NCLEX Pulmonary System
You're caring for a patient with pneumonia. The patient has just started treatment for pneumonia and is still experiencing hypoxemia. You know that respiratory acidosis is very common with patients with pneumonia. Which arterial blood gas readings below represent respiratory acidosis that is NOT compensated? A. pH 7.29, PaCO2 55, HCO3 23, PO2 85 B. pH 7.48, PaCO2 35, HCO3 22, PO2 85 C. pH 7.20, PaCO2 20, HCO3 28, PO2 85 D. pH 7.55, PaCO 63, HCO3 19, PO2 85
A. pH 7.29, PaCO2 55, HCO3 23, PO2 85
A 25 year-old female patient with pneumonia is prescribed Doxycycline. What question is important to ask the patient prior to administration of this medication? A. "Do you take birth control pills?" B. "Are you allergic to Penicillin?" C. "Are you allergic to eggs?" D. "Do you have a history of diabetes?"
A. "Do you take birth control pills?"
When helping a client with emphysema, the nurse employs several steps to teach pursed-lip breathing. Place these steps of the process in the correct sequence. 1. Purse lips as if to blow a whistle 2. Assume a sitting position with shoulders back 3. Take a deep, slow inspiration of air 4. Have client give a return demonstration without prompting by the nurse 5. Blow air through pursed lips for a time equal to or longer than inhalation
2. Assume a sitting position with shoulders back 3. Take a deep, slow inspiration of air 1. Purse lips as if to blow a whistle 5. Blow air through pursed lips for a time equal to or longer than inhalation 4. Have client give a return demonstration without prompting by the nurse
A client is admitted to the emergency department with dyspnea, a productive cough, and fever. The healthcare provider suspects pneumonia and writes prescriptions. Place the nursing actions in the order they should be performed. 1. Obtain a sputum culture. 2. Elevate the head of the bed. 3. Administer the prescribed intravenous piggyback antibiotic. 4. Review the results of the sensitivity test. 5. Insert a catheter to establish venous access.
2. Elevate the head of the bed. 5. Insert a catheter to establish venous access. 1. Obtain a sputum culture. 3. Administer the prescribed intravenous piggyback antibiotic. 4. Review the results of the sensitivity test.
The nurse in the postanesthesia care unit is caring for a client who had a left-sided pneumonectomy. Which goal is priority? A. Replace blood loss B. Maintain ventilatory exchange C. Maintain closed chest drainage D. Replace supplemental oxygenation
B. Maintain ventilatory exchange
The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding? A. Productive coughing B. Return of breath sounds C. Increased pleural drainage in the chamber D. Constant bubbling in the water-seal chamber
B. Return of breath sounds
The nurse is caring for a client who has a tracheostomy tube with a high-volume, low-pressure cuff. What does the cuff prevent? A. Leakage of air B. Lung infection C. Mucosal necrosis D. Tracheal secretion
C. Mucosal necrosis
A nurse instructs a client to breathe deeply to open collapsed alveoli. What is the best explanation the nurse could offer to explain the relationship between alveoli and improved oxygenation? A. The alveoli need oxygen to live. B. The alveoli have no direct effect on oxygenation. C. Collapsed alveoli increase oxygen demand. D. Oxygen is exchanged for carbon dioxide in the alveolar membrane.
D. Oxygen is exchanged for carbon dioxide in the alveolar membrane.
Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. What should the nurse instruct the client about the purpose of pursed-lip breathing? A. Decreases chest pain B. Conserves energy C. Increases oxygen saturation D. Promotes elimination of CO2
D. Promotes elimination of CO2
The nurse instructed a client with asthma about the use of a peak flow meter at home. The client assesses the peak expiratory flow by using the peak flow meter. Which action performed by the client would be appropriate when the reading is in the yellow zone? A. Perform the peak expiratory flow again immediately B. Increase the prescribed drug therapy C. Use a prescribed reliever drug therapy D. Reassess the asthma plan and change the controller medication
C. Use a prescribed reliever drug therapy
You are about to hang a bag of intravenous Vancomycin for a patient who has severe pneumonia. Which statement by the patient causes you to hold the bag of Vancomycin and notify the doctor immediately? A. "I'm seeing yellow halos around the light." B. "My mouth tastes like metal." C. "My head hurts." D. "I have this constant ringing in my ears."
D. "I have this constant ringing in my ears."
The nurse provides preoperative education to a client with extensive cancer of the upper right lobe of the lung who is scheduled for a lobectomy. The nurse concludes that the teaching was effective when the client makes which statement? A. "The healthcare provider is going to use a laser to destroy all of the cancer cells. I will have oxygen in place to help me breathe after the surgery." B. "I don't even need the lobe they are taking out. I still have three lobes in my left lung to help me breathe after the surgery." C. "I know that my entire right lung will be removed. I will have chest tubes to help with drainage after surgery." D. "The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery."
D. "The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery."
A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? A. Distended neck veins B. Paradoxical respirations C. Increasing amounts of purulent sputum D. Absence of breath sounds over the affected area
D. Absence of breath sounds over the affected area
A patient is being discharged home on Doxycyline for treatment of pneumonia. Which statement by the patient indicates they understood your education material? A. "I will wear sunscreen when outdoors." B. "I will avoid green leafy vegetables while taking this medication." C. "I will monitor my blood glucose regularly due to the side effects of hypoglycemia." D. "I will take this medication with a full glass of milk."
A. "I will wear sunscreen when outdoors."
A nurse witnesses a client collapse during a home care visit. Place the basic life support actions in the order they should be performed by the nurse. 1. Perform 30 chest compressions. 2. Listen and observe for spontaneous breaths. 3. Palpate to determine the presence of a carotid pulse. 4. Use physical and auditory stimulation to attempt to elicit a response. 5. Open the airway with the head tilt-chin lift method and give two breaths. 6. Direct the client's spouse to call the emergency management system.
4. Use physical and auditory stimulation to attempt to elicit a response. 6. Direct the client's spouse to call the emergency management system. 2. Listen and observe for spontaneous breaths. 3. Palpate to determine the presence of a carotid pulse. 1. Perform 30 chest compressions. 5. Open the airway with the head tilt-chin lift method and give two breaths.
A client with chronic bronchitis smokes one or two cigarettes a day and has not been performing the prescribed pulmonary physiotherapy exercises because they are too tiring. Which is the best response by the nurse? A. "Tell me about your typical day before the exercises were prescribed." B. "Smoking is probably the cause of the severity of your disease at this time." C. "I can't make you stop doing what you are doing, and it's your choice to be sick or well." D. "Your being so sick is probably because of your smoking and your choosing not to exercise."
A. "Tell me about your typical day before the exercises were prescribed."
During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response? A. "You seem concerned about your diagnosis." B. "You are feeling guilty about your smoking." C. "There have been advances in lung cancer therapy." D. "Trust your healthcare provider, who is very competent in treating cancer."
A. "You seem concerned about your diagnosis."
What is the normal value of functional residual capacity? A. 2.5 L B. 3.5 L C. 4.5 L D. 6.0 L
A. 2.5 L
Which of the following patients are MOST at risk for developing pneumonia? Select-all-that-apply: A. A 53 year old female recovering from abdominal surgery. B. A 69 year old patient who recently received the pneumococcal conjugate vaccine. C. A 42 year old male with COPD and is on continuous oxygen via nasal cannula. D. A 8 month old with RSV (respiratory syncytial virus) infection.
A. A 53 year old female recovering from abdominal surgery. C. A 42 year old male with COPD and is on continuous oxygen via nasal cannula. D. A 8 month old with RSV (respiratory syncytial virus) infection.
A nurse is suctioning a client's airway. Which nursing action will limit hypoxia? A. Apply suction only after catheter is inserted B. Limit suctioning with catheter to half a minute C. Lubricate the catheter with saline before insertion D. Use a sterile suction catheter for each suctioning episode
A. Apply suction only after catheter is inserted
A client enters the emergency department reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention? A. Assess vital signs. B. Insert a saline lock. C. Place client on oxygen. D. Draw blood for troponins.
A. Assess vital signs.
Which would the nurse consider to be a potential respiratory system-related complication of surgery? A. Atelectasis B. Hyperthermia C. Wound dehiscence D. Hypovolemic shock
A. Atelectasis
A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse concludes the client is experiencing? A. Bargaining B. Frustration C. Depression D. Rationalization
A. Bargaining
A client is admitted to the hospital for cancer of the larynx, and a laryngectomy is scheduled. What should the nurse include in the postoperative teaching plan? A. Importance of cleanliness around the site of the stoma B. Necessity of covering the tube opening while swimming C. Establishment of a regular schedule for suctioning the tube D. Usage of sterile technique when caring for the tracheostomy tube
A. Importance of cleanliness around the site of the stoma
After the removal of a cast from a fractured arm, an 82-year-old client is to receive physical therapy. In an older adult, how is mild exercise expected to affect respirations? A. Increase to 24 breaths per minute B. Become progressively more difficult C. Decrease in rate as their depth increases D. Become irregular but remain within normal rates
A. Increase to 24 breaths per minute
A patient is admitted with pneumonia. Sputum cultures show that the patient is infected with a gram positive bacterium. The patient is allergic to Penicillin. Which medication would the patient most likely be prescribed? A. Macrolide B. Cephalosporins C. Pencillin G D. Tamiflu
A. Macrolide
Select all the medications used to treat pneumonia that are narrow-spectrum? A. Macrolides B. Tamiflu C. Fluroquinolones D. Penicillins
A. Macrolides D. Penicillins
The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema? A. Palpate around the tube insertion sites for crepitus B. Auscultate the breath sounds for crackles and atelectasis C. Observe the client for the presence of a barrel-shaped chest D. Compare the length of inspiration with the length of expiration
A. Palpate around the tube insertion sites for crepitus
A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. What should a nurse do first? A. Raise the head of the bed. B. Apply oxygen. C. Assess breath sounds. D. Call the primary healthcare provider requesting a STAT chest x-ray.
A. Raise the head of the bed.
A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities? A. Remain with the client to assess responses. B. Allow family members to participate in the process. C. Permit the client more extended times alone for independence. D. Observe monitoring devices at the control panel of the ventilator.
A. Remain with the client to assess responses.
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care? A. The disease process and breathing exercises B. How to control or prevent respiratory infections C. Using aerosol therapy, especially nebulizers D. Priorities in carrying out everyday activities
A. The disease process and breathing exercises
The primary healthcare provider is preparing to instill medication into the pleural space via thoracentesis. Which interventions does the nurse consider to be appropriate when performing a thoracentesis? Select all that apply. A. Verify breath sounds. B. Encourage deep breaths. C. Observe for signs of pneumonia. D. Ensure a chest x-ray is performed after the procedure. E. Instruct the client to cough during the procedure.
A. Verify breath sounds. B. Encourage deep breaths. D. Ensure a chest x-ray is performed after the procedure.
A client is to continue oxygen therapy at home when discharged. Which client statement indicates the need for further instruction by the nurse? A. "I will use only grounded electrical equipment." B. "I have a new woolen blanket to keep me warm." C. "I have told my family they cannot smoke in the house." D. "I will keep a pitcher of water near me so I drink enough."
B. "I have a new woolen blanket to keep me warm."
You're providing discharge teaching to a patient who was admitted for pneumonia. You are discussing measures the patient can take to prevent pneumonia. Which of the following statements by the patient indicates they did NOT understand your education material? A. "I'll use hand sanitizer regularly while I'm out in public." B. "It is important I don't receive the Pneumovax vaccine since I'm already immune to pneumonia." C. "I will try to avoid large crowds of people during the peak of flu season." D. "It is important I try to quit smoking."
B. "It is important I don't receive the Pneumovax vaccine since I'm already immune to pneumonia."
A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse? A. "I will ask the primary healthcare provider to clarify the diagnostic procedure." B. "Tell me more about the conversation you had with your healthcare provider." C. "The procedure will be fast so that you will experience minimal discomfort." D. "Your perception of the diagnostic test is incorrect."
B. "Tell me more about the conversation you had with your healthcare provider."
A client is brought to the emergency department after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. What client reaction should cause a nurse the most concern? A. Ischemia B. Asphyxia C. Lactic acidosis D. Increased blood pressure
B. Asphyxia
A nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. What does the nurse conclude is the probable cause of the severe dyspnea? A. Abdominal distention or pressure B. Bronchial obstruction or pleural effusion C. Fluid retention as a result of renal failure D. Anxiety associated with pain on inspiration
B. Bronchial obstruction or pleural effusion
Which of the following are typical signs and symptoms of pneumonia? Select-all-that-apply: A. Stridor B. Coarse crackles C. Oxygen saturation less than 90% D. Non-productive, nagging cough E. Elevated white blood cells F. Low PCO2 of less than 35 G. Tachypnea
B. Coarse crackles C. Oxygen saturation less than 90% E. Elevated white blood cells G. Tachypnea
A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a history of systolic heart failure and arthritis. On assessment, you note the patient has a respiratory rate of 21, oxygen saturation 93% on 2L nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply: A. Keep head-of-the-bed less than 30 degrees at all times. B. Collect sputum cultures. C. Encourage 3L of fluids a day to keep secretions thin. D. Provide education about receiving the Pneumovax vaccine every 5 years.
B. Collect sputum cultures. D. Provide education about receiving the Pneumovax vaccine every 5 years.
Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? A. Cerebral palsy B. Cystic fibrosis C. Muscular dystrophy D. Multiple sclerosis
B. Cystic fibrosis
A patient is admitted with rupture of the Achilles tendon. The patient was recently treated with antibiotics for pneumonia. Which of the following medications below can cause this adverse effect? A. Penicillin B. Fluroquinolones C. Tetracyclines D. Macrolides
B. Fluroquinolones
A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client? A. Limiting hydration B. Improving ventilation C. Decreasing exogenous oxygen D. Correcting the bicarbonate deficit
B. Improving ventilation
Oxygen therapy is prescribed for a client being cared for in the coronary care unit. The nurse implements safety precautions. Which information should the nurse consider when planning care for this client? A. Oxygen is flammable. B. Oxygen supports combustion. C. Oxygen has unstable properties. D. Oxygen converts to an alternate form of matter.
B. Oxygen supports combustion.
What are the uses of pulmonary function tests (PFT)? Select all that apply. A. Pulmonary function tests (PFT) can detect lung cancer. B. Pulmonary function tests (PFT) can measure lung volume. C. Pulmonary function tests (PFT) can assess responses to bronchodilators. D. Pulmonary function tests (PFT) are performed on the pulmonary nodules. E. Pulmonary function tests (PFT) can diagnose pulmonary disease.
B. Pulmonary function tests (PFT) can measure lung volume. C. Pulmonary function tests (PFT) can assess responses to bronchodilators. E. Pulmonary function tests (PFT) can diagnose pulmonary disease.
An older client complains of confusion, dry mouth, and constipation. The client was treated for rhinitis a week ago and is taking chlorpheniramine. Which information provided by the nurse would be beneficial to the client? A. Chlorpheniramine needs to be stopped immediately. B. These are common side effects of chlorpheniramine. C. Hydroxyzine needs to be taken with chlorpheniramine. D. The chlorpheniramine prescription needs to be changed.
B. These are common side effects of chlorpheniramine.
While caring for a client with asthma, the nurse auscultates a bilateral high-pitched, continuous whistling sound in the anterior lung fields. What finding does the nurse document in the medical record? A. Crackles B. Wheezes C. Rhonchus D. Pleural friction rub
B. Wheezes
A patient was admitted to the intensive care unit 48 hours ago for treatment of a gunshot wound. The patient has recently developed a productive cough and a fever of 104.3 'F. The patient is breathing on their own and doesn't require mechanical ventilation. On assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with consolidation in the right lower lobe. Based on this specific patient scenario, this is known as what type of pneumonia? A. Aspiration pneumonia B. Ventilator acquired pneumonia C. Hospital-acquired pneumonia D. Community-acquired pneumonia
C. Hospital-acquired pneumonia
After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? A. "Lately I can only breathe well if I sit up." B. "During the night I sometimes get the chills." C. "I get a sharp, stabbing pain when I take a deep breath." D. "I'm coughing up larger amounts of thicker mucus for the last several days."
C. "I get a sharp, stabbing pain when I take a deep breath."
A client who had a total laryngectomy is using a pad and pencil to communicate. The client becomes frustrated and writes, "When can I learn how to speak again?" Which is the best response by the nurse? A. "Every client with a laryngectomy is different. It's difficult to say." B. "It must be difficult for you, but be patient. These things take time." C. "Perhaps I can have someone from the Laryngectomy Club come speak with you." D. "I can provide you with more information after your incision has had time to heal."
C. "Perhaps I can have someone from the Laryngectomy Club come speak with you."
A nurse identifies 12 mm of induration at the site of a Mantoux test when a client returns to the health office to have it read. Which explanation of this result should the nurse give to the client? A. Result is negative, and follow-up is not needed. B. The disease is active, and medication is required. C. Additional tests are needed, such as a chest x-ray. D. Outcome is inconclusive, and the test will be repeated in six weeks.
C. Additional tests are needed, such as a chest x-ray.
The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include? A. They are indicative of pleural rubbing. B. They are signs of bronchial constriction. C. Crackles are located in the smaller air passages. D. Crackles are heard during respiratory expiration.
C. Crackles are located in the smaller air passages.
A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? A. Report of pain when taking deep breaths B. Client is observed splinting the fracture site C. Diminished breath sounds on the affected side D. Bowel sounds are auscultated in the lower chest
C. Diminished breath sounds on the affected side
After a laryngectomy a client is concerned about improving the ability to communicate. Which topic should the nurse include in a teaching plan for the client? A. Sign language B. Body language C. Esophageal speech D. Computer-generated speech
C. Esophageal speech
A client who had surgery for a laryngectomy is returned to the surgical unit from the postanesthesia care unit. In which position is it most appropriate for the nurse to place the client at this time? A. Prone with the head turned to one side B. Supine with the knees flexed at 10 degrees C. Lateral with the head slightly elevated and flexed D. Supine with the head in a hyperextended position
C. Lateral with the head slightly elevated and flexed
A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do? A. Raise the drainage system to bed level and check its patency B. Clamp the tube when moving the client from the bed to a chair C. Mark the time and fluid level on the side of the drainage chamber D. Secure the chest catheter to the wound dressing with a sterile safety pin
C. Mark the time and fluid level on the side of the drainage chamber
The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? A. Respiratory alkalosis B. Poor oxygen perfusion C. Normal acid-base balance D. Compensated metabolic acidosis
C. Normal acid-base balance
A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what? A. Providing more oxygen to lung tissue B. Forcing pressure into lung tissue, which improves gas exchange C. Opening collapsed alveoli and keeping them open D. Opening collapsed bronchioles, which allows more oxygen to reach lung tissue
C. Opening collapsed alveoli and keeping them open
A client is experiencing dyspnea. In which position should the nurse place the client? A. Sims B. Supine C. Orthopneic D. Trendelenburg
C. Orthopneic
Which statement is true regarding the Hering-Breuer reflex? A. Increases tidal volume B. Decreases respiratory rate C. Prevents overdistension of the lungs D. Reduces the number of functional alveoli
C. Prevents overdistension of the lungs
After abdominal surgery a client should be encouraged to turn from side to side and to engage in deep breathing exercises. The nurse explains that these activities are essential to prevent which condition? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
C. Respiratory acidosis
You're educating a patient with pneumonia on how to deep breathe by using an incentive spirometer. Which of the following is the correct way to use this device? A. Encourage the patient to use it twice a day. B. The patient exhales into the device rapidly and then coughs. C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales. D. The patient rapidly inhales 10 times from the device and then exhales for 6 seconds.
C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales.
A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), what should the nurse do? A. Initiate pulmonary hygiene to clear air passages of trapped mucus B. Instruct to deep breathe slowly with inhalation longer than exhalation C. Encourage continuous rapid panting to promote respiratory exchange D. Administer oxygen at a low concentration to maintain respiratory drive
D. Administer oxygen at a low concentration to maintain respiratory drive
What breathing exercises should the nurse teach a client with the diagnosis of emphysema? A. An inhalation that is prolonged to promote gas exchange. B. Abdominal exercises to limit the use of accessory muscles. C. Sit-ups to help strengthen the accessory muscles of respiration. D. Diaphragmatic exercises to improve contraction of the diaphragm.
D. Diaphragmatic exercises to improve contraction of the diaphragm.
A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? A. Question the client about the confusion. B. Change the method of oxygen delivery. C. Percuss and vibrate the client's chest wall. D. Discontinue or decrease the oxygen flow rate.
D. Discontinue or decrease the oxygen flow rate.
Which chest examination findings can be observed in a client with pneumonia? A. Absent sounds on auscultation B. Hyperresonance on percussion C. Prolonged expiration on inspection D. Increased fremitus over affected area on palpation
D. Increased fremitus over affected area on palpation
A client presenting with an acute asthma attack is being assessed in the emergency room. The client's spouse reports that the client currently is being treated for an upper respiratory infection. The nurse should understand that the client most likely has which type of asthma? A. Allergic B. Emotional C. Extrinsic D. Intrinsic
D. Intrinsic
A nurse is teaching a preoperative client about postoperative breathing exercises. Which information should the nurse include? Select all that apply. A. Take short, frequent breaths B. Exhale with the mouth open wide C. Perform the exercises twice a day D. Place a hand on the abdomen while feeling it rise E. Hold the breath for several seconds at the height of inspiration
D. Place a hand on the abdomen while feeling it rise E. Hold the breath for several seconds at the height of inspiration
In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? A. Chest tube insertion B. Aggressive diuretic therapy C. Administration of beta-blockers D. Positive end-expiratory pressure (PEEP)
D. Positive end-expiratory pressure (PEEP)
A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? A. Obtain a new sterile drainage system. B. Use two clamps to close the drainage tube. C. Place the client in the high-Fowler position. D. Reconnect the client's tube to the drainage system.
D. Reconnect the client's tube to the drainage system.
A client is admitted to the emergency department with multiple injuries, including fractured ribs. Which assessment is priority? A. Pneumonitis B. Hematemesis C. Pulmonary edema D. Respiratory acidosis
D. Respiratory acidosis
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? A. Administer sedatives around the clock B. Turn client every four hours C. Increase ventilator settings as needed D. Suction as needed
D. Suction as needed
A nurse is caring for a client who had a bronchoscopy one hour ago. Which nursing action is most appropriate for assessing the return of the client's gag reflex? A. Ask the client to say several words. B. Give the client a small swallow of water. C. Stroke the anterior third of the client's tongue. D. Touch the client's pharynx with a tongue depressor.
D. Touch the client's pharynx with a tongue depressor.
