Respiratory System
An older adult comes for an annual physical and tells the nurse, "I had three respiratory infections last year. How can I prevent this from happening again?" What is the nurse's best response? 1."Stay away from preschool and school-age children." 2."Avoid putting your hands near your nose and mouth." 3."Wear a sweater under your coat when going outside in cold weather." 4."Take an aspirin when you think you may be coming down with a cold."
2."Avoid putting your hands near your nose and mouth."
A client with tuberculosis asks the nurse how long treatment will be continued. The nurse's most accurate reply is: 1.One to 2 weeks 2.Four to 5 months 3.6 to 12 months 4.Three years or longer
3. 6 to 12 months
A client with cancer of the lung says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse conclude the client is in? 1.Bargaining 2.Frustration 3.Depression 4.Rationalization
1.Bargaining
A client with a history of closed-angle glaucoma is scheduled for abdominal surgery. Because the client is extremely anxious, surgery is to be performed under general anesthesia. What should the nurse teach the client to do to prevent respiratory complications postoperatively? 1.Deep-breathing techniques 2.Performing productive coughing 3.Turning from side to side frequently 4.Pant breathing while gently closing the eyelids
1.Deep-breathing techniques
After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? 1.Pink 2.Clear 3.Green 4.Yellow
1.Pink
A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, the nurse should: 1.Provide a means for the client to write. 2.Allow the client more time for articulation. 3.Use visual clues, such as gestures and objects. 4.Face the client and speak slowly and distinctly
1.Provide a means for the client to write.
Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? 1.Apply a thoracic binder for support. 2.Encourage coughing and deep breathing. 3.Defer pain medication the first day after injury. 4.Position the client face-down on a soft mattress
2.Encourage coughing and deep breathing.
A nurse is caring for a client who had an open abdominal cholecystectomy because of biliary colic. Which nursing action is most important during the postoperative period? 1.Maintaining T-tube drainage 2.Ensuring a pain-free experience 3.Encouraging coughing and deep breathing 4.Providing a heating pad for shoulder pain for 15 minutes hourly
3.Encouraging coughing and deep breathing
The nurse provides discharge teaching to a client with tuberculosis and reinforces that the treatment measure with the highest priority is: 1.Getting sufficient rest 2.Getting plenty of fresh air 3.Changing the current lifestyle 4.Consistently taking prescribed medication
4.Consistently taking prescribed medication
A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is: 1.Spasm of the bronchi that traps the air 2.Increase in the vital capacity of the lungs 3.Too rapid expulsion of the air from the alveoli 4.Difficulty in expelling the air trapped in the alveoli
4.Difficulty in expelling the air trapped in the alveoli
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? 1.Productive cough 2.Clubbing of the fingertips 3.Crackles at the height of inhalation 4.Diminished breath sounds on auscultation
4.Diminished breath sounds on auscultation
A client with a 30-year history of smoking has several episodes of blood in the sputum. A bronchoscopy with a lung biopsy is performed. After the procedure, the most important nursing intervention is to: 1.Assess for signs of hemoptysis 2.Have the client rest in the supine position 3.Check the client's level of consciousness frequently 4.Ensure nothing by mouth (NPO) until the gag reflex returns
4.Ensure nothing by mouth (NPO) until the gag reflex returns
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's blood studies indicate pH 7.30, Po2 60 mm Hg, Pco2 55 mm Hg, and HCO3 23 mEq/L. The nurse concludes that the client is experiencing: 1.Hypocapnia 2.Hyperkalemia 3.Generalized anemia 4.Respiratory acidosis
4.Respiratory acidosis
What should the nurse include in the plan of care for a client who just had a total laryngectomy? 1.Instructing the client to whisper 2.Removing the outer tracheostomy tube as needed 3.Placing the client in the orthopneic position 4.Suctioning the tracheostomy tube whenever necessary
4.Suctioning the tracheostomy tube whenever necessary
A client with chronic bronchitis smokes one or two cigarettes a day and has not been performing the prescribed pulmonary physiotherapy exercises because they are too tiring. What is the best response by the nurse? 1."Tell me about your typical day before the exercises were prescribed." 2."Smoking is probably the cause of the severity of your disease at this time." 3."Your being so sick is probably because of your smoking, and your choosing not to exercise." 4."I can't make you stop doing what you are doing, and it's your choice to be sick or well."
1."Tell me about your typical day before the exercises were prescribed."
A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished? 1.Assess the person's breathing 2.Offer the person sips of water 3.Cover the person with a warm blanket 4.Calculate the extent of the person's burns
1.Assess the person's breathing
A nurse provides smoking cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client states: 1."I'll just finish the carton that I have at home." 2."I'll cut back to a half pack a day." 3."I find that smoking is the only way I can relax." 4."I should find this easy because I don't smoke when I drink."
2."I'll cut back to a half pack a day."
A graduate nurse reminds a client who just had a laryngoscopy not to take anything by mouth until instructed to do so. What conclusion should be made about this intervention by the nurse preceptor who is evaluating the performance of the graduate nurse? 1.Appropriate, because such clients usually experience painful swallowing for several days 2.Appropriate, because early eating or drinking after such a procedure may cause aspiration 3.Inappropriate, because the client is likely to be anxious and it is easier to remove the water pitcher 4.Inappropriate, because the client is conscious and may be thirsty after not being allowed to drink fluids
2.Appropriate, because early eating or drinking after such a procedure may cause aspiration
After thoracic surgery a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, the nurse should: 1.Strip the chest tube catheter 2.Check the system for air leaks 3.Decrease the amount of suction pressure 4.Recognize that the system is functioning correctly
2.Check the system for air leaks
A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client's response to this injury? 1.Level of pain 2.Quality and depth of respirations 3.Amount of serosanguineous drainage 4.Blood pressure and pupillary response
2.Quality and depth of respirations
A client newly diagnosed with tuberculosis has a productive cough. The most appropriate nursing intervention is to teach the client to: 1.Exercise daily 2.Use disposable tissues 3.Avoid foods high in sodium 4.Monitor blood pressure weekly
2.Use disposable tissues
A client with a diagnosis of tuberculosis is receiving isoniazid (INH) as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response? 1.Orange feces 2.Yellow sclera 3.Temperature of 96.8° F 4.Weight gain of 5 pounds
2.Yellow sclera
Before signing a consent form for a total laryngectomy, a client asks, "Because part of my throat will be taken out and I will breathe through a hole in my neck, will I be able to talk like I did before I had the surgery?" Which is the nurse's best response? 1."There are many clients that have had this operation. You'll talk again." 2."That's a good question. I'll have the health care provider talk with you." 3."You seem very concerned. Tell me what you know about your surgery." 4."Not like before but there is nothing to worry about. We do a lot of these surgeries."
3."You seem very concerned. Tell me what you know about your surgery."
A nurse teaches a client how to perform diaphragmatic breathing. The nurse advises the client to: 1.Take rapid, deep breaths 2.Breathe with hands on the hips 3.Expand the abdomen on inhalation 4.Perform exercises leaning forward while in a sitting position
3.Expand the abdomen on inhalation
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. The priority nursing assessments are: 1.Level of consciousness and pupil size 2.Characteristics of pain and blood pressure 3.Quality of respirations and presence of pulses 4.Observation of abdominal contusions and other wounds
3.Quality of respirations and presence of pulses
When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider? 1.Substernal chest pain 2.Episodes of palpitation 3.Severe shortness of breath 4.Dizziness when standing up
3.Severe shortness of breath
A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a total laryngectomy is scheduled. Which nursing action is most important in the immediate postoperative management of this client? 1.Instructing the client to whisper 2.Placing the client in the orthopneic position 3.Suctioning the tracheostomy tube whenever necessary 4.Changing the outer tracheostomy tube at least once a day
3.Suctioning the tracheostomy tube whenever necessary
A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. What precautions should the nurse take? 1.Put on a gown when entering the room. 2.Place the client with another client who has TB. 3.Wear a particulate respirator when caring for the client. 4.Don a surgical mask with a face shield when entering the room
3.Wear a particulate respirator when caring for the client.
A client with a history of pulmonary emboli is taking warfarin (Coumadin) daily. The nurse teaches the client about foods that are appropriate to consume when taking this medication. The nurse evaluates that the client needs further teaching when the client states: 1."Eggs provide a good source of iron, which is needed to prevent anemia." 2."Yellow vegetables are high in vitamin A and should be included in the diet." 3."Milk and other high-calcium dairy products are necessary to counteract bone density loss." 4."Dark green leafy vegetables are high in vitamin K and should be eaten to prevent clotting.
4."Dark green leafy vegetables are high in vitamin K and should be eaten to prevent clotting.
A nurse is teaching a client with tuberculosis about recovery after discharge from the hospital. Which instruction is the priority? 1.Having sufficient rest 2.Getting plenty of fresh air 3.Changing the current lifestyle 4.Consistently taking prescribed medication
4.Consistently taking prescribed medication