250 NCLEX questions final

A nurse is explaining a chest tube to a family member who does not understand where it is placed. What would the nurse tell them? "It is inserted into the space between the lining of the lungs and the ribs" "I don't exactly know, but I will make sure the doctor comes to explain" "It is inserted directly into the lung itself, connecting to a lung airway" "It is inserted into the peritoneal space and drains into the lungs"

"It is inserted into the space between the lining of the lungs and the ribs"

A client who utilizes a portable oxygen device reports planning to attend an upcoming bonfire on the beach. What is the appropriate response? "Have an enjoyable time." "You should not leave the house with portable oxygen." "When using portable oxygen, you should avoid any fire" "Saltwater can increase the potential for oxygen toxicity"

"When using portable oxygen, you should avoid any fire"

A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included? "Make each breath deep enough to move the bottom ribs" "Breathe through the mouth when you inhale and exhale" "Breathe in through the mouth and out through the nose" "Practice deep breathing at least once each week"

"Breathe through the mouth when you inhale and exhale"

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home? "Although the test is uncomfortable, it is not painful" "You will be asked to forcefully exhale into a mouthpiece" "The test is used to determine how much air you inhale" "You will do this each morning while still lying in bed"

"You will be asked to forcefully exhale into a mouthpiece"

Intermittent (Bolus)

-300-500 mL several times a day over 30 minutes -Initial intermittent should be no more than 120 mL

Nutritional considerations for the older adult

-Fewer calories -Increased fiber -GI changes and psychosocial factors that impact appetite/nutritional status

Checking residuals for continuous feeds and intermittent feeds

-Residual: how much feeding not absorbed -Check hourly when feeding initiated, then q4hrs or before meds, or adding more feeding for infusion -If more than 100 mL or amount specified by agency or MD, feeding should be stopped and notify MD

What prevents air from reentering the pleural space when chest tubes are inserted? The location of the tube insertion The sutures that hold in the tube A closed water-seal drainage system Respiratory inspiration and expiration

A closed water-seal drainage system

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What is the abnormal respiratory process does this demonstrates? Changes in the alveolar-capillary membrane and diffusion Alterations in the structures of the ribs and diaphragm Rapid decreases in atmospheric and intrapulmonary pressures Lower-than-normal concentrations of environmental oxygen

Changes in the alveolar-capillary membrane and diffusion

Pneumothorax List treatment

Chest tubes typically release the air trapped in the pneumothorax space. Typically remain in place for 1-3 days for pneumothorax

Pneumothorax List signs and symptoms

Decreased oxygenation, difficulty breathing, increased need for oxygen, decreased tissue perfusion, diminished breath sounds

A nurse is caring for an older adult who is to be discharged from the health care facility. The client has been prescribed an oxygen concentrator at home to continue oxygen therapy. What instructions would the nurse tell the client regarding the use of the oxygen concentrator in the home? Select all that apply. Do not smoke or use oxygen where open flames, such as a gas stove, are in use The unit may give off an odor even if cleaned regularly The oxygen concentrator needs to be used in a grounded electrical plug Keep the oxygen concentrator flush with the wall and out of the way The oxygen concentrator is portable and cost-effective

Do not smoke or use oxygen where open flames, such as a gas stove, are in use The oxygen concentrator needs to be used in a grounded electrical plug The oxygen concentrator is portable and cost-effective

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is ineffective airway clearance related to copious and tenacious secretions. Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? Encouraging the client to consume 2 to 3 wt (1.9 L to 2.9 L) of clear fluids daily Creating an environment that is likely to reduce anxiety Positioning the client supine Encouraging the client to decrease the number of cigarettes smoked daily.

Encouraging the client to consume 2 to 3 wt (1.9 L to 2.9 L) of clear fluids daily

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal? Fine crackles to the bases of the lungs bilaterally Respiratory rate of 18 breaths per minute Resonance on percussion of lung fields Vesicular breath sounds audible over peripheral lung fields

Fine crackles to the bases of the lungs bilaterally

Manage Clogged Feeding Tubes

Flush with 30 mL of water before, between, and after each separate med Use a 60-mL syringe Reposition client Flush and aspirate tube with warm water Use of carbonated beverage has not shown to be effective but you may see this attempted Follow facility P&P for use of enzyme products to unclog

The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply. Inhale slowly through the nose for a count of three Keep abdominal muscles in a relaxed state Shape the lips as if you were about to blow a whistle Over time, begin to increase the length of the exhale Exhale slowly through pursed lips Ensure that the exhale lasts twice as long as the inhale

Inhale slowly through the nose for a count of three Shape the lips as if you were about to blow a whistle Over time, begin to increase the length of the exhale Exhale slowly through pursed lips Ensure that the exhale lasts twice as long as the inhale

A nurse is teaching a preoperative client how to use an incentive spirometer. Which instruction should be included in the teaching plan? Instruct the client to inhale normally and then place the lips securely around the mouthpiece. Instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose When the client cannot inhale anymore, the client should hold his or her breathing and count to 10 Encourage the client to perform incentive spirometry hourly, if possible.

Instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose

Which teaching about the humidifier is important for the nurse to provide to a client using oxygen? It prescribes oxygen concentration It regulates the amount of oxygen received It determines whether the client is getting enough oxygen It decreases dry mucous membranes via delivering small water droplets

It decreases dry mucous membranes via delivering small water droplets

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. Monitor the client's respiratory rate Notes the amount of oxygen administered Check the symmetry of the client's chest Observe the breathing pattern and effort Check the devices used to deliver oxygen

Monitor the client's respiratory rate Check the symmetry of the client's chest Observe the breathing pattern and effort

The nurse assesses a client with suspected sleep apnea. Which concern(s) does the nurse expect the client to verbalize during the health history interview? Select all that apply. Nocturnal panic attacks Fear of dying while sleeping Disruptive daytime sleepiness Embarrassment about loud snoring

Nocturnal panic attacks Disruptive daytime sleepiness Embarrassment about loud snoring

Administering a tube feeding- Key pointers

Position pt with HOB >30-45- degrees Ensure placement of tube Assess abdomen Aspirate all gastric contents to check for residual Flush with 30-50 mL of water to irrigate tube (Q4hr with continuous) Date and time all supplies used Flush at end with 30-60 mL of water Clamp tube when not in use Patient remains upright 1 hour post feed

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? Uses upper chest muscles more effectively Replaced the use of incentive spirometry Reduced the need for PRN pain medications Prolongs expiration to reduce airway resistance

Prolongs expiration to reduce airway resistance

NG feedings and nursing actions/considerations

Purpose -Restore or maintain nutritional status -Admin meds Assessment -s/sx of dehydration -Allergies -Bowel sounds -Delayed gastric emptying -Abdominal distention -Diarrhea and cramping -Residual

Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply. Deep breathing Incentive spirometry Pursed-lip breathing Diaphragmatic breathing Apply nasal strips

Pursed-lip breathing Diaphragmatic breathing

The nurse prepares to apply the pulse oximeter to the client's hand. The fingers are edematous, cool to touch, and have black nail polish, Which actions should the nurse take? Select all the apply. Remove the black nail polish and assess circulation Assess mental status Apply to warm, swollen finger Auscultate lungs Use alternate site; earlobe or bridge of the nose

Remove the black nail polish and assess circulation Assess mental status Auscultate lungs Use alternate site; earlobe or bridge of the nose

A nurse is delivering oxygen to a client via an oxygen mask. Which guideline is recommended for this procedure? Adjust mask so it is fully airtight around the face For a mask with a reservoir, fill the reservoir half full of oxygen Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously If the client is experiencing redness around the mask, remove and apply powder to the mask

Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously

While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event? Submerge the end of the chest tube in a container of sterile water Clamp the tube near the end and also near the insertion point Place the end of the tube on a sterile surface and seek help promptly Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit

Submerge the end of the chest tube in a container of sterile water

Pneumonia List signs and symptoms of respiratory distress

Tachycardia Tachypnea Anxiety hyperventilation

A physician prescribes the use of water-seal chest tube drainage for a client at a healthcare facility. What should the nurse ensure when using the water-seal chest tube drainage? Filters need to be cleaned regularly to avoid unpleasant taste of smell The chest tube should not be separated from the drainage system unless clamped A nasal cannula should be used to administer oxygen when cleaning the opening A secondary source of oxygen should be available in case of power failure.

The chest tube should not be separated from the drainage system unless clamped

A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching? Importance of communicating with the client The safety measures necessary to prevent a fire The cost and source of supply for the oxygen The need to provide good skincare

The safety measures necessary to prevent a fire

Continuous is administered 24 hours

Use infusion pump Initial rate 10-40 mL/hr If tolerated increase by 10-20 mL/hr to desired rate Monitor F&E status Use sterile water to reduce microbial contamination in immunocompromised patients Change bag and tubing every 24 hours for open system, closed system, every 48 hour

What is the most important risk factor in pulmonary disease? Air pollution from vehicles Dangerous chemicals in the workplace Active and passive cigarette smoke Loss of the ozone layer of the atmosphere

active and passive cigarette smoke

A client is experiencing hypoxia. Which nursing diagnosis would be appropriate? Anxiety Nausea Pain Hypothermia

anxiety

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of: Atelectasis Bronchospasm Croup Epiglottitis

atelectasis

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? Inhale through the nose instead of the mouth Be sure to shake the canister before using it Inhale the medication rapidly Inhale two sprays with one breath for faster action

be sure to shake the canister before using it

Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body? Chronic anemia Graves' disease Parkinson's disease Pancreatitis

chronic anemia

In which client would the nurse assess a depressed respiratory system? Client taking amlodipine for hypertension Client taking antibiotics for a urinary tract infection Client taking insulin for diabetes Client taking opioids for cancer pain

client taking opiods for cancer pain

The nurse assesses a client with chronic obstructive pulmonary disease (COPD) suspects chronic hypoxia based on which assessment finding? Edema Clubbing fingers Cyanosis Frequent urination

clubbing fingers

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? Crackles in the lower lobes Inspiratory stridor Expiratory stridor Wheezing in the upper lobes

crackles in the lower lobes

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario? Cyanosis Eupnea Hypercapnia Pallor

cyanosis

Oxygen and carbon dioxide move between the alveoli and the blood by: Osmosis Hyperosmolar pressure Diffusion Negative pressure

diffusion

TB True or False: a positive reaction on the TB skin test indicates active disease.

false

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? Flowmeter Oxygen analyzer Humidifier Nasal cannula

flowmeter

The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client? Supine Prone High fowlers Trendelenburg

high fowlers

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea? Lying with the head slightly lowered High Fowler's position Supine with one pillow Side-lying with head slightly elevated

high fowlers position

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test? Monitor the pressure of oxygen dissolved in plasma Measure the volume of air exhaled or inhaled over time Calculate the pressure of carbon dioxide in plasma Monitor the amount of oxygen saturation in the blood

monitor the amount of oyxgen saturation in the blood

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? Nasal cannula Simple oxygen maks Venturi mask Partial rebreather mask

nasal cannula

An adult client is discharged to home with a prescription for oxygen at 2 L/min. Which method of oxygen delivery should the nurse use in this situation? Nasal cannula Oxygen mask Oxygen hood Oxygen tent

nasal cannula

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). In what position does the nurse place the client in order to promote adequate oxygenation? Semi-fowler's High-Fowler's Supine Prone

prone

The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next? Provide oxygen for consistent hypoxia Encourage the use of spirometry to improve oxygenation through the lungs Continue to monitor oxygen to ensure the level does not fall below 90% Obtain blood for hemoglobin testing to determine oxygen transport level

provide oxygen for consistent hypoxia

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating". Based upon this diagnosis, which nursing intervention is appropriate to include in the client's care plan? Provide six small meals daily Provide three large meals daily Encourage the client to eat immediately before breathing treatments Encourage the client to alternate eating and using a nebulizer during mealtime

provide six small meals daily

A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? Chemoreceptors Stretch receptors Respiratory center Oxygen center

resp center

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? Clubbing fingers Respirations 26 breaths/minutes Heart rate 110 beats/min SpO2 96%

spo2 96%

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select? Face tent Simple mask Nasal cannula Tracheostomy collar

trach collar

Pneumonia True or False: Fluid losses are due to increased temperature and respiratory rate

true

Pneumonia True or False: on X-ray, alveoli filled with exudate and WBCs appear as patch or lobe consolidation or infiltrates

true

TB True or False: A sputum culture is the diagnostic test that will confirm a TB diagnosis?

true

TB True or False: Most clients have negative cultures after 3-months of medication treatment

true

TB True or False: after two weeks of medication therapy the patient should no longer be contagious?

true

TB True or False: every two to four weeks after medication therapy is started to treat TB, sputum cultures are obtained to determine effectiveness of therapy?

true

TB True or False: the following s/sx are typically present with a person with TB: dyspnea, night sweats, blood-productive cough, and a productive cough with mucoid sputum

true

pneumothorax True or False: pneumothorax can be due to rib fracture, stab or gunshot wound or a thoracentesis

true