medical Surgical: Reparatory [ATI Adaptive quizzes]

A nurse is reinforcing teaching about pursed-lip breathing with a client who has chronic obstructive pulmonary disease (COPD) and emphysema. The nurse should explain that this breathing technique does which of the following?

Keep the airway open on exhalation

A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. Which of the following pieces of information should the nurse include in the teaching?

Use pursed-lip breathing during periods of dyspnea

A nurse is reinforcing teaching with a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?

A tissue sample might be obtained during the procedure

A nurse is assisting with the care of a client who had a chest tube inserted 12 hours ago. The nurse notes a crackling sensation upon palpation of the skin on the right side of the client's chest. The nurse should notify the charge nurse that the client is demonstrating a clinical manifestation of which of the following complications?

Crepitus

A nurse is assisting with the development of a teaching plan about how to prevent an acute asthma attack for a young adult client. Which of the following should the nurse plan to discuss first?

Determine the clients perception of the disease process and what might have triggered the current attack.

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first?

Evaluate the client for stridor

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors has a significant impact on the plan of care for this client?

Lung cancer usually has metastasized before the client has symptoms

A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses trans illumination, the nurse should explain to the client that this technique helps evaluate which of the following structures?

Maxillary sinuses

A nurse in a provider's office is collecting data from a client who reports recent exposure to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis?

Night sweats

A nurse is collecting data from a client who has a positive tuberculin skin test. Which of the following findings should the nurse identify as an indication that the client has active tuberculosis?

Night sweats.

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse to hear?

Noisy wheezing

A nurse is reviewing the results of a client who has metabolic alkalosis. Which of the following values should the nurse expect?

PH7.49, HCO3-32mEq/l,Paco 40

A nurse is collecting data from a client who has a prescriptior for cisplatin IV to treat lung cancer. Which of the following findings is an adverse effect of this medication?

Tinnitus

A nurse is reinforcing teaching with a client pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation?

Total lung capacity

A nurse is assisting with preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.)

[A] Explain that the client will receive sedation and will not remember the procedure. [B] verify that the client understands the purpose and nature of the procedure.

A nurse is assisting with planning postoperative education for a client who will undergo a radical dissection for cancer of the larynx. The nurse should suggest including which of the following topics? all that apply.)

[A] NPO status [B] Alternative methods of commination. [D] change in body images. [E] swallowing exercises

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.)

[A] assign the client to a private room with negative pressure airflow. [C] Wear an N95 respirator when entering the clients room

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings indicate a tension pneumothorax? (Select all that apply.)

[A] tracheal deviation to the left. [C] absent breath sounds on the right side. [D] neck vein distention.

A nurse is reinforcing preoperative teaching with a client who has lung cancer and will undergo a pneumonectomy. Which of the following pieces of information should the nurse include? (Select all that apply.)

[A] you will have a chest tube in place after surgery. [B] Well help you turn cough and breath deeply frequently after surgery. [D] well give you oxygen to support your breathing if you need it.

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus?

a client who has a chest tube following pneumothorax

A nurse is assisting with the plan of care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse recommend to use for this client?

a nasal cannula

A nurse on a medical unit is assisting with the care of a client who has a possible closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should hear which of the following findings when auscultating the client's lung sounds?

absence of breath sounds

A nurse is reinforcing discharge instructions with a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications?

aspiration of water

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take?

auscultate the lungs after removal

A nurse is preparing to assist a provider in withdrawing arterial from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take?

check the circulation in the clients ulnar artery prior to obtaining the specimen

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority?

confirming the gag reflex

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. Which of the following actions should the nurse take to assist the client with smoking cessation?

discuss ways the client can reduce the number of cogitates somked per day

A nurse in an urgent care clinic is collecting data from a client who exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax?

dry cough.

A nurse is assisting with the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?

eat high calorie food first

A nurse is caring for a client who has pneumonia and is experiencing thick oral secretions. Which of the following actions should the nurse take first?

encourage-deep breathing and coughing

A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority?

ensure an adequate airway

A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon?

frequent swallowing.

A nurse is reinforcing preoperative teaching with a client who will undergo a total laryngectomy. Which the following statements should the nurse identify as an indication that the client understands the impact of the surgery?

i understand that i will have a permanent tracheostomy after surgery

A nurse is reinforcing teaching with a client who is to undergo a pneumonectomy. The client states, "i am afraid that coughing will hurt after the surgery." Which of the following should the nurse make?

i will show you how to splint your incision while coughing

A nurse is reinforcing discharge teaching with a client who had a pulmonary embolism. Which of the following statements should the nurse identify as an indication that the client understands the information?

ill call the doctor if is see any blood in my Urine or stool

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take?

immerse the end of the chest tube in a bottle of sterile water

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take?

increase the oxygen flow and request an arterial blood gas determination

A nurse on a medical-surgical unit is collecting data from a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the charge nurse?

increased coughing

A nurse is collecting data from a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider?

inspiratory stridor

A nurse is assisting with discharge teaching for a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include?

lie on your back with your head elevated 30 when resting

A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following recommendations should the nurse make?

maintain the head of the bed at 30 degrees

A nurse on a medical unit is assisting with the care of a client who aspirated gastric contents prior to admission. The provider prescribed 100% oxygen by nonrebreather mask after the client reported severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)?

paO2 50 mm Hg

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse take first?

place the client in an upright position

A nurse is assisting with the care of a client who has a chest tube in place following a thoracotomy. Which of the following actions should the nurse take?

place the drainage unit below the clients chest level

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) and pneumonia. The nurse should monitor the client for which of the following acid-base imbalances?

respiratory acidosis

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaC02 27 mmHg, and HC03- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

respiratory alkalosis

A nurse in the PACU is collecting data from a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify that these findings are manifestations of which of the following complications?

respiratory obstruction

A nurse is helping the provider prepare a client for a thoracentesis. The nurse should instruct the client that which of the following positions will be used for this procedure?

sitting while learning forward over the bedside table.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism?

stabbing chest pain

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement. The client reports feeling apprehensive and restless. The nurse collects additional data from the client. Which of the following findings is an indication of pulmonary embolism?

sudden onset of dyspnea

A nurse is collecting data about the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of the early onset of respiratory failure?

tachycardia

A nurse is assisting with the plan of care for a client following placement of a chest tube 1 hour ago. Which of the following actions should the nurse include in the plan of care?

tape all connections between the chest tube and drainage system

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions?

the client has coarse crackles in the lung fields

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place, 1 in the lower portion of the thorax and the other higher up on the chest wall. When the family asks the nurse why the client has 2 chest tubes, which of the following responses should the nurse make?

the lower tube will drain blood and the higher tube will remove air

A nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. The nurse should instruct the client that which of the following is the purpose of these treatments?

to mobilize secretion in the airways

A nurse is reinforcing discharge teaching with a client who has emphysema. Which of the following instructions should the nurse include?

try to drink at least 2 to 3 liters of fluid per day

A nurse is reinforcing teaching about breathing techniques with a client who has emphysema. Which of the following statements should the nurse identify as an indication that the client understands the mechanics behind pursed-lip breathing?

when i breath out through pursed lip my airways don't collapse between breaths

A nurse in a clinic is reinforcing teaching with a client who is scheduled to have a skin test. Which of the following pieces of information should the nurse include?

you must return to the clinic to have the test read in 2 or 3 days