PrepU 39
a
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed: a. 6 L/minute. b. 1 L/minute. c. 4 L/minute. d. 10 L/minute.
a
A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client? a. Nebulizer b. Dry powder inhaler c. Metered-dose inhaler with spacer d. Metered-dose inhaler without spacer
d
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? a. Crackles b. Bronchovesicular c. Bronchial d. Vesicular
c
The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly? a. small amount of subcutaneous air is detected at the site of tube insertion b. dressing is moist and intact c. respirations are at 20 breaths per minute d. drainage system is positioned slightly above chest level
d
The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? a. Tidal volume (TV) b. Total lung capacity (TLC) c. Forced Expiratory Volume (FEV) d. Residual Volume (RV)
b
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? a. an older adult client who has COPD b. a child who has pneumonia c. an adult who is receiving oxygen at home d. an adolescent who has asthma
d
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? a. Chest x-ray b. Bronchoscopy c. Skin tests d. Pulmonary function tests
b
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? a. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. b. Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. c. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. d. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
D
A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver? a. "Place your parent at the sink to allow teeth brushing and stand outside of the shower to help if needed." b. "Whichever position helps your parent feel most comfortable and will allow you to help with hygiene is fine." c. "A standing position works best to allow your parent to move around in the bathroom and to allow you to help your parent in and out of the shower." d. "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."
b
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? a. "An occasional cigarette will not hurt you." b. "You should never smoke when oxygen is in use." c. "I understand; I used to be a smoker also." d. "Oxygen is a flammable gas."
d
A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? a. "The chest tube cannot be moved." b. "You will need to use a bedpan while the chest tube is in position." c. "Let me get the unlicensed assistive personnel (UAP) for you." d. "I can assist you to the bathroom and back to bed."
c
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? a. Oxygen mask b. Nasal cannula c. Ambu bag d. Oxygen tent
d
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: a. croup. b. asthma. c. alcohol use. d. pneumonia.
b
A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants? a. Atelectasis b. Bronchitis c. Bronchiectasis d. Croup
a
A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: a. a bronchospasm. b. bronchitis. c. bronchiectasis. d. bronchiolitis.
b
During assessment of a 4-year-old client, the nurse notes a respiratory rate of 35 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next? a. Administer oxygen therapy b. Proceed with the assessment c. Notify the health care provider d. Obtain arterial blood sampling
c
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? a. Stridor b. Crackles c. Wheezing d. Absent breath sounds in lower lobes
a
The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate? a. Check the fit of the oxygen mask. b. Increase the flow of oxygen. c. Contact the oxygen supplier to request an oxygen tent. d. Discontinue oxygen therapy until the client is reassessed by the healthcare provider.
a
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? a. face tent b. simple mask c. nasal cannula d. tracheostomy collar
b
The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response? A. Page the respiratory therapist STAT. B. Maintain the client's oxygenation and alert the health care provider immediately. C. Cover the tracheostomy stoma and apply oxygen by nasal cannula D. Assess the client's respiratory status and check vital signs every 1 minute for the next hour.