Respiratory NCLEX

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

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

Dyspnea on exertion Presence of a productive cough Difficulty breathing while talking

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

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

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

Obtain a culture and sensitivity of sputum.

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, which was auscultated the previous day. How should this finding be interpreted?

Pleural fluid has accumulated in the inflamed area

The nurse is admitting a client to the nursing unit who is suspected of having tuberculosis (TB). 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 listening to the client's breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. How should the nurse interpret these noises?

Wheezes

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 reinforcing discharge teaching with a client diagnosed with tuberculosis (TB) and has been on 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."

A nursing student prepares to instruct a client to expectorate a sample of sputum that will be sent to the laboratory for Gram stain, culture, and sensitivity and describes the procedure to the licensed practical nurse (LPN), who is the primary nurse. The LPN corrects the student if which incorrect description is provided?

"I will have the client take a shallow breath before coughing."

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

1

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? Refer to figure. View Figure

1

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

Dyspnea

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? Refer to figure.

1 (Semifowlers)

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 caring for a client with emphysema receiving oxygen. The nurse should check the oxygen flow rate to ensure the client does not exceed how many L/min of oxygen?

2

The 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. View Figure

2

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

Dyspnea

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

Hemoptysis A sensation of a "lump" in the throat Hoarseness lasting more than 3 weeks

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 should 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 clientt's chest An occlusive dressing is in place over the chest-tube insertion site Fluctuation of water in the tube of the the water-seal chamber during inhalation and exhalation

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

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

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

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

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

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

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

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

Be sure all connections remain airtight Be sure all connections are taped and secure Monitor closely for tubing that is kinked or obstructed by the weight of the client

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

Bilateral wheezing

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

Breath sounds are clear

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 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 hours

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 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 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

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

Cyanosis

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.

Early onset cough Purulent mucous production Mild episodes of dyspnea

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.

Early onset cough Purulent mucous production Mild episodes of 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 forms of CAL?

Emphysema

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which information about this type of tube?

Enables the client to speak

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

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

Frothy sputum

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

Hyperinflated lungs on chest x-ray

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 oxygen and carbon dioxide exchange

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?

Inspect of chest tube connections

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 which fact with regard to turning up the wall suction?

It 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 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 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 are caused by which?

Opening of small airways that contain fluid

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 are caused by which? Play Sound

Opening of small airways that contain fluid

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

In which area of the chest should the nurse expect to auscultate this breath sound? (Refer to audio.) Play Sound

Over the peripheral lung fields

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 should be used to monitor the client for crepitus?

Palpating for the leakage of air into the subcutaneous tissues

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 mmHg, Paco2 52 mmHg

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

Perform Valsalva's maneuver

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

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 mmHg and Pco2 of 50 mmHg

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 mmHg and Pco2 of 50 mmHg

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

The 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 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 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 what equipment is available, in the event that the drainage system needs to be changed?

Rubber-shod clamps

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 should the nurse instruct the client to assume?

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

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

Slow, deep respirations

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

Sputum culture

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

Stridor

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

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.

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

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 which action is taken?

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

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 should the nurse make?

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

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 should 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

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.

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

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 family members and others. Which information should 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 preparing to perform chest physiotherapy (CPT) on a client. Before determining the correct position in which to place the client, which information should the nurse ascertain?

The lung areas involved

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

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.

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, which requires immediate investigation and correction

The 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 this is indicative of which occurrence?

There is an air leak somewhere in the system

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

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

Tubular structure below trach

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 client with arthritis of the hands and fingers is having difficulty using a metered-dose inhaler (MDI). The nurse suggests asking the health care provider for which prescription?

Use of a spacer

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

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 mmHg, HCO3- of 36 mEq/L

The nurse is assisting in caring for a client with a tracheal 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

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

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

Assess the client.

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

Verify placement by a chest x-ray.

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.

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

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

A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse should perform which action?

Notify the registered nurse.

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

Notify the registered nurse.

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

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

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

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

Verify placement by a chest x-ray

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

Assess the client

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

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

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

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

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

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

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should 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

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should 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.

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 accurately indicates effectiveness of the treatments prescribed for this problem?

Arterial blood gases indicate a pH of 7.4, Po2 of 80 mmHg, and Pco2 of 40 mmHg

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.

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

Avoid 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. Which type of drainage is expected?

Bloody

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? Play Sound

Bronchial breath sounds

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 should 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 should the nurse implement?

Check the amount of suction pressure being applied

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

Check the amount of suction pressure being applied.

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

Complaints of night sweats

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, because this an expected finding

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, because this is an expected finding.

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

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 should the nurse implement?

Cover the insertion site with sterile Vaseline gauze

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 should the nurse implement?

Cover the insertion site with sterile Vaseline gauze.

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 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

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

Discontinue suctioning until the client is stabilized and monitor vital signs

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

Discourage smoking Use a room humidifier Use lozenges that contain a topical anesthetic agent

The nurse is assisting a health care provider with the insertion of a wet-suction 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 caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply.

Dyspnea on exertion Presence of a productive cough Difficulty breathing while talking

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

Expected and the client should very gradually increase activity as tolerated

A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike 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 enters the urgent care center with epistaxis but no obvious facial injury. The nurse should take which action?

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

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

Headache especially in the morning Elevated white blood cell (WBC) count Feeling of heaviness over affected areas

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 problem?

Hypotension

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 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

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 should the nurse do first?

Inspect chest tube connections

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 should the nurse do first?

Inspect chest tube connections.

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 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 to more than 2 L/min. The nurse responds that this would 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 should monitor the status of breath sounds in that area by placing the stethoscope in which location?

Just under the left clavicle

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

Lateral position

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?

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

The 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

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

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

The nurse is reading the results of a Mantoux tuberculin skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. Which interpretation should the nurse make of these results?

Negative

The nurse is reading the results of a tuberculin 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 the data as which result?

Negative

The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations?

Neurologic disorders

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 enough

A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse should perform which action?

Notify the registered nurse

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

Notify the registered nurse

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 should the nurse do next?

Notify the registered nurse (RN)

A client with pneumonia is admitted to the hospital, and the health care provider writes prescriptions for the client. Which prescription should 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 should the nurse plan to have at the bedside when the client returns from surgery?

Obturator

The 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 which positioning?

On the right side

The nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse should reinforce instructing the client to do which 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 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

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

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

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

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

Promote carbon dioxide elimination

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

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

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 should 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

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 should take which action after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour?

Refrigerate the specimen

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

The nurse is collecting data on a client with chronic sinusitis. The nurse interprets that which client sign/symptom is unrelated to this problem?

Severe evening headache

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 should 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 should the nurse implement?

Stop the suctioning procedure

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 should 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 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 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. The nurse analyzes this finding as indicative of which outcome?

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. How does the nurse interpret this finding?

The tube is patent

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

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

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

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

Immerse the end of the tube in sterile saline.

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.

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

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

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 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 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.

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.

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

Lorazepam (Ativan)

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

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.

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

Refrigerate the specimen.

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

Report the findings.

The 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 types of drainage expected in the immediate postoperative period?

Serosanguineous

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

Shortness of breath and tracheal deviation

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 should the nurse make?

The chest tube is functioning as expected.

The nurse reads a client's tuberculin 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 which statement is true for this client?

The client has been exposed to tuberculosis

The 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 outcome?

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. How does the nurse interpret this finding?

The tube is patent.

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 should 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