respiratory- Nclex 5th edition

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 assisting in preparing a list of instructions for an adult client who is being discharged following a tonsillectomy. Choose the instructions that the nurse should place on the list. Select all that apply.

-Avoid hot fluids. -Avoid rough foods. -Rest for the next 24 hours.

A nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator of the effectiveness of suctioning?

Breath sounds are now clear.

A nurse is collecting data from a client with pneumonia. Chest auscultation over areas of consolidation reveals this breath sound. (Click on the sound button.) <refer to audio> The nurse would interpret this breath sound to be which of the following?

Bronchial breath sounds

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.) <refer to audio> The nurse determines that this finding is characteristic of which disorder?

Bronchitis

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%.

A nurse should plan to fill which chamber of the chest drainage unit to prevent atmospheric air from re-entering the pleural space? Refer to figure.

2

A nurse is caring for a client with emphysema who is receiving oxygen. The nurse checks the oxygen flow rate to ensure that it does not exceed:

2 L/min

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 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 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 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 nurse is caring for a client who has bilateral vocal cord paralysis. The client begins to experience severe dyspnea; the nurse listens to the client's breath sounds and hears this sound. (Click on the sound button.) <refer to audio> What intervention should the nurse take immediately?

Notify the registered nurse.

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 preparing a plan of care for the 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 should avoid positioning this client:

On the right side

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 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 client arrives in the emergency department with an episode of status asthmaticus. The nurse first:

Places the client in high-Fowler's position

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 client with a respiratory disorder has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if the client:

Planned to eat the largest meal of the day at a time when hungry

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

Rest Local heat Analgesics

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 nurse is collecting data on a client with chronic sinusitis. The nurse interprets that which of the following client manifestations is unrelated to this problem?

Severe evening headache

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 respirations

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 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 nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse analyzes this finding as indicative of which of the following?

The system is functioning as expected.

A client has a closed-chest tube drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets that:

The tube is patent.

A nurse is reviewing the arterial blood gas results of an assigned client. Which of the following arterial blood gases indicates metabolic alkalosis?

pH of 7.48, PCO2 of 40 mm Hg, HCO of 36 mEq/L

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

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

Absence of breath sounds in the right upper lobe

A nurse is assisting in caring for a client with an endotracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause?

Accumulation of secretions in the client's lungs

Several clients arrive simultaneously to the emergency department, after sustaining burn injuries in a house fire. Which client will require the closest observation for signs of respiratory distress?

A client who has singed nasal hairs and worsening hoarseness

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

A hyperinflated chest on x-ray

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 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 client is at risk of developing a pulmonary embolism. The nurse monitors for which of the following, which commonly is reported initially?

Chest pain that occurs suddenly

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 determines that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs with suctioning

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 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 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.

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 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 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 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

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 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 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 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 cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The immediate nursing action is to:

Assess the client.

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

"I will need surgery to drain my sinuses."

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 nurse positions a client for a surgical procedure. Which position can likely lead to the potential for decreased lung expansion in the client?

Lithotomy

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 client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The appropriate nursing action would be to:

Notify the registered nurse.

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

Oral airway

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 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 client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which of the following should be instituted immediately by the nurse?

Droplet precautions

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

Dyspnea

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. -Hyperoxygenate the client before suctioning. -Apply intermittent suction while rotating and withdrawing the catheter. -Advance the catheter until resistance is met and then pull the catheter back 1 cm

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 nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides 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.Use diluted alcohol on the stoma to clean it. 5.Apply a thin layer of petroleum jelly to the skin surrounding the stoma.

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 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 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 client has had a set of arterial blood gases drawn. The results are pH 7.34, Paco2 of 37, Pao2 of 79, HCO of 19. The nurse interprets that the client is experiencing:

Metabolic acidosis

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

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

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

Petrolatum (Vaseline) gauze

A 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%. The nurse would:

Stop the suctioning procedure

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 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 noting the presence of:

Respiratory distress

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 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 interprets that:

The behavior is likely the result of hypoxia.

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 collecting data from a client who is experiencing the typical clinical manifestations of tuberculosis (TB). The nurse would expect the client to report having symptoms of fatigue and cough that have been present for

Several weeks to months

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

Instruct the client not to move the sensor.

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:

Just under the left clavicle

A client seeks treatment for a complaint of hoarseness that has lasted for 6 weeks. Based on this symptom, the nurse interprets that the client is at risk of having:

Laryngeal cancer

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 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 nurse is suctioning a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. The nurse should:

Stop the procedure and oxygenate the client.

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

A nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observation by the nurse is inconsistent with the need for suctioning?

Low peak inspiratory pressure on the ventilator

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 client is being prepared for a thoracentesis. The nurse assigned to care for the client assists the client to which of the following positions for the procedure?

Lying in bed on the unaffected side with the head of the bed elevated 45 degrees

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

PO2 of 60 mm Hg and PCO2 of 50 mm Hg

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 of the following results, which are consistent with this disorder?

Pao2 49 mm Hg, Paco2 52 mm Hg

A 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. The nurse would first:

Disconnect the suction source from the catheter.

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 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 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 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.

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 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:

Trauma

A nurse is assisting in admitting a client to the emergency department with suspected carbon monoxide poisoning. The nurse understands that which of the following manifestations is least reliable for determining the oxygenation status of this client?

skin color

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

stridor

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 of the following complications of this disorder?

Increased intracranial pressure

A nurse is preparing to perform chest physiotherapy (CPT) on a client. Before determining the correct position in which to place the client, the nurse must ascertain:

The lung areas involved

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

Use a picture or word board.

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

Ventilate the client with a resuscitation bag.

A nurse is assisting a health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan to ensure that which of the following is done as a final measure to determine correct tube placement?

Verify placement by a chest x-ray.

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

Bilateral wheezing

A nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further instruction about its use if the client says she must:

After maximal inspiration, hold the breath for 10 seconds and then exhale.

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.