larynx connects to the trachea 4. The area connecting the oropharynx to the laryngopharynx

2. The bifurcation of the right and left main bronchi

The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation? 1. There is a leak in the system. 2. The chest tube is functioning as expected. 3. The amount of suction needs to be decreased. 4. The occlusive dressing at the insertion site needs reinforcement.

2. The chest tube is functioning as expected.

The nurse instructs a client regarding pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? 1. The client breathes in through the mouth. 2. The client breathes out slowly through the mouth. 3. The client avoids using the abdominal muscles to breathe out. 4. The client puffs out the cheeks when breathing out through the mouth.

2. The client breathes out slowly through the mouth.

The client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics? 1. The drainage is serous. 2. The drainage is bloody. 3. The drainage is serosanguineous. 4. The drainage is bloody, with frequent small clots.

2. The drainage is bloody.

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? 1. Sitting position 2. Tripod position 3. Supine position 4. High Fowler's position

2. Tripod position

A nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? 1. pH, 7.40; Pao2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L 2. pH, 7.32; Pao2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L 3. pH, 7.47; Pao2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L 4. pH, 7.31; Pao2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

2. pH, 7.32; Pao2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L;

The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information regarding the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments? 1. "I should avoid all contact with my family." 2. "I should avoid large crowds for at least 3 weeks." 3. "I cannot give Legionnaires' disease to other people." 4. "I will have to take antibiotics until my symptoms disappear."

3. "I cannot give Legionnaires' disease to other people."

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1. A 25-year-old woman with diabetic ketoacidosis 2. A 65-year-old man out of bed 1 day after prostate resection 3. A 73-year-old woman who has just had pinning of a hip fracture 4. A 38-year-old man with pulmonary contusion sustained in an automobile crash

3. A 73-year-old woman who has just had pinning of a hip fracture

A nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse should determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis? 1. An uninsured man who is homeless 2. A newly immigrated woman from Korea 3. A man who is an inspector for the US Postal Service 4. An older woman admitted from a long-term care facility

3. A man who is an inspector for the US Postal Service

A nurse is performing a respiratory assessment on a client with a left lower lobe lung mass. Chest auscultation over the posterior left lower lobe reveals these breath sounds.The nurse would interpret this as which sound? 1. Pleural friction rub 2. Vesicular breath sounds 3. Bronchial breath sounds 4. Bronchovesicular breath sounds

3. Bronchial breath sounds

A nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The health care provider states that because of fluid in the alveoli, surfactant production is falling. The nurse understands that insufficient surfactant causes which effect? 1. Atelectasis and viral infection 2. Bronchoconstriction and stridor 3. Collapse of alveoli and decreased compliance 4. Decreased ciliary action and retained secretions

3. Collapse of alveoli and decreased compliance

A nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The health care provider states that as a result of fluid in the alveoli, surfactant production is falling. The nurse understands that which is the natural consequence of insufficient surfactant? 1. Atelectasis and viral infection 2. Bronchoconstriction and stridor 3. Collapse of alveoli and decreased compliance 4. Decreased ciliary action and retained secretions

3. Collapse of alveoli and decreased compliance

A nurse should determine that tracheal suctioning is needed if which is noted? 1. Arterial oxygen level of 90 mm Hg 2. 2 hours elapsed since the last suctioning 3. Congested breath sounds in the lung fields 4. Respiratory rate of 18 breaths/min, up from 16 breaths/min

3. Congested breath sounds in the lung fields

A nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube system. Which nursing action is appropriate? 1. Suction the client. 2. Increase the suction. 3. Document the findings. 4. Encourage coughing and deep breathing.

3. Document the findings.

The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine (Nicorette) gum. When reviewing this treatment with the client, the nurse should provide which instruction to the client? 1. Drink water while chewing the gum. 2. Only chew the gum for a maximum of 10 minutes. 3. Hold the gum between the cheek and teeth periodically. 4. Eat a light snack immediately before chewing the gum.

3. Hold the gum between the cheek and teeth periodically.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? 1. Increased oxygen saturation with ambulation 2. A widened diaphragm documented by chest x-ray 3. Hyperinflation of lungs documented by chest x-ray 4. A shortened expiratory phase of the respiratory cycle

3. Hyperinflation of lungs documented by chest x-ray

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope in which location? 1. Near the lateral 12th rib 2. In the fifth intercostal space 3. Just under the left-sided clavicle 4. Posteriorly, under the left-sided scapula

3. Just under the left-sided clavicle

The client who has had radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated? 1. Monitoring the client's airway 2. Applying manual pressure over the site 3. Lowering the head of the bed to a flat position 4. Calling the health care provider (HCP) immediately

3. Lowering the head of the bed to a flat position

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing? 1. Sitting up and leaning on a table 2. Standing and leaning against a wall 3. Lying on the back in a low-Fowler's position 4. Sitting up with the elbows resting on the knees

3. Lying on the back in a low-Fowler's position

A nurse providing instructions to a client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that the primary benefit is to have which effect? 1. Dilate the major bronchi. 2. Increase surfactant production. 3. Maintain inflation of the alveoli. 4. Enhance ciliary action in the tracheobronchial tree.

3. Maintain inflation of the alveoli.

A nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because, in normal respiration, as the diaphragm contracts, it takes which action? 1. Aids in exhalation 2. Moves up and inward 3. Moves downward and out 4. Makes the thoracic cage smaller

3. Moves downward and out

A nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm? 1. Aids in exhalation as it contracts 2. Moves up and inward as it contracts 3. Moves downward and out as it contracts 4. Makes the thoracic cage smaller as it contracts

3. Moves downward and out as it contracts

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? 1. Initiate and maintain supplemental oxygen as prescribed. 2. Plan activities with rest periods to conserve oxygen needs. 3. Provide nasotracheal suctioning as needed to remove secretions. 4. Monitor oxygenation (the oxygen saturation [SaO2]) during activity.

3. Provide nasotracheal suctioning as needed to remove secretions.

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? 1. Cyanosis 2. Hyperinflated chest 3. Rapid, shallow respirations 4. Coarse crackles auscultated bilaterally

3. Rapid, shallow respirations

A nurse is caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse should assess for which characteristic of wound drainage expected in the immediate postoperative period? 1. Serous 2. Grossly bloody 3. Serosanguineous 4. Serous with sputum

3. Serosanguineous

A client is experiencing severe dyspnea, and the nurse listens to the client's breath sounds and hears this sound. The nurse should document this finding as which sound? 1. Crackles 2. Rhonchi 3. Stridor 4. High-pitched wheezes

3. Stridor

A client arrives at the emergency department with a nosebleed. On assessment, the nurse determines that the nosebleed began suddenly and for no apparent reason. What is the initial nursing action? 1. Insert nasal packing. 2. Prepare a nasal balloon for insertion. 3. Place the client in a semi-Fowler's position, and apply ice packs to the nose. 4. Ask the client to sit down and lean forward, and apply pressure to the nose for 5 to 10 minutes.

4. Ask the client to sit down and lean forward, and apply pressure to the nose for 5 to 10 minutes.

A nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note? 1. High fever 2. Flushed skin 3. Complaints of weight gain 4. Complaints of night sweats

4. Complaints of night sweats

The nurse is providing care for a client recently admitted with new onset pleurisy. Upon auscultation of the client's lungs, the nurse notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds? 1. Effectiveness of medication therapy 2. The deep breaths that the client is taking 3. Decreased inflammatory reaction at the site 4. Accumulation of pleural fluid in the inflamed area

4. Accumulation of pleural fluid in the inflamed area

The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action should the nurse perform prior to reinserting the inner cannula? 1. Suction the client's airway. 2. Wipe the inner cannula off with a clean washcloth. 3. Dry the inner cannula thoroughly with sterile gauze. 4. Allow the inner cannula to dry after washing it with sterile water.

4. Allow the inner cannula to dry after washing it with sterile water.

The nurse determines the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this? 1. Tidaling is absent. 2. Gentle bubbling is observed in the suction control chamber. 3. Vacillation of water in the water seal chamber occurs during respiration. 4. Continuous bubbling is observed in the water seal during inspiration and expiration.

4. Continuous bubbling is observed in the water seal during inspiration and expiration.

A nurse understands that increasing the flow of oxygen to more than 2 L/min in the client with chronic obstructive pulmonary disease (COPD) could be harmful because it has which effect? 1. Is drying to nasal mucosal passages 2. Decreases diaphragmatic excursion and depth 3. Increases the risk of pneumonia and atelectasis 4. Decreases the client's oxygen-based respiratory drive

4. Decreases the client's oxygen-based respiratory drive

A nurse is assisting the health care provider (HCP) with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse should take which action? 1. Ensure that suction is turned on. 2. Reinforce the occlusive dressing. 3. Encourage the client to breathe deeply. 4. Document the accurate functioning of the tube.

4. Document the accurate functioning of the tube.

A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action should the nurse take to eliminate the problem? 1. Silence the alarm to avoid disturbing the client. 2. Check the ventilator circuit for any disconnections. 3. Inflate the cuff of the endotracheal tube to a pressure of 25 mm Hg. 4. Empty excess accumulated water from the ventilatory circuit tubing.

4. Empty excess accumulated water from the ventilatory circuit tubing.

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but is unable to expectorate sputum. Which problem is the priority? 1. Low cardiac output secondary to cor pulmonale 2. Gas exchange alteration related to ventilation-perfusion mismatch 3. Altered breathing pattern secondary to increased work of breathing 4. Inability to clear the airway related to inability to expectorate sputum

4. Inability to clear the airway related to inability to expectorate sputum

A nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching regarding positioning? 1. Sitting up and leaning on a table 2. Standing and leaning against a wall 3. Sitting up with elbows resting on knees 4. Lying on his or her back in a low Fowler's position

4. Lying on his or her back in a low Fowler's position

A nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. The nurse determines that these breath sounds are usually caused by which condition? 1. Obstruction of the bronchus 2. Inflammation of the pleural surfaces 3. Passage of air through a narrowed airway 4. Opening of small airways that contain fluid

4. Opening of small airways that contain fluid

A health care provider (HCP) is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the health care provider should ask the client to perform which procedure? 1. Take a deep breath. 2. Exhale immediately. 3. Breathe in and out quickly. 4. Perform the Valsalva maneuver.

4. Perform the Valsalva maneuver.

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? 1. Focus only on the physical examination. 2. Obtain all information from family members. 3. Use the health care provider's medical history. 4. Plan short sessions with the client to obtain data.

4. Plan short sessions with the client to obtain data.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? 1. Ask a family member to stay with the client at all times. 2. Ask the health care provider for a prescription for succinylcholine. 3. Encourage the client to sleep until arterial blood gas results improve. 4. Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

4. Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

A client's baseline vital signs are as follows: temperature 98.8° F oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103° F. Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? 1. Respiratory rate of 12 breaths/min 2. Respiratory rate of 16 breaths/min 3. Respiratory rate of 18 breaths/min 4. Respiratory rate of 22 breaths/min

4. Respiratory rate of 22 breaths/min

A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively the nurse should place the client in which position? 1. Sims 2. Supine 3. Side-lying 4. Semi-Fowler's

4. Semi-Fowler's

A client with an endotracheal tube attached to mechanical ventilation begins to cough, and his face appears flushed. Which action should the nurse take first? 1. Call respiratory therapy. 2. Contact the health care provider. 3. Check the client's blood pressure. 4. Suction the client through the endotracheal tube.

4. Suction the client through the endotracheal tube.

A nurse in an ambulatory clinic is preparing to administer a tuberculin skin test (Mantoux test) to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacille Calmette-Guérin (bCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make? 1. The client has no risk of acquiring TB and needs no further workup. 2. The client is at increased risk for acquiring TB and needs immediate medication therapy. 3. The client's test result will be negative, and a sputum culture will be required for diagnosis. 4. The client's test result will be positive, and a chest x-ray study will be required for evaluation.

4. The client's test result will be positive, and a chest x-ray study will be required for evaluation.

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented? 1. The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3. The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding owing to which physical response to this disorder? 1. The stretch receptors in the lungs are irritated. 2. The diaphragm is weak and is difficult to move. 3. This condition causes nerve endings to be especially sensitive. 4. The inflamed pleurae cannot glide against each other as they normally do.

4. The inflamed pleurae cannot glide against each other as they normally do.

A nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. How should the nurse interpret this finding? 1. The drainage chamber is full. 2. The pneumothorax is resolving. 3. The suction chamber system is shut off. 4. There is an air leak somewhere in the system.

4. There is an air leak somewhere in the system.