MedSurg Respiratory

Which client will the nurse consider to be at greatest risk for an airway obstruction? a. A 25 year old with a sinus infection b. A 65 year old who has chronic mouth dryness and many dental caries c. A 35 year old with a traumatic brain injury d. A 55 year old who wears upper and lower dentures

c. A 35 year old with a traumatic brain injury

Which symptom will the nurse expect as typical in an 82-year-old client with pneumonia? a. High fever b. Profound bradycardia c. Acute confusion d. Coughing spasms

c. Acute confusion

Which action has the highest priority for the nurse caring for a client with facial trauma who has new-onset restlessness? a. Preparing the next dose of prescribed pain medication b. Providing ventilation with a manual resuscitation bag c. Applying oxygen d. Assessing for bleeding on the drip moustache dressing

c. Applying oxygen

Which action will the nurse take first when a client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure? Which nursing action must be taken first? a. Cleaning the tracheostomy inner cannula and stoma b. Observing for indications that suctioning is needed c. Auscultating lung sounds d. Changing the tracheostomy dressing immediately

c. Auscultating lung sounds The first step of the nursing process and nursing action for a client following an airway procedure is to assess for a patent airway by auscultating the client's lungs and assessing the client's respiratory status. Suction is not needed if the lungs and airways are clear to auscultation. Although cleanliness is important, the PACU nurse will not typically perform this procedure immediately after the tracheotomy is created, unless copious secretions are blocking the tube.Performing a dressing change is done every 8 hours or per hospital policy. The PACU nurse will perform this if the dressing is soiled or bloody, but assessment of airway must be performed first.

What is the priority assessment the nurse will make for a client with a posterior nosebleed who has posterior packing and is receiving oxygen therapy, antibiotics, and opioid analgesics. What is the priority assessment? a. Determining the degree of mouth dryness b. Examining the skin around the nares for breakdown c. Checking gag and cough reflexes d. Asking about pain relief

c. Checking gag and cough reflexes

Which assessment finding in an older client with pneumonia will the nurse report immediately to the primary health care provider? a. Productive cough and normal temperature b. Flushed cheeks and increased respiratory rate c. Hypotension and rapid, weak pulse d. SpO2 of 86% and confusion

c. Hypotension and rapid, weak pulse Hypotension and a rapid, weak pulse are indications of dehydration with possible impending sepsis and shock. This condition all result in poor perfusion and can progress to extreme hypoxemia and death. These symptoms require immediate attention and intervention.The other symptoms are expected with pneumonia and do not represent rapid progression to a more serious problem.

What is the nurse's best response when a client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck?" a. "Your family and those who love you won't care." b. "It won't take you long to learn to manage." c. "But you know you need this to breathe, right?" d. "The hole can be hidden with a light scarf."

d. "The hole can be hidden with a light scarf."

The nurse has just received report on a group of clients. Which client is the nurse's first priority? a. A 50 year old who is 1 day postoperative from abdominal surgery and is receiving 2 L oxygen by nasal cannula. b. A 55 year old was admitted yesterday with pneumonia and is receiving antibiotics and oxygen through a nasal cannula. c. A 45 year old who is being discharged with a new prescription for home oxygen therapy by nasal cannula. d. A 60 year old admitted 2 hours ago who has a 90-pack-year smoking history and is receiving 50% oxygen by Venturi mask.

d. A 60 year old admitted 2 hours ago who has a 90-pack-year smoking history and is receiving 50% oxygen by Venturi mask

What is the most relevant technique for the nurse to use when assessing a client for dyspnea? a. Checking oxygen saturation by pulse oximetry b. Observing the client's rate, depth, and ease of inhalation and exhalation c. Comparing previous respiratory assessment information with current data d. Asking the client about whether any breathlessness is present

d. Asking the client about whether any breathlessness is present Dyspnea, difficulty in breathing or breathlessness, is a subjective perception and varies among clients. Thus, only the client can rate his or her level of dyspnea.The other measures listed for assessment of respiratory status and adequacy of ventilation and oxygenation are objective measures.

Which associated health problems will the nurse expect a client with long-term obstructive sleep apnea (OSA) to have? a. Hypertension and weight gain b. Cancer and autoimmune disorders c. Hypotension and chronic hypoglycemia d. Asthma and chronic obstructive pulmonary disease

a. Hypertension and weight gain

Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction? a. Hemoptysis and shortness of breath b. Fever and tracheal deviation c. Audible wheezing on inhalation and exhalation d. Paradoxical chest movements

a. Hemoptysis and shortness of breath

What is the nurse's best response when a client with emphysema asks how removing part of the lungs through lung volume reduction surgery will improve breathing? a. "By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best." b. "This surgery is preventive, because the parts of the lungs being removed are those that having the highest probability for developing cancer." c. "Breathing will be improved because diseased lung parts are removed and replaced with healthy parts." d. "This surgery makes room for the new lungs when a lung transplant is available."

a. "By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best."

What is the nurse's best response to a client with obstructive sleep apnea (OSA) who asks, "Why does it feel like I wake up every 5 minutes?" a. "Carbon dioxide builds up while you are not breathing, which stimulates your body to wake up and breathe." b. "Excessive sleeping during the day interferes with deeper sleep at night." c. "Your tongue may be blocking your throat, and you wake up because you are choking." d. "You really aren't waking up that often. It just feels that way."

a. "Carbon dioxide builds up while you are not breathing, which stimulates your body to wake up and breathe."

Which statements made by a client going home with a tracheostomy indicate to the nurse the need for further teaching about correct tracheostomy care? (Select all that apply.) a. "I can only take baths, but no showers." b. "I will be unable to wear a necklace." c. "I should put cotton or foam over the tracheostomy hole." d. "I will have to learn to suction myself." e. "I will notify my primary health care provider if my secretions develop a foul odor." f. "I can put normal saline in my tracheostomy to keep the secretions from getting thick."

a. "I can only take baths, but no showers." b. "I will be unable to wear a necklace." c. "I should put cotton or foam over the tracheostomy hole." f. "I can put normal saline in my tracheostomy to keep the secretions from getting thick."

Which client statements about using an aerosol inhaler for asthma management indicate to the nurse that he has correct understanding of this drug delivery system? (Select all that apply.) a. "I will hold my breath for at least 10 seconds after inhaling the drug." b. "When I suspect the canister is close to empty, I will shake it to check how much is left." c. "If I use a spacer, I don't have to wait a minute between the two puffs." d. "If the spacer makes a whistling sound, I am breathing in too rapidly." e. "Rinsing my mouth after using the inhaler and then swallowing the rinse ensures I will get all of the drug."

a. "I will hold my breath for at least 10 seconds after inhaling the drug." d. "If the spacer makes a whistling sound, I am breathing in too rapidly."

The nurse has just received report on a group of clients. Which client is the nurse's first priority? a. A 45 year old with a peritonsillar abscess who can no longer swallow. b. A 65 year old with rhinosinusitis and a fever of 102° F (38.9° C) c. A 25 year old who had endoscopic sinus surgery 8 hours ago. d. A 55 year old with tuberculosis who is standard first-line therapy.

a. A 45 year old with a peritonsillar abscess who can no longer swallow.

Which client will the nurse recognize as being at risk for bacterial sinusitis? a. A 45 year old with multiple dental caries and infected gums b. A 25 year old with seasonal pollen allergies c. A 65 year old who has a poor gag reflex after a stroke d. A 35 year old with a 20-pack-year smoking history who now vapes

a. A 45 year old with multiple dental caries and infected gums

Which client will the nurse consider to be a poor candidate for continuous positive airway pressure (CPAP) management for obstructive sleep apnea? a. A 65 year old with chronic confusion b. A 45 year old with septal deviation who is a mouth-breather c. A 75 year old who lives alone d. A 55 year old with an unusually large uvula

a. A 65 year old with chronic confusion

Drugs from which class will the nurse prepare to administer as first-line therapy for a client just diagnosed with pulmonary embolism (PE)? a. Anticoagulants b. Antihypertensives c. Antidysrhythmics d. Antibiotics

a. Anticoagulants

Which action will the nurse take to ensure that a client who requires drug therapy for multi-drug resistant tuberculosis and also is addicted to heroin adheres to the treatment regimen? a. Arranging for a health care worker to directly observe the client take the drugs b. Giving the client written instructions about how and when to take the drugs c. Instructing the client about the consequences of not taking the drugs d. Having the client repeat the drug names and side effects

a. Arranging for a health care worker to directly observe the client take the drugs

Which assessment findings in a client with asthma indicate to the nurse that the client's asthma condition is deteriorating and progressing toward respiratory failure? a. Audible wheezing with use of accessory muscles on inhalation b. Crackles, rhonchi, and productive cough with yellow sputum c. Tachypnea, thick and tenacious sputum, and hemoptysis d. Respiratory alkalosis; slow, shallow respiratory rate

a. Audible wheezing with use of accessory muscles on inhalation Normal exhalation is passive. When airways narrow, wheezing is first heard on exhalation. Wheezing on inhalation along with the use of accessory muscles for inhalation indicates more severe airway problems and a worsening of asthma.Worsening asthma would cause acidosis, not alkalosis. Hemoptysis is not associated with asthma. Crackles are not present because asthma is an airway problem, not an alveolar problem.

Which personal factors or health problems will the nurse suspect as possible causes of a client's diagnosis of cancer of the sinuses? a. Chronic exposure to wood dust and cigarette smoking b. Yearly colds leading to development of sinus infections c. Heavy sun exposure and use of antihistamine nasal spray d. Swimming in the ocean and heating the home with a forced-air furnace

a. Chronic exposure to wood dust and cigarette smoking

Which condition indicates to the nurse that the treatment plan for a client with streptococcal pneumonia is effective? a. Client has been afebrile for 48 hours. b. Oxygen saturation ranges between 90% and 92% on room air. c. White blood cell count is 16, 000 cells/mm3 (16 × 109/L). d. Bronchial breath sounds present in lung periphery.

a. Client has been afebrile for 48 hours.

Which factors or conditions will the nurse identify as increasing the risk for clients to develop aspiration pneumonia? (Select all that apply.) a. Continuous nasogastric (NG) tube feedings b. Bronchoscopy procedure c. Decreased level of consciousness d. Magnetic resonance imaging (MRI) procedure e. Stroke f. Chest tube

a. Continuous nasogastric (NG) tube feedings b. Bronchoscopy procedure c. Decreased level of consciousness e. Stroke The risk for aspiration pneumonia is increased whenever the client has a reduced or absent gas reflex (e.g., decreased level of consciousness, stroke, following local anesthesia for a bronchoscopy procedure), and when a client's lower esophageal sphincter does not close complete. This situation occurs when an NG tube is in place, preventing complete or tight constriction of the sphincter.

Which changes in arterial blood gas (ABG) values will the nurse expect in a client with long-term chronic obstructive pulmonary disease (COPD)? a. Decreased pH; Decreased PaO2; Increased PaCO2; Increased bicarbonate level b. Increased pH; increased PaO2; increased PaCO2; Increased bicarbonate level c. Increased pH; increased PaO2; increased PaCO2; decreased bicarbonate level d. Decreased pH; decreased PaO2; decreased PaCO2; decreased bicarbonate level

a. Decreased pH; Decreased PaO2; Increased PaCO2; Increased bicarbonate level Hallmark changes in ABGs for long-term COPD is respiratory acidosis (increased arterial carbon dioxide [Paco2]); metabolic alkalosis (increased arterial bicarbonate) as compensation by kidney retention of bicarbonate (seen as an elevation of HCO3− although pH remains lower than normal); and lower-than-normal PaO2 from poor gas exchange.

Which action will the nurse teach a client with chronic bronchitis to use to mobilize secretions? a. Drinking at least 2 L of fluid daily b. Avoiding triggers that cause coughing c. Elevating the head of the bed 45 degrees d. Assuming the tripod position as often as possible

a. Drinking at least 2 L of fluid daily

What type of percussion note or sound will the nurse expect on the affected chest side of a client who has a hemothorax? a. Dull b. Hyperresonant c. Crackling d. Hypertympanic

a. Dull

For which symptom or problem will the nurse instruct a client who is being discharged after a modified uvulopalatopharyngoplasty (modUPPP) surgery to notify the surgeon immediately? (Select all that apply.) a. Fever b. Anorexia c. Pain only during swallowing d. Oozing of bright red blood where the uvula was removed e. Beefy red color of the soft palate f. Foul-smelling breath

a. Fever d. Oozing of bright red blood where the uvula was removed e. Beefy red color of the soft palate f. Foul-smelling breath

Which features will the nurse expect to be present in a client who has long-term chronic obstructive pulmonary disease? (Select all that apply.) a. Increased anteroposterior chest diameter from air-trapping b. Respiratory acidosis with a low pH c. Poor gas exchange from decreased alveolar surface area d. Increased eosinophil count e. Hypercapnia from retained PaCO2 f. Arterial blood gas value with increased PaO2 level

a. Increased anteroposterior chest diameter from air-trapping b. Respiratory acidosis with a low pH c. Poor gas exchange from decreased alveolar surface area e. Hypercapnia from retained PaCO2

What is the nurse's best first action when a client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused? a. Increasing the oxygen flow rate b. Documenting the observation as the only action c. Notifying the primary health care provider immediately d. Repositioning the client from a high-Fowler to a low-Fowler position

a. Increasing the oxygen flow rate Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client's condition, the best action is to first increase the oxygen flow rate and then notify the physician. Changing the client's position to less upright, would not improve gas exchange.

Which assessment findings in a client at high risk for pulmonary embolism (PE) indicates to the nurse the probably presence of a PE? (Select all that apply.) a. Inspiratory chest pain b. Dizziness and syncope c. Pink, frothy sputum d. Worsening dyspnea for 3 days e. Tachycardia f. Productive cough

a. Inspiratory chest pain b. Dizziness and syncope e. Tachycardia

Which action will the nurse teach an older client with a respiratory problem to make as an accommodation to promote adequate gas exchange? a. Notify your primary health care provider at the first sign of respiratory infection. b. If you must walk any distance in cool weather move quickly to keep warm. c. Replace at least one meal each day with a high-calorie liquid food supplement. d. Avoid any nonessential physical activity or exercise.

a. Notify your primary health care provider at the first sign of respiratory infection. A respiratory infection can become serious very quickly in an older client with a pre-existing respiratory problem and must be addressed as early as possible before complications occur.Older clients with respiratory problems are encouraged to perform low-impact exercises, such as walking, daily but should not rush through it. The client is taught to pace the exercise and stop and rest as often as needed. High-calorie liquid food drinks are meant to supplement meals, not replace them.

Which action is most important for the nurse to take when a client with chronic obstructive pulmonary disease who is taking a cholinergic antagonist now reports nausea, blurred vision, headache, and inability to sleep? a. Reporting the symptoms to the primary health care provider immediately b. Asking the client to explain the exact techniques he or she uses when taking the drug c. Requesting an order to draw blood to determine the drug level d. Reminding the client that these side effects are normal and not to worry

a. Reporting the symptoms to the primary health care provider immediately

Which change in the condition of a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen indicates to the nurse that an increase in the fraction of inspired oxygen (FiO2) may need to be increased? a. Restlessness has increased over the past hour. b. Client reports increased mouth dryness. c. Heart rate has decreased from 90 to 82 beats/min. d. Blood pressure has changed from 106/80 to 110/70.

a. Restlessness has increased over the past hour. The nurse needs to assess the client who has recently become restless for the need to increase this client's FiO2. This client may be exhibiting symptoms of hypoxemia including restlessness. Additional symptoms of hypoxemia include increased heart rate and blood pressure, oxygen desaturation, cyanosis, restlessness, and dysrhythmias.A heart rate decrease to 82 beats/min and not cause for alarm or a change in FiO2. The change in blood pressure is a positive indicator of reasonable perfusion and gas exchange. Mouth dryness is not an indicator of poor gas exchange and the need for more oxygen.

Which is the priority action for the nurse to take first after applying oxygen when caring for an older client admitted with symptoms of possible seasonal influenza accompanied by vomiting and high fever? a. Starting an IV line to begin hydration therapy b. Administering IM influenza vaccination c. Asking the client when symptoms began d. Placing the client in a negative air pressure room

a. Starting an IV line to begin hydration therapy

What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear? a. Suctioning the tracheostomy tube b. Remove the inner cannula of the tracheostomy c. Humidifying the oxygen source d. Increasing the percentage of oxygen

a. Suctioning the tracheostomy tube

Which adults will the nurse identify as having a higher risk for active tuberculosis? (Select all that apply.) a. Those who were treated previously for active tuberculosis b. Kidney transplant recipients c. Homeless adults d. Those who have received bacille Calmette-Guérin (BCG) vaccine e. Those in the local prison f. Recent immigrants to the United States

a. Those who were treated previously for active tuberculosis b. Kidney transplant recipients c. Homeless adults e. Those in the local prison f. Recent immigrants to the United States

Which questions are most relevant for the nurse to ask a client when assessing for risk factors and indications for head and neck cancer? (Select all that apply.) a. "When was the last time you saw your dentist?" b. "Do you have recurrent laryngitis or frequent episodes of sore throat?" c. "Have you had frequent episodes of acute or chronic visual problems?" d. "How many packs per day do you smoke and for how many years?" e. "Have you had a problem with sores in your mouth?" f. "How many servings per day of alcohol do you typically drink?

b. "Do you have recurrent laryngitis or frequent episodes of sore throat?" d. "How many packs per day do you smoke and for how many years?" e. "Have you had a problem with sores in your mouth?" f. "How many servings per day of alcohol do you typically drink?

With which client will the nurse take immediate actions to reduce the risk for developing a pulmonary embolism (PE)? a. A 50 year old with type 2 diabetes mellitus and cellulitis of the leg b. A 36 year old who had open reduction and internal fixation of the tibia c. A 25 year old receiving IV antibiotics through a peripheral line d. A 72 year old with dehydration and hypokalemia taking oral potassium supplements

b. A 36 year old who had open reduction and internal fixation of the tibia

The nurse has just received report on a group of clients. Which client is the nurse's first priority? a. A 60 year old who was recently extubated and reports a sore throat. b. A 50 year old being mechanically ventilated who has tracheal deviation. c. A 30 year old receiving continuous positive airway pressure (CPAP) and has intermittent wheezing. d. A 40 year old receiving oxygen facemask and whose respiratory rate is 24 breaths/min.

b. A 50 year old being mechanically ventilated who has tracheal deviation.

Which action will the nurse take first when caring for a client with pneumonia who has ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness? a. Administer oxygen to prevent hypoxemia and atelectasis. b. Administer the prescribed bronchodilator therapy to decrease bronchospasms. c. Encourage oral fluids to greater than 3000 mL/day to ensure adequate hydration. d. Maintain semi-Fowler position to facilitate breathing and prevent further fatigue.

b. Administer the prescribed bronchodilator therapy to decrease bronchospasms. Although all actions are helpful and important, bronchodilator therapy is performed first to increase the size of the airways to improve clearance.

Which action will the nurse take first when a client with obstructive sleep apnea (OSA) who has been using continuous positive airway pressure (CPAP) with a facemask, returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness? a. Reminding the client that sleep is important and to go ahead and take daytime naps b. Asking the client whether the mask fits tightly over the mouth and nose c. Encouraging the client to consider using over-the-counter sleep aids for deeper sleeping at night d. Suggesting that a nasal mask be used instead of a nose and mouth facemask

b. Asking the client whether the mask fits tightly over the mouth and nose

Which nursing action will the nurse take to prevent harm from disruption of oxygen therapy for the client receiving low-flow oxygen by simple facemask? a. Keeping a small cylinder of oxygen at client's bedside stand for emergency use in case the central oxygen delivery system fails b. Changing to a nasal cannula during meals c. Sealing the edges of the mask to the client's skin with a water-soluble lubricant. d. Ensuring that the flaps are closed over the exhalation ports

b. Changing to a nasal cannula during meals The facemask covers the client's mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes.Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients' bedsides for this potential emergency.

Which complication does the nurse suspect when a client with severe chronic obstructive pulmonary disease COPD has new-onset increased fatigue, dependent edema, neck vein distension, and oral cyanosis? a. Lung cancer b. Cor pulmonale c. Pneumonia d. Asthma

b. Cor pulmonale The client with long-term COPD develops higher pressures in pulmonary blood vessels making the right ventricle of the heart work harder to generate pressures that are high enough to perfuse the lungs. This persistent over-working of the right ventricle leads to right-sided heart failure that is not related to independent cardiac damage (cor pulmonale). This complication remains a constant risk for anyone with COPD.These symptoms are not related to asthma or pneumonia. Although some are also associated the lung cancer, they would appear slowly over time.

For which problem does the nurse assess the client who cannot breathe through the nose because of a severe septal deviation? a. Difficulty swallowing b. Dry respiratory tract membranes c. development of nasal polyps d. frequent episodes of tonsillitis

b. Dry respiratory tract membranes When inspired air passes through the nose, it is filtered, warmed, and humidified. When a person is unable to breathe through the nose because of an anatomical obstruction, he or she is at risk for excessive drying of the respiratory mucous membranes. This anatomical problem does not influence the development of tonsillitis or difficulty swallowing. Nasal polyps can contribute to nasal obstruction but is not caused by a septal deviation.

Which laboratory finding does the nurse expect in a client who has metastatic lung cancer and new-onset back pain? a. Hypernatremia b. Hypercalcemia c. Hyperglycemia d. Hyperkalemia

b. Hypercalcemia

Which best practice technique will the nurse use when suctioning a client's tracheostomy tube place earlier today? a. Applying suction only during insertion of the catheter b. Hyperoxygenating the client before and after suctioning c. Ensuring each suction pass lasts no longer 30 seconds d. Suctioning repeatedly until the secretions are is clear

b. Hyperoxygenating the client before and after suctioning

What is the nurse's first priority action to prevent harm when an 82-year-old client with pneumonia has become increasingly confused with an SpO2 change from 91% 1 hour ago to 88% now, and a respiratory rate that has increased from 26 to 32 breaths/min? a. Increasing the flow rate of the IV piggy-back antibiotic b. Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes c. Assisting the client to a more upright position d. Reporting the change in status to the client's primary health care provider

b. Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes

Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion? a. Assessing gums daily for indications of bleeding b. Monitoring the platelet count daily c. Assessing breath sounds d. Comparing pedal pulses bilaterally

b. Monitoring the platelet count daily

For which situation will the nurse take immediate action to prevent harm for a client with pneumonia who is receiving 100% oxygen via a nonrebreather mask? a. Sputum is now rust-colored. b. Oxygen reservoir deflates during inspiration. c. Crackles are present in the lung bases. d. Skin is pink and flushed.

b. Oxygen reservoir deflates during inspiration. The nurse takes action immediately if the reservoir bag is deflated. Suffocation can occur if the reservoir bag deflates, kinks, or if the oxygen source disconnects. The nurse needs to remove the device, refill the reservoir, and then reapply the mask.It is anticipated that the client's color is now pink. The client's color is expected to improve (from ashen or gray to pink) because of an increase in PaO2 level. Crackles in lung bases are an expected finding in a client with pneumonia, as is expectorating rust-colored sputum.

Which problem experienced by a man with late-stage lung cancer is the priority for immediate action by the nurse? a. Anorexia and weight loss b. Pain rating of 9 on a 0-10 scale c. Constipation for 2 days d. Extreme fatigue

b. Pain rating of 9 on a 0-10 scale

How will the nurse categorize the level of asthma control for a client who reports usually waking at night with wheezing once weekly and needing to use the prescribed reliever inhaler to stop the episode? a. Minimally controlled b. Partly controlled c. Controlled d. Uncontrolled

b. Partly controlled The client meets the criteria for partly controlled asthma, which are that any of these symptoms occur one to two times per week:Daytime symptoms of wheezing, dyspnea, coughingWaking from night sleep with symptoms of wheezing, dyspnea, coughingReliever (rescue) drug needed no more than twice weekly

Which complication of seasonal influenza will the nurse suspect in a 78-year-old client whose temperature remains elevated and now has new-onset confusion? a. Tuberculosis b. Pneumonia c. Emphysema d. Heart failure

b. Pneumonia

In addition to the pulmonary health care provider, which other member of the interprofessional team will the nurse expect to collaborate with most frequently when providing care to a client with a pulmonary embolism (PE)? a. Registered dietitian nutritionist b. Respiratory therapist c. Occupational therapist (OT) d. Pharmacist

b. Respiratory therapist

Which action will the nurse take to prevent harm from tracheal stenosis in a client after tracheostomy? a. Using commercial tube holders instead of standard tracheostomy ties b. Securing the tube in a midline position c. Assessing bilateral breath sound every 2 hours d. Ensuring maximum cuff pressure

b. Securing the tube in a midline position

Which action to prevent harm is has the highest priority for the nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy regimen? a. Be sure to drink at least 2 L of fluids daily. b. Take these drugs daily exactly as prescribed. c. Expect a change in urine color. d. Wear use sunscreen and wear protective clothing when you are out-of-doors.

b. Take these drugs daily exactly as prescribed.

For which symptoms would a nurse assess a client who worries a thoracentesis earlier today may have caused a pneumothorax? (Select all that apply.) a. slowing heart rate b. sensation of air hunger c. pain at insertion site d. Cyanosis of oral mucous membranes e. Wheezing on inhalation and exhalation f. Tracheal deviation

b. sensation of air hunger d. Cyanosis of oral mucous membranes f. Tracheal deviation Signs and symptoms of a pneumothorax include sensation of air hunger, tracheal deviation, and cyanosis. Other symptoms include pain on the affected side (not at the needle insertion site), rapid heart rate, rapid, shallow respirations, prominence of the affected side that does not move in and out with respiratory effort, and new onset of "nagging" cough. Wheezing is a bronchial and bronchiolar problem. It is not produced as a result of a pneumothorax.

Which statement made by a client scheduled for a total laryngectomy indicates to the nurse that further teaching about the procedure is needed? a. "It is hard to believe that I will never hear my own voice again." b. "I hope I can learn esophageal speech." c. "I will have to take special care not to aspirate while eating." d. "I won't be able to breathe through my nose anymore."

c. "I will have to take special care not to aspirate while eating." Aspiration cannot occur after a total laryngectomy because the airway is completely separated from the esophagus.The client will not be able to breathe through the nose. The client will be able to vocalize after working with a speech/language pathologist if he or she chooses; however, the voice will sound different than the client is used to. Esophageal or mechanical speech will permit the client to speak, but the voice will not sound like his or her own.

Which statement made by a client prescribed a reliever drug inhaler for asthma indicates to the nurse correct understanding of this therapy? a. "If I forget a dose, I will use the inhaler as soon as I remember it." b. "At night, I will be sure to store the inhaler in a cool, dry place." c. "I will keep this inhaler with me at all times." d. "Reliever drugs are needed to prevent asthma attacks."

c. "I will keep this inhaler with me at all times." reliever drug vs. controller drug

Which assessment finding in a client who has had a lobectomy and placement of a chest tube 8 hours ago requires immediate follow-up by the nurse? a. Report of pain at the chest tube insertion site b. 3-cm area of red drainage on the incisional dressing c. 200 mL red drainage from chest tube over 2 hours d. Client sleepy but able to be aroused

c. 200 mL red drainage from chest tube over 2 hours

The nurse has just received report on a group of clients. Which client is the nurse's first priority? a. A 62 year old with chronic obstructive pulmonary disease (COPD) being discharged with an oxygen saturation of 90% b. A 42 year old with lung cancer who needs an IV antibiotic administered before going to surgery c. A 22 year old with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min d. A 52 year old with end-stage pulmonary fibrosis and an oxygen saturation of 89%

c. A 22 year old with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min

The nurse has just received report on a group of clients. Which client is the nurse's first priority? a. A 40 year old admitted 3 hours ago for a scheduled thoracentesis in 30 minutes. b. A 55 year old with bronchogenic lung cancer who returned from bronchoscopy 4 hours ago. c. A 30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry. d. A 68 year old with pleural effusion who has decreased breath sounds at the right base.

c. A 30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry.

Which action is most important for a nurse to take to prevent complications for a client with a history of chronic obstructive pulmonary disease (COPD) is admitted for a surgical procedure that is unrelated to the respiratory system? a. Assessing the client's respiratory system every 8 hours b. Instructing the client to use a tissue when coughing or sneezing c. Monitoring for signs and symptoms of pneumonia d. Ensuring the client remains in bed for a full 24 hours after surgery

c. Monitoring for signs and symptoms of pneumonia

Which assessment has the highest priority for the nurse to make when caring for a client who had a tracheostomy placed yesterday? Which of these assessments is essential for the nurse to make? a. Examining the color and consistency of secretions b. Measuring the cuff pressure c. Observing for tachypnea d. Checking arterial blood gas values

c. Observing for tachypnea

Which behavior indicates to the nurse that a client preparing for discharge after surgery understands how to perform self-care to prevent harm from aspiration? a. Eats small frequent meals that include a variety of textures and nutrients. b. Uses a straw when drinking liquid nutrition supplements. c. Positions self upright before eating or drinking anything. d. Chooses thin liquids that cause coughing but knows to take small sips.

c. Positions self upright before eating or drinking anything.

How will the nurse expect a client's age-related decreased skeletal muscle strength to affect gas exchange? a. Reduced gas exchange as a result of decreased alveolar surface b. Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles c. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity d. Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue

c. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.

Which assessment finding is most important for the nurse caring for a client with laryngeal trauma to report immediately to health care provider to prevent harm? a. Productive cough b. Aphonia c. Stridor d. Hoarseness

c. Stridor Stridor, representing airway obstruction is the most critical sign/symptom exhibited by the client with laryngeal trauma and must be addressed immediately.

Which actions will the nurse take to reduce risk for aspiration for a client with a tracheostomy? (Select all that apply.) a. Inflating the tracheostomy cuff during meals b. Encouraging water with meals c. Teaching the client to "tuck" the chin down in the forward position to swallow d. Maintaining the client upright for 30 minutes after eating e. Encouraging frequent sipping from a cup f. Providing small, frequent meals

c. Teaching the client to "tuck" the chin down in the forward position to swallow d. Maintaining the client upright for 30 minutes after eating f. Providing small, frequent meals

What is the nurse's interpretation of a 50-year-old client's respiratory assessment findings when hearing bronchial breath sounds over the left lower lobe and noting decreased fremitus and dullness to percussion in the same area? a. Obstruction of the larger airways b. Normal physical exam for a 50 year old c. area of increased density d. Subcutaneous emphysema

c. area of increased density Peripheral bronchial breath sounds are abnormal and can indicate atelectasis, tumor, or pneumonia. Decreased fremitus and dullness to percussion may indicate pleural effusion, which is more dense than air.Bronchial breath sounds are normally heard only over the large airways in patients of any age, not in the periphery. An obstructed airway would have reduced bronchial breath sounds, and they would not be present in the periphery. Subcutaneous emphysema is a condition in which air is trapped within or beneath the skin. It is felt and heard as a "crackling" in the skin and subcutaneous tissues, not within any part of the respiratory tract.

When performing an assessment on an older client, which finding is most important for the nurse to assess further? a. soft speaking voice b. Slight kyphoscoliosis c. inability to state name and date of birth d. Need to rest after activity

c. inability to state name and date of birth

What is the nurse's best first action when finding that a client's skin flap created after laryngectomy now appears dusky in color? a. Massaging the flap site gently with the palms rather than the fingers b. Notifying the surgeon or the primary health care provider c. Applying moist heat over the flap site and surrounding tissue d. Assessing blood flow in the flap using a Doppler device

d. Assessing blood flow in the flap using a Doppler device

Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left-sided tension pneumothorax? a. Left chest caves in on inspiration and "puffs out" on expiration. b. The left lung field is dull to percussion and crackles are present on auscultation. c. The client has bloody sputum and wheezes. d. Chest is asymmetrical and trachea deviates toward the right side.

d. Chest is asymmetrical and trachea deviates toward the right side.

Which new assessment finding in a client being managed for a pulmonary embolism (PE) indicates to the nurse that the client's condition is worsening? a. Increasing temperature b. Abdominal cramping c. Hand tremors d. Distended neck veins in the high-Fowler position

d. Distended neck veins in the high-Fowler position

Which action is most appropriate for the nurse to take first when the water seal chamber of the chest drainage device in a client who had a lobectomy has small bubbles when the client coughs the appropriate action by the nurse? a. Add additional sterile water to the water seal chamber b. Checking the tubing for blood clots c. Briefly increasing the amount of suction d. Documenting the finding in the medical record

d. Documenting the finding in the medical record The nurse recognizes that gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. This indicates air is leaving the pleural space which is the intended purpose of the chest drain.Bubbling in the water seal chamber is absent if a kink or a blockage is present because air would not be able to escape from the chest cavity. Increasing the amount of suction without an order could damage lung tissue. There is no indication that the level of fluid in the water seal chamber is low.

Which order or prescription will the nurse perform first for a client admitted with pneumonia who is febrile and also agitated as a result of alcohol intoxication? a. Assessing the need for an immediate dose of lorazepam b. Requesting a referral to a social worker for alcohol counseling d. Drawing blood for aerobic and anaerobic blood cultures e. Administering intravenous antibiotics

d. Drawing blood for aerobic and anaerobic blood cultures

In addition to notifying the pulmonary health care provider, what is the most important action for the nurse to take first for a client with a pulmonary embolism (PE) whose arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and HCO3− 24 mEq/L (24 mmol/L)? a. Administering sodium bicarbonate b. Having the client breathe rapidly and deeply into a paper bag c. Assessing for the presence of adventitious lung sounds d. Increasing the oxygen flow rate

d. Increasing the oxygen flow rate

What is the nurse's best first action when the clear fluid draining from the nose of a client with a nasal fracture dries on a piece of filter paper and leaves a yellow "halo" ring at the dried edge of the fluid? a. Culture the sample. b. Elevate the head of the bed to 90 degrees. c. Document the finding as the only action. d. Notify the primary health care provider.

d. Notify the primary health care provider.

What is the priority action for the nurse to take when a client comes to the emergency department with extremely labored breathing and a history of asthma that is unresponsive to prescribed inhalers? a. Establishing IV access to give emergency medications. b. Asking the client how long he or she has had asthma and what triggered this attack c. Preparing the client for intubation d. Placing the client in a high-Fowler position, and starting oxygen

d. Placing the client in a high-Fowler position, and starting oxygen

What is the nurse's best first action on finding the client's oxygen saturation by pulse oximetry on the finger is 84%? a. Apply supplemental oxygen by mask or nasal cannula. b. Notify the Rapid Response Team immediately. c. Assess the client's cognitive function. d. Recheck the value on the forehead.

d. Recheck the value on the forehead. Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented.

Which point is most important to prevent harm for the nurse to teach a client with chronic obstructive pulmonary disease (COPD) who is being discharged on home oxygen? a. Correct performance when setting up the oxygen delivery system b. Understanding the signs and symptoms of hypoxemia c. Demonstrating how to use a pulse oximetry device d. Removing combustion hazards present in the home

d. Removing combustion hazards present in the home

What is the basis for the decreased oxygen saturation the nurse assesses in a client with a pulmonary embolism (PE)? a. Partial bronchial airway obstruction b. Thickened alveolar membranes and poor gas exchange c. Increased oxygen need resulting from a septic clot PE d. Shunting of deoxygenated blood to the left side of the heart

d. Shunting of deoxygenated blood to the left side of the heart

Which outcome indicates to the nurse that oxygen therapy for the client with chronic obstructive pulmonary disease (COPD) who has hypoxemia and hypercarbia is effective? a. PCO2 is within normal range. b. Finger clubbing has resolved. c. Client reports decreased distress. d. SpO2 is between 88% and 90%.

d. SpO2 is between 88% and 90%.

Which primary health care provider's instruction will the nurse question for a client being discharged with nasal packing in place after a posterior nosebleed? a. Sleep in a recliner or with the head in an elevated position. b. Go to the nearest emergency room if bleeding recurs. c. Use a home humidifier for at least 5 days. d. Take ibuprofen 800 mg every 8 hours as needed for pain.

d. Take ibuprofen 800 mg every 8 hours as needed for pain.

Which action is most important to teach a client living with progressing idiopathic pulmonary fibrosis? a. Maintaining an oral fluid intake of at least 2 L daily b. Taking oral temperature daily c. Using oxygen by nasal cannula whenever dyspnea is present d. Using energy conservation measures

d. Using energy conservation measures

How will the nurse document the client's respiratory assessment findings on auscultation that are heard as popping, discontinuous, high-pitched sounds at the end of exhalation? a. course crackles b. rhonchi c. wheezes d. fine crackles

d. fine crackles Fine crackles are heard as popping, discontinuous sounds that are high-pitched heard at the end of inhalation. Squeaky, musical continuous sounds heard when the client inhales and exhales are abnormal (adventitious) and described as wheezes. Coarse crackles are a rattling sound. Rhonchi are heard as low-pitched continuous snoring sounds.