NCLEX Respiratory Adult

The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder?

Arterial Pao2 of 48

A client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. The nurse determines that which data accurately indicate effectiveness of the treatments prescribed for this problem?

Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, and Pco2 of 40 mm Hg.

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which best action to ensure accurate readings on the oximeter?

Ask the client to limit motion in the hand attached to the pulse oximeter.

The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement?

"After maximal inspiration, I will hold my breath for 10 seconds and then exhale."

The 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 which occurs?

Aspiration of gastric contents occurs when suctioning.

The nurse is collecting data from a client with pneumonia. Chest auscultation over areas of consolidation reveals this breath sound. (Refer to audio.) The nurse should interpret this sound to be indicative of which breath sound?

Bronchial breath sounds

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding would be reported immediately to the primary health care provider (PHCP)?

Bronchospasm

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

Changing the client's position every 2 hours

The 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. Which would the nurse do first?

Check for kinks in the chest drainage system.

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action would the nurse implement?

Check the amount of suction pressure being applied.

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?

Check the client for spontaneous breathing.

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action?

Check the client.

The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when an alarm sounds. Which action would the nurse do first?

Check the client.

A client is at risk of developing a pulmonary embolism. The nurse monitors for which initial sign/symptom?

Chest pain that occurs suddenly

The nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection?

Chills and night sweats Rationale: The client with tuberculosis usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse would expect to note which finding?

Complaints of night sweats

A primary health care provider has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. The nurse reinforces instructions given to the client about the medication and tells the client to monitor for which side effect?

Constipation

The 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

The 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 Rationale: Cough is the most frequent early sign of lung cancer that begins as nonproductive and hacking and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs. Wheezing and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature.

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs with suctioning.

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

Coughing occurs with suctioning.

The 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. Which action would the nurse implement?

Cover the insertion site with sterile gauze.

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

Cyanosis

Which are signs and symptoms characteristic of emphysema? Select all that apply.

Cyanosis Weight loss Barrel chest Shortness of breath Decreased lung sounds

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially?

Determine the client's ability to follow verbal commands.

A client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation?

Directly observed therapy

The 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 frequent early symptom of lung cancer?

Nonproductive hacking cough

The nurse is caring for a restless client who keeps biting down on an orotracheal tube. The nurse uses which intervention to prevent the client from obstructing the airway with the teeth?

Oral airway

A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action?

Place the client in high-Fowler's position.

The 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

The 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 that was auscultated the previous day. How would this finding be interpreted?

Pleural fluid has accumulated in the inflamed area. Rationale:Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears.

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 results would the nurse expect to note?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which arterial blood gas supports this diagnosis?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

The nurse is instructing a client about pursed-lip breathing, and the client asks the nurse about its purpose. The nurse would tell the client that the primary purpose of pursed-lip breathing is which?

Promote carbon dioxide elimination

Cycloserine is added to the medication regimen for a client with tuberculosis. Which instruction would the nurse include in the client teaching plan regarding this medication?

Return to the clinic weekly for serum drug levels.

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

The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax?

Shortness of breath

The nurse is reinforcing 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

The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention?

Suction the client.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs would the nurse expect to note in the health record when collecting data related to the respiratory system for this client?

Wheezes and use of accessory muscles

The nurse is giving discharge instructions to the client concerning theophylline. Which client statement indicates a need for further teaching?

"I can keep on being the charcoal grill king and eat a lot of beef steak."

The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has been taking medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made?

"I should not be contagious after 2 to 3 weeks of medication therapy."

Which statement by the client indicates a need for further teaching regarding the reinforced home care instructions for acute sinusitis?

"I will need surgery to drain my sinuses."

The nurse is talking with a client who is going to have a radical neck dissection and total laryngectomy. Which client statement indicates a need for further teaching concerning postoperative management?

"I will require a lot of pain medication after surgery."

The nurse is caring for a client with fractured ribs. Which statement indicates a need for further teaching?

"My ribs will be healed in a month."

The nurse is assigned to assist in caring for a client diagnosed with a pneumothorax who has a chest tube connected to a closed-chest drainage system. The client asks the nurse why a chest tube was inserted. Which response by the nurse explains the purpose of a chest tube?

"To allow for reexpansion of the lung."

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points would be included in the instructions? Select all that apply.

1 The client leans over a bedside table. 2 The client should sit on the edge of the bed. 3 A time-out is performed before the procedure. 4 A local anesthetic is administered before the procedure.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which would the nurse expect to note in this client? Select all that apply.

1. Dyspnea during exertion 2. Presence of a productive cough 3. Difficulty breathing while talking

The 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.

1 50 mL of drainage in the drainage-collection chamber 2 The drainage system is maintained below the client's chest. 3 An occlusive dressing is in place over the chest-tube insertion site. 4 Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation Submit

The nurse is assisting in planning care for a client with a chest tube. The nurse would suggest including which interventions in the plan? Select all that apply.

1 Be sure all connections remain airtight. 2 Be sure all connections are taped and secure. 3 Monitor closely for tubing that is kinked or obstructed.

The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions would the nurse anticipate performing during this process? Select all that apply.

1 Cover the site with an occlusive dressing after the tube is removed. 2 Have the client perform the Valsalva maneuver as the chest tube is pulled out.

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply.

1 Enables the client to speak 2 Must have the cuff deflated when capped Rationale:A fenestrated tracheostomy tube is used when a client is being weaned from breathing through the tracheostomy to breathing normally through the nose and mouth. A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. The cuff of the tracheostomy tube must always be deflated before the fenestrated tube is capped.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions would the nurse take? Select all that apply.

1 Notify the RN 2 Discontinue suctioning until the client is stabilized.

The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis? Select all that apply.

1. Early onset cough 2. Purulent mucous production 3. Mild episodes of dyspnea Submit.

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. Which statements indicate prevention of transmission of tuberculosis? Select all that apply.

1. "My family and I will practice good hand hygiene." 2. "I will discard disposable tissues into a plastic bag." 3. "I will cover my mouth when I cough, sneeze, or laugh."

The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse reinforce? Select all that apply.

1. Activities should be resumed gradually. 2. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 3. Respiratory isolation is not necessary because family members have already been exposed. 4. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags.

A client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions would be done? Select all that apply.

1. Administer humidified oxygen. 2. Instruct on the use of the incentive spirometer. 3. Monitor vital signs and pulse oximetry frequently.

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

1. Apply suction for up to 10 seconds. 2. Hyperoxygenate the client before suctioning. 3. Apply intermittent suction while rotating and withdrawing the catheter. 4. Advance the catheter until resistance is met, and then pull the catheter back 1 cm.

The nurse is preparing to assist a primary health care provider with the insertion of a chest tube. The nurse anticipates that which supplies will be required for the chest tube insertion site? Select all that apply.

1. Elastoplast tape 2. Sterile 4 × 4 gauze pads 3. Povidone-iodine solution 4. Petrolatum (Vaseline) gauze Rationale:The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of sterile 4 × 4 gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. Povidone-iodine solution may be used to clean the insertion site before the insertion of the chest tube.

The nurse is assisting in preparing a list of instructions for a client who is being discharged following a tonsillectomy. Which instructions would the nurse include in the list? Select all that apply.

1. Avoid hot fluids. 2. Avoid rough foods. 3. Rest for the 24 hours.

The nurse is assigned to assist in caring for a client with a chest tube drainage system. Which interventions would the nurse implement? Select all that apply.

1. Check for subcutaneous emphysema. 2. Check to see that the chest tube drainage is fluctuating. 3. Maintain the chest tube drainage container below the client's chest.

A client at risk for pulmonary embolism (PE) suddenly develops respiratory distress, chest pain, and anxiety. The nurse would plan to take which actions? Select all that apply.

1. Check vital signs. 2. Notify the registered nurse. 3. Begin low-flow oxygen therapy.

Which diagnostic tests indicate active tuberculosis?

1. Chest x-ray 2. Gastric analysis washings 3. Sputum smear and culture Rationale: A diagnosis of active TB is established when the tubercle bacillus has been found in the sputum or gastric washings.

The nurse is caring for a client with laryngitis. Which interventions would the nurse implement? Select all that apply.

1. Discourage smoking. 2. Use a room humidifier. 3. Use lozenges that contain a topical anesthetic agent.

The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)?

A client with pancreatitis and gram-negative sepsis

A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. Which recommendations by the nurse are therapeutic? Select all that apply.

1. Get plenty of rest. 2. Take antipyretics for fever. 3. Increase intake of liquids.

The nurse is assessing a client diagnosed with sinusitis. Which are signs and symptoms of sinusitis? Select all that apply.

1. Headache, especially in the morning 2. Elevated white blood cell (WBC) count 5. Feeling of heaviness over affected areas

The nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms? Select all that apply.

1. Hemoptysis 2. A sensation of a "lump" in the throat 3. Hoarseness lasting more than 3 weeks Rationale: Hemoptysis, a sensation of a lump in the throat, and hoarseness lasting more than 3 weeks are common signs and symptoms of laryngeal cancer.

The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problems? Select all that apply.

1. Hypotension 2. Use of peripheral vasoconstrictors

The nurse is helping perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which would the nurse include for this type of data collection? Select all that apply.

1. Listening to lung sounds 2. Obtaining the client's temperature 3. Obtaining information about the client's respirations

The nurse is collecting data on a client with chronic sinusitis. Which are signs and symptoms of chronic sinusitis? Select all that apply.

1. Loss of smell 2. Chronic cough 3. Nasal stuffiness

A client is admitted to the emergency department with carbon monoxide poisoning. Which signs and symptoms indicate carbon monoxide poisoning? Select all that apply.

1. Mental changes 2. Cardiac irregularities 3. Cherry-red skin color

The nurse is collecting data from a client who is experiencing the typical signs/symptoms of tuberculosis (TB). Which are signs and symptoms of tuberculosis? Select all that apply.

1. Night sweats 2. Mucopurulent sputum 3. Afternoon low grade fever

The nurse is caring for a newly admitted client with pneumonia. The primary health care provider has prescribed a sputum specimen for culture and sensitivity. The nurse would perform the actions concerning the sputum collection in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

1. Obtain and label a sterile container. 2. Have the client brush teeth and rinse mouth with water. 3. Have the client take several deep breaths before coughing. 4. Have the client expectorate sputum (not saliva) into sterile container. 5. Send the specimen immediately to the laboratory. 6. Administer the prescribed antibiotics.

Which medications would the nurse expect to be prescribed to effectively reduce nasal edema and rhinorrhea (thin watery discharge from the nose)?

1. Oxymetazoline 2. Pseudoephedrine

The client is diagnosed with pleurisy. The nurse would expect to see which signs and symptoms? Select all that apply.

1. Pleural friction rub 2. Sharp, knife-like pain 3. Pain that occurs most often during inspiration

Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply.

1. Position on the side until fully recovered 2. Encouraging coughing and deep breathing 3. Monitoring pulse oximetry readings frequently 4. Encouraging the use of an incentive spirometer.

The nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Which instructions would the nurse provide to the client? Select all that apply.

1. Protect the stoma from water. 2. Soaps should be avoided near the stoma. 3. Wash the stoma daily using a washcloth. 4. Apply a thin layer of petroleum jelly to the skin surrounding the stoma.

The nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention would be included? Select all that apply.

1. Rest 2. Local heat 3. Analgesics

The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observations are consistent with the need for suctioning? Select all that apply.

1. Restlessness 2. Gurgling sounds with respiration 3. Presence of congestion in the lungs 4. Increased pulse and respiratory rates.

The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter?

10 seconds

The nurse is preparing to perform chest physiotherapy (CPT) on a client. In performing postural drainage, which statement is incorrect?

Breathe in a fast-paced pattern.

The nurse is caring for a client with emphysema receiving oxygen. The nurse would consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen?

2 L/min

The 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

The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client?

Abdominal distention

A client has undergone fluoroscopy-assisted aspiration biopsy of a lung lesion. The nurse determines that the client is experiencing complications from the procedure if the nurse makes which observation?

Absence of breath sounds in the right upper lobe

The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure?

Administer pain medication 15 to 30 minutes before the procedure.

A client arrives in the emergency department with a bloody nose. Which 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. Which intervention would the client be encouraged to perform?

Avoid foods that are highly seasoned.

The nurse is assessing a client who has frequent episodes of asthma. Which assessment finding is most closely associated with asthma?

Bilateral wheezing

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. Which type of drainage is expected?

Bloody

The nurse has finished suctioning a client. The nurse would use which parameters to best determine the effectiveness of suctioning?

Breath sounds are clear

The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator that suctioning has been effective?

Breath sounds are now clear.

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 which sign/symptom?

Breath sounds greater on the right than the left

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?

Disconnect the suction source from the catheter.

A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which manifestation of histoplasmosis?

Dyspnea

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom would the nurse expect the client to experience?

Dyspnea

The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis?

High-grade fever

The nurse in the emergency department has just assumed care from emergency medical services for a client that has a large penetrating stab wound. A chest x-ray has determined the diagnosis of hemothorax. Which initial action would the nurse take?

Ensure a patent airway

The nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which intervention is important to ensure accurate monitoring of the client's oxygenation status?

Instruct the client not to move the sensor.

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation?

Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out.

A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse would provide which explanation for these symptoms?

Expected, and the client should very gradually increase activity as tolerated

The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse sign/symptom indicating acute pulmonary edema?

Frothy sputum

A client enters the urgent care center with epistaxis but no obvious facial injury. The nurse would take which action?

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

The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining a proper specimen?

Have the client take three deep breaths.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which would the nurse expect to note?

Hyperinflated lungs on chest x-ray

A client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. In addition to respiratory failure, the nurse plans to monitor the client for which complication of this disorder?

Increased intracranial pressure

The nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse would assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate

The 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 gas exchange

The nurse is checking 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 data collection, the nurse notes that the bubbling in the water-seal chamber is now constant, and the client appears dyspneic. Based on these findings, which action would the nurse do first?

Inspect chest tube connections.

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

Instruct the client to reposition himself.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased. The nurse explains that this can be harmful because it could cause which difficulty?

It could decrease the client's oxygen-based respiratory drive.

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope in which location?

Just under the left clavicle

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position because it will aggravate breathing?

Lying on his or her back in low-Fowler's position

While assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder?

Knifelike pain that worsens on inspiration

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?

Lateral position

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 position for the procedure?

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

A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the primary health care provider whether this process would be delayed temporarily based on administration of which medication to the client in the last hour?

Lorazepam

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

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

Mask

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action would the nurse take?

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

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

The 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. After immediately applying sterile gauze over the chest tube insertion site, which would the nurse do next?

Notify 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 perform which action?

Notify the registered nurse.

A client who has just suffered a flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action?

Notify the registered nurse.

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

Obtain a culture and sensitivity of sputum.

The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment would the nurse plan to have at the bedside when the client returns from surgery?

Obturator

The nurse is preparing a plan of care for a client who will be returning from surgery following a right lung wedge resection. Included in the plan of care is that in the postoperative period, the nurse would avoid which positioning?

On the right side

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. (Refer to audio.) The nurse determines that these breath sounds usually result from which cause?

Opening of small airways that contain fluid

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method would be used to monitor the client for crepitus?

Palpating the skin around the chest and neck for a crackling sensation

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which results that are consistent with this disorder?

Pao2 49 mm Hg, Paco2 52 mm Hg

A primary 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 primary health care provider asks the client to do which action?

Perform the Valsalva maneuver.

A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect?

Peripheral neuritis

The 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 action 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 client has a chest tube that is attached to a chest drainage system. The chest tube becomes disconnected. What would the nurse do immediately?

Put open end under sterile water.

The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. Which nursing action would be immediate?

Reattach the chest tube to the drainage system.

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

Refrigerate the specimen. Rationale: Refrigeration will stabilize the culture and prevent the growth of additional bacteria.

A client has just returned from intrathoracic surgery where a chest tube was placed. The nurse notes a small amount of serosanguineous drainage on the chest tube's dressing. Which action would the nurse take?

Reinforce the dressing.

A licensed practical nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. Which action should the nurse take?

Report the client's symptoms to the registered nurse (RN).

The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority?

Report the findings.

The 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

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?

Respiratory distress

The 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 would monitor for which item as the best indicator of an adequate respiratory status?

Respiratory rate of 18 breaths per minute

The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement?

Shortness of breath and tracheal deviation Rationale:Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from decreased area available for diffusion of gases

The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position would the nurse instruct the client to assume?

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

The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse would review the results of which diagnostic test to confirm this diagnosis?

Sputum culture

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which would be the nurse's next action?

Stop the procedure and oxygenate the client.

The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action would the nurse implement?

Stop the suctioning procedure.

The nurse is assisting in caring for a client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client would be reported immediately to the registered nurse (RN)?

Stridor

A client with respiratory congestion is scheduled to receive acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer. The nurse checks the client's room to ensure that which equipment is available for use following administration of this medication?

Suction equipment

A postoperative client has received a dose of naloxone for respiratory depression. The nurse anticipates that the client will have which additional effect from the administration of this medication?

Sudden increase in pain

The nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse uses this data to make which interpretation?

The behavior is likely the result of hypoxia.

The 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, which conclusion would the nurse make?

The chest tube is functioning as expected.

The 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.

The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client?

The client is breathing through the nose.

The 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?

The client is placed in the Fowler's position for nasotracheal suctioning. This position promotes lung expansion and is also the preferred position for eating and nasogastric tube insertion.

A client with chronic obstructive pulmonary disease has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if which action is taken?

The client plans to eat the largest meal of the day at a time when hungry.

A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?

Use a picture or word board.

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, which interpretation would the nurse make?

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

The nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique?

The client's exhalation is twice as long as inhalation. Rationale:Prolonging the time for exhaling reduces air trapping because of airway narrowing or collapse in chronic obstructive pulmonary disease. Tightening the abdominal muscles aids in expelling air. Exhaling through pursed lips increases the intraluminal pressure and prevents the airway from collapsing.

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information would reassure the client that contaminating family members and others is not likely?

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

The nurse is assisting a client who underwent radical neck surgery to get out of bed. How does the nurse provide support to this client who is afraid to move the head?

The nurse places a hand behind the client's head.

The 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. Which statement represents the nurse's accurate interpretation of this finding?

This finding requires further data collection.

A client reports the chronic use of nasal sprays. The nurse reinforces 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.

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination?

The system is functioning as expected.

A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. Which finding does this indicate?

The tube may be occluded.

The nurse is collecting respiratory data from an adult client and is auscultating for normal breath sounds. The nurse would expect to hear bronchial breath sounds in which anatomical area?

There are three types of normal breath sounds in the adult and older child. These include bronchial (sometimes called "tracheal" or "tubular"), bronchovesicular, and vesicular sounds. Bronchial breath sounds are heard over the trachea and larynx. Bronchovesicular breath sounds are heard over the major bronchi. Vesicular breath sounds are heard over peripheral lung fields where the air enters the alveoli.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which?

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

A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason?

To expel mucus from the airways

The nurse would plan to fill which chamber of the chest drainage unit to prevent atmospheric air from reentering the pleural space?

To prevent atmospheric air from reentering the client's pleural space, the nurse needs to fill the water seal chamber to the level prescribed by the manufacturer, usually 2 cm. This is the minimum amount of fluid needed to prevent atmospheric air from reentering the pleural space.

The licensed practical nurse (LPN) in the emergency department is caring for a client who was assaulted and sustained blunt force injuries to the chest and abdomen. Which priority client data would the LPN immediately report to the registered nurse (RN)?

Tracheal deviation to the left

A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which sign or symptom observed by the nurse clearly indicates that the pneumothorax is rapidly worsening?

Tracheal deviation to the right

A client experiencing a pleural effusion had a thoracentesis. Analysis of the extracted fluid revealed a high red blood cell count. The nurse interprets that this result is consistent with which diagnosis?

Trauma

The primary health care provider has prescribed amantadine for a client admitted to the hospital for hip replacement surgery. The nurse recognizes that this medication was prescribed because the client's history showed recent exposure to which?

Type A influenza

The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action would the nurse take?

Ventilate the client manually.

The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. Which would be the next immediate nursing action?

Ventilate the client with a resuscitation bag.

The nurse is assisting in admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse plans to admit the client to which type of room?

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

The nurse is assisting a primary health care provider with the insertion of an endotracheal tube (ETT). The nurse would plan which as a final measure to determine correct tube placement?

Verify placement by a chest x-ray.

The nurse is listening to the client's breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. How would the nurse interpret these noises?

Wheezes

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?

pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L