nclex resp

A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit?

Nasal obstruction

A nurse is assigned to care for a client after a left pneumonectomy. Which one of the follow positions would be contraindicated for this client?

On the side

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and has an arterial blood gas test done. Which of the following results would the nurse expect to note?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

A nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. The nurse is aware that this finding:

Requires further data collection

A nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse should monitor for which item as the best indicator of an adequate respiratory status?

Respiratory rate of 18 breaths per minute

A nurse is providing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation?

Shortness of breath

A nurse is monitoring a client following a motor vehicle accident. The nurse determines the need to prepare for chest tube insertion when the client exhibits:

Shortness of breath and tracheal deviation

A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position?

Right lateral

A nurse is assigned to assist in caring for a client with a chest tube drainage system. In planning for the client, the nurse makes certain that which of the following is available, in the event that the drainage system needs to be changed?

Rubber-shod clamps

A client with arthritis of the hands and fingers is having difficulty using a metered-dose inhaler (MDI). The nurse suggests to ask the health care provider for a prescription to use a(n):

Spacer

A nurse is gathering data on a client with a diagnosis of tuberculosis (TB). The nurse reviews the results of which diagnostic test that will confirm this diagnosis?

Sputum culture

A nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which of the following statements?

"I should use disposable plates, forks, and knives."

A client is admitted to the hospital with a diagnosis of pleurisy. The nurse checks the client for which characteristic symptom of this disorder?

Knifelike pain that worsens on inspiration

A client receiving parenteral nutrition through a central intravenous line is exhibiting signs and symptoms of an air embolism. The nurse immediately places the client in which position?

Left side in Trendelenburg's

A nursing student is caring for a hospitalized client with a diagnosis of lung cancer. The health care provider has prescribed a partial rebreathing face mask for the client, and the nursing instructor asks the student about its purpose. The student correctly responds by stating that:

"The device conserves oxygen by having the client rebreathe her own exhaled air."

A nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?

A man who is an inspector for the U.S. Postal Service

A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply.

50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

A nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub, which was auscultated the previous day. The nurse interprets that this is likely a result of:

Accumulation of pleural fluid in the inflamed area

The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Choose the instructions that the nurse will include on the list. Select all that apply.

Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary because family members have already been exposed. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags.

A nurse is told that an assigned client will have the chest tubes removed. In preparation for the procedure, the nurse plans to:

Administer pain medication 15 to 30 minutes before the procedure.

A tuberculin test (Mantoux test) is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse checks the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which of the following findings did the nurse note to make this interpretation?

An area of induration at the test site measuring 7 mm

A nurse is preparing to suction an adult client through the client's tracheostomy tube. Which intervention(s) would the nurse perform for this procedure? Select all that apply.

Apply suction for up to 10 to 15 seconds. 2. Hyperoxygenate the client before suctioning. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm.

A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when:

Aspiration of gastric contents occurs when suctioning.

A client arrives in the emergency department with a bloody nose. What is the initial nursing action?

Assist the client to a sitting position with the head tilted slightly forward.

A clinic nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. What intervention will the client be encouraged to perform?

Avoiding foods that are highly seasoned

A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage and expects to note that it is:

Bloody

A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes:

Breath sounds greater on the right than the left

A nurse in the emergency department is listening to the breath sounds of a client with respiratory distress and hears this sound. (Click on the sound button.)

Bronchitis

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. The nurse would first:

Check the client for spontaneous breathing.

A nurse evaluates the client following treatment for carbon monoxide poisoning. The nurse would document that the treatment has been successful when the:

Carboxyhemoglobin levels are less than 5%.

The nurse is caring for an older client who is on bedrest. The nurse plans which intervention to prevent respiratory complications?

Changing the client's position every 2 hours

A nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse would first:

Check for kinks in the chest drainage system.

A nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. The nurse would first:

Check the amount of suction pressure being applied.

A nurse is collecting subjective and objective assessment data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which of the findings?

Complaints of night sweats

A nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate?

Continue to monitor, because this is an expected finding.

A nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer?

Cough

A nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations are made?

Coughing occurs with suctioning.

A nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. The immediate nursing action is to:

Cover the insertion site with sterile Vaseline gauze.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could:

Decrease the client's oxygen-based respiratory drive.

A client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse suggests to the health care team that this client ultimately may need:

Directly observed therapy

A nurse has given the client with tuberculosis instructions for proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes which of the following?

Discard used tissues in a plastic bag.

A nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. What should the nurse do?

Discontinue suctioning until the client is stabilized and monitor vital signs.

A nurse is assisting a health care provider with the insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse plans to take which appropriate action?

Document the accurate functioning of the tube.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which one of the following would the nurse expect the client to experience?

Dyspnea

The nurse is collecting data on a client with chronic airflow limitation (CAL) and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of CAL?

Emphysema

A nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse prepares the client for the procedure, knowing that this type of tube:

Enables the client to speak

A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse plans to tell the client that this is:

Expected and the client should very gradually increase activity as tolerated

A nurse reads a client's Mantoux skin test as positive. The nurse notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse's response is based on the understanding that the client has:

Exposure to tuberculosis

A nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which of the following adverse signs and symptoms, indicating acute pulmonary edema?

Frothy sputum

A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flu-like symptoms. Which recommendation by the nurse is therapeutic? Select all that apply.

Get plenty of rest. Take antipyretics for fever. Increase intake of liquids.

A client presents to the urgent care center with epistaxis but no obvious facial injury. The nurse should take which action first?

Have the client sit down, lean forward, and apply pressure to the nose.

A nurse is preparing to obtain a sputum specimen from the client. Which nursing action will facilitate obtaining the specimen?

Have the client take three deep breaths.

A nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which action first?

Immerse the end of the tube in sterile saline.

A nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a PaO2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client?

Ineffective oxygen and carbon dioxide exchange

A nurse is preparing a client for the administration of a Mantoux skin test. The nurse determines that which body area is the appropriate area for injection of the medication? Select all that apply.

Inner aspect of the forearm Dorsal aspect of the upper arm Away from heavy pigmentation

A male client with chronic obstructive pulmonary disease (COPD) on bedrest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, what is the priority client activity for the nurse to incorporate in the plan of care?

Instruct the client to reposition himself.

A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated?

Lowering the head of the bed to a flat position

A nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which of the following items during periods of exposure to silica particles?

Mask

A nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. What should the nurse do?

Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.

A client with pneumonia is admitted to the hospital, and the health care provider writes prescriptions for the client. Which of the following prescriptions written by the health care provider would the nurse complete first?

Obtain a culture and sensitivity of sputum.

A nurse is reading the results of the Mantoux skin test for a client who has no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that the result is:

Negative

A nurse is caring for the client who is at risk for lung cancer because of an extremely long history of heavy cigarette smoking. The nurse tells the client to report which most frequent early symptom of lung cancer?

Nonproductive hacking cough

A client has a chest tube that is attached to a chest drainage system. The client asks the nurse, "Can the tube come out faster if you turn the wall suction up higher?" The nurse's response is based on the understanding that turning up the wall suction would:

Not increase the actual suction in the system but would cause more air to be pulled through the air vent and suction chamber to the suction source

A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site and next:

Notifies the registered nurse (RN)

A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse would:

Notify the registered nurse.

A nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse instructs the client to do which of the following during this process?

Perform Valsalva's maneuver.

A health care provider is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the health care provider asks the client to:

Perform the Valsalva maneuver.

A nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure?

Places the stethoscope on the client's gown

A nurse is assisting a client who underwent radical neck surgery to get out of bed. The nurse provides the support to the client, who is afraid to move the head by doing which of the following?

Placing a hand behind the client's head

A nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse tells the client that the primary purpose of pursed lip breathing is to:

Promote carbon dioxide elimination.

A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen test will be performed. In performing the Allen test, the nurse assists to occlude the:

Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery

A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse should do which of the following after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour?

Refrigerate the specimen.

A nurse is monitoring a client for bradypnea. Which is characteristic of this respiratory pattern?

Regular but abnormally slow

Which of the following identifies the route of transmission of tuberculosis (TB)?

The airborne route

A nurse is assessing the chest tube drainage system of a postoperative client who had a right upper lobectomy. The closed drainage system has 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water-seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water-seal chamber is now constant and the client appears dyspneic. Based on these findings, the nurse should first check:

The chest tube connections

A nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, the nurse determines that:

The chest tube is functioning as expected.

A nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly?

The client breathes out slowly through the mouth.

A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, what interpretation should the nurse make?

The client should be repeating the sequence 10 to 20 times in each session.

A client with tuberculosis (TB) asks a nurse about precautions to take after discharge from the hospital to prevent transmitting infection of others. The nurse develops a response to the client's question, based on the understanding that:

The disease is transmitted by droplet nuclei.

A client being discharged from the hospital to home with a diagnosis of tuberculosis (TB) is worried about the possibility of infecting the family and others. The nurse determines that the client would get the most reassurance from the knowledge that:

The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

A client reports the chronic use of nasal sprays. The nurse provides instructions to this client about which piece of information related to chronic use of nasal sprays?

The protective mechanism of the nose may be damaged

The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene?

The student suctions the client's tracheotomy tube for 15 seconds.

A nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse determines that:

The system is functioning as expected.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a Pleur-Evac drainage system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines that:

There is a leak in the system, which requires immediate investigation and correction.

A nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. The nurse determines that which of the following is occurring?

There is an air leak somewhere in the system.

A nurse is listening to the client's breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. The nurse interprets that this client has:

WHEEZES

A nurse is admitting a client to the nursing unit who is suspected of having tuberculosis (TB). The nurse plans to admit the client to a room that has:

Venting to the outside, six air exchanges per hour, and ultraviolet light

A nurse determines that which of the following clients is at greatest risk for development of acute respiratory distress syndrome (ARDS)?

A client with pancreatitis and gram-negative sepsis

A client who has laryngeal nodules is scheduled for outpatient surgery to have them removed. The nurse collects data on the client and expects the client to complain of which typical symptom associated with this condition?

Hoarseness

A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which of the following positions for the procedure?

Left side-lying with the head of the bed elevated 45 degrees

A client with tuberculosis is being started on antitubercular therapy with isoniazid (INH). The nurse reviews the client's health care record to be sure that which of the following baseline studies have been completed before giving the client the first dose?

Liver enzymes

The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds.

Opening of small airways that contain fluid

A nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse would incorporate which of the following as the best strategy to assist the client in coping with the disease?

Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

A nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB?

Residents of a long-term care facility

A nurse is assisting in caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse monitors the portable wound suction for which of the following types of drainage expected in the immediate postoperative period?

Serosanguineous

A nurse is providing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic periods. Which position will the nurse instruct the client to assume?

Sitting on the side of the bed, leaning on an overbed table

A nurse is reading the results of a Mantoux skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that the result is:

negative

A nurse is monitoring the respiratory status of a client who has suffered a fractured rib. The nurse monitors the client and understands that which manifestation is unrelated to the rib fracture?

slow deep resp

A nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the client's bed in which position to effectively perform this procedure? Refer to figure.

1

A nurse is discussing signs of severe airway obstruction with a group of nursing students. Which one of the following signs would the nurse emphasize is one that indicates severe airway obstruction?

Cyanosis