A&P Respiratory, Lymphatic, Microbiology Basics

A nurse is teaching a client about performing a breast self-examination at home. In which order should the nurse instruct the client to perform the steps of breast self-examination?

*look at the breasts in front of a mirror w hands placed on hips is the first step *inspect the breasts for changes in shape, color, or contour *inspect the nipples for a rash or drainage *lie down and prepare to palpate breasts with the pads of the second, third, and fourth fingers *palpate each breast from the outer edge, moving from top to bottom across the breasts

A nurse is discussing ventilation and perfusion withe a newly licensed nurse. The nurse should include in the discussion that the exchange oof oxygen and carbon dioxide occurs at which of the following locations?

Alveoli

A nurse is caring for a client who is dying and he's having periods of deep breathing Alternating with Apnea. The nurse should identify this as which of the following types of breathing?

Cheyne-Stokes breathing Cheyne-Stokes breathing can occur if the central nervous system is grossly affected by lack of oxygen or disease progression. It appears to have a respiratory "start-stop" breathing pattern. The client will have a deeper breath that might quicken, followed by hypoventilation and progression to apnea. This is an end-of-life breathing pattern.

A nurse is assessing a client who has COPD. The nurse should identify that which of the following is an expected finding?

Clubbing of the fingers

A nurse is inspecting a client and documents that the spine is straight and the movement upon inspirations is symmetrical. Which of the following describes the location that the nurse is documenting?

The posterior chest

The nurse is inspecting a client's anterior chest. Which of the following findings should the nurse expect?

The ribs are sloping downward at an angle

A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?

Tripod position Involves leaning over a table with arms placed on the table or sitting with the arms on the knees. This position allows for lung expansion which can help ease respiratory distress.

Which normal breath sounds are heard over the largest portions of the lungs and are soft-sounding like wind blowing through trees

Vesicular

A nurse is caring for a client who requires 7 L of oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use?

Simple face mask

A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect?

Stenosis

A nurse is planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the client's cardiac output?

Stroke volume

During a client assessment, you noted edema of the left arm. What subjective data should you collect from the client?

Did you have any surgery on your left breast?

A nurse is performing a physical assessment of a client. In which of the following positions should the nurse place the client prior to inspecting the client's breasts?

Sitting straight up w arms relaxed and close to the body.

A nurse is providing teaching for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include?

1. Post a "No smoking" sign inside the home 2. Attach oxygen containers to a fixed object 3. Notify the fire department that oxygen is used in the home

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Crackles in the lungs

A nurse is teaching a client who has an abdominal incision about coughing and deep breathing. In which order should the nurse instruct the client to perform the following steps?

1. Take a deep breath 2. Hold your breath for several seconds 3. Exhale slowly 4. Brace the incision with a pillow and try to cough deeply

Which of the following tools or techniques should you plan to use during a breast assessment? a. Inspection b. Doppler c. Percussion d. Sterile gloves

Inspection

A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation? A. I cannot sleep at night because I get short of breath B. Client seems to not like certain staff members C. Client's partner does not visit the client enough D. Inspiratory wheeze auscultated at left lateral chest

Inspiratory wheeze auscultated at left lateral chest

A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take?

Listen for a hollow sound when performing chest percussion therapy

A nurse caring for a client who has a chest tube. Which of the following actions should the nurse take

Monitor the client for subcutaneous emphysema

A nurse is auscultating a client's heart sounds and hears low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following?

Murmur

A nurse is assessing a client who is dark skinned. In which of the following areas of the clients body should the nurse assess the client for adequate oxygenation?

Nail beds Lips Oral Mucosa

A nurse is caring for a client who is hyperventilating. The nurse should identify that which of the following circumstances an contribute to hyperventilation?

Pain Anxiety Fear

A nurse is reviewing breast self-examination techniques w a client. Which of the following client statements indicates an understand of the techniques?

"I will use circular motions to feel the texture of my breast tissue."

A nurse is providing teaching for a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include?

"Use the incentive spirometer every hour while awake."

What should you include when providing instructions on performing breast self-examination to a client?

"Use the pads of the three middle fingers to examine your breasts."

A client who is considered at low risk for breast cancer asks how often she should receive a mammogram. Which of the following is the best response?

"You should have a mammogram every 1 to 2 years beginning at age 45."

A nurse is planning care for a group of clients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first?

A client who reports dyspnea when walking to the bathroom

A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take?

Administer 100% oxygen before the procedure

A nurse is discussing breast cancer with a group of male clients. The nurse should include that which of the following findings is a potential indication of breast cancer?

Dilation of the hair follicles Nipple retraction A small bulging nodule lateral to one breast

What findings requires further investigation?

Discharge from one nipple

A nurse is caring for a client was having difficulty breathing. Which of the following actions should the nurse take first?

Elevate the head of the client's bed

A client reports experiencing stress about their new diagnosis of coronary artery disease (CAD). Which of the following are manifestations of prolonged stress?

Increased cortisol

A nurse is assessing a client who is being discharged. The nurse notes the client has a regular and quiet breathing. The nurse should identify this breathing pattern as which of the following?

Normal breathing

A nurse is performing a breast inspection on a client. Which of the following findings should the nurse report to the provider?

dimpling

What is an unexpected finding associated with male breast cancer?

A painless nodule near the nipple

A nurse is performing a breast inspection during a client's routine physical examination. Which of the following findings should the nurse report to the provider?

Scaley skin at the border of one areola

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub?

Coarse grating tone Heard on inspiration and expiration Pain with breathing A pleural friction rub occurs because of inflammation of the pleura. It is a low-pitched, coarse grating tone that sounds like rubbing two pieces of leather together. It can be heard on inspiration and expiration and is very painful.

A nurse is caring for a client who reports palpable lymph nodes under one axilla. The nurse can see small nodules under the skin in the area the client describes. Which of the following should the nurse identify as a potential cause of the client's lymph node enlargement?

Infection (the nurse should recognize that an infection of the hand, breast, or arm can cause lymph nodes in the axillae to enlarge so that they become palpable, and sometimes they can even be visible upon inspection)

A nurse is preparing education material for a client to maintain a healthy respiratory status. Which of the following information should the nurse include in the materials?

Instruct and encourage the client to obtain the influenza vaccine Counsel the client about smoking cessation Educate the client that hand hygiene is the first line of defense to prevent illness

A nurse is caring for a client with obstructive sleep apnea (OSA). Which of the following are manifestations of OSA? (Select all that apply.)

Loud snoring Restlessness Extreme daytime drowsiness

A nurse is caring for a male client who has recently diagnosed w gynecomastia. Which of the following should the nurse identify as a potential cause of this condition?

Medication adverse effects (The nurse should identify that gynecomastia, or swelling of the breast tissue in males, can be caused by medication adverse effects. This condition can also be caused by hormonal changes or weight gain.

A nurse is teaching a group of female clients about breast self-awareness. Which of the following instructions should the nurse include?

Menstruating females should examine their breasts about 5 days after their menstrual cycle begins.

A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery devices should the nurse expect to us?

Nasal cannula

A nurse is caring for a client is experiencing episodes of hyperventilation. Which of the following manifestation sure the nurse expect during hyperventilation?

Numbness and tingling of extremities Lightheadedness Chest pain A client who is hyperventilating can show manifestations such as numbness and tingling of the extremities, heart palpitations, chest pain, and lightheadedness.

A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first?

Obtain the oxygen saturation

A nurse is assessing a client and notes minimal air movement with the client's inspirations. Which of the following should the nurse recognize as a contributing factor?

Pneumonia Chest trauma Prolonged bed rest

A nurse is performing a breast examination on a client and notices that the client's right arm is edematous. Which of the following should the nurse identify as a potential cause of this condition?

Recent surgery on the right side (surgery on the client's right side, such as a mastectomy, can disrupt the flow of lymphatic drainage. which can cause edema)

A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data?

Report from client says they sleep while propped on two pillows at night Client says they quit smoking 2 years ago Client states, "Being short of breath all of the time is making me depressed." This information is reported by the client and is therefore subjective.

A client is experiencing hypoxia. Which of the following manifestation can a nurse expect to find in this client?

Restlessness

A nurse is assessing a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity?

Ringing in the ears

A nurse is inspecting a client's axillae. Which of the following should the nurse identify as an expected finding?

Skin has a uniform consistency.

A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify that which of the following can cause hypoxia?

Smoke inhalation

What findings of the axillae is expected?

Smooth, moist skin

A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis?

Surfactant

A nurse in the emergency department is assessing a client who has experience thoracic trauma from a motor vehicle crash. Which of the following findings is an indication of pneumothorax?

The client is experiencing unequal movement of the posterior chest

A nurse is performing a head-to-toe assessment of a client. Which of the following findings indicates a client might be experiencing respiratory difficulties?

The client is sitting in a tripod position The client is using pursed lipped breathing The client appears confused

A nurse is teaching a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity?

The maximum volume of air that is expired after a maximum inspiration

Which of the following questions provides subjective data about present breast health conditions? Select all that apply. a. Have you noticed any redness or rashes on your breasts? b. Have any of your relatives had breast cancer? c. Have you ever had a breast biopsy? d. Have you felt any lumps during breast self-examinations? e. Do you have any drainage form your nipples?

a. Have you noticed any redness or rashes on your breasts? d. Have you felt any lumps during breast self-examinations? e. Do you have any drainage form your nipples?

Which of the following structures is responsible for producing an oil to provide nipple lubrication during breastfeeding? a. Lactiferous ducts b. Montgomery glands c. Alveoli clusters d. Tail of Spence

b. Montgomery glands

A nurse is teaching a group of newly licensed nurses about routine mammography screenings for female clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

"A 55 y/o client should receive mammography screenings at least every 2 years." (Guidelines recommend routine mammography screenings every 1-2 years for female clients between 40-75 years old.

A nurse is discussing atrial fibrillation with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrillation?

"Atrial fibrillation is caused by electrical signals outside of the SA node".

A charge nurse is teaching a new release recognize manifestation of decreased oxygenation In a client. Which of the following statements by the new license nurse indicate an understanding of the teaching?

"Clubbing of fingers indicates a chronic stage of impaired perfusion." Clubbing of the ends of the fingers can indicate a chronic state of decreased oxygenation and perfusion.

A nurse is providing teaching for a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include?

"Cover your nose with the CPAP mask".

A nurse is providing discharge teaching to a client who has a COPD regarding the influenza vaccine. Which of the following statements should the nurse make?

"You should make every effort to receive a flu vaccine every year."

A nurse is obtaining a past health history for a client prior to a breast examination. Which of the following questions should the nurse ask while obtaining the client's past health history?

"have you ever had breast disease?" "have you experienced breast trauma?" "have you had breast surgery?" "do you perform breast self-examinations?"

A nurse is preparing to review health promotion recommendations for breast health with a client. Which of the following actions should the nurse plan to take when reviewing health promotion recommendations for breast health?

*ask the client to describe the process for breast self-examination at the end of the teaching *document instructions provided in the client's medical record *review recommendations for mammography based on risk with the client

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as risk factors for heart disease?

- A diet high in saturated fats - A history of smoking for 25 years - A sedentary lifestyle

A nurse is explaining the sequence of electrical conduction in the heart to a newly licensed nurse. What should the nurse include as the correct sequence of the transmission of electrical impulses?

- SA node - AV node - Bundle of His - Right and left bundle branches - Purkinje fibers

A nurse is reviewing the anatomy of the pulmonary system. How many lobes are in the left wing?

2

A nurse is reviewing the medical record of a client who was assessed as having a barrel chest resulting from COPD. Which of the following images shows a client who has a barrel chest?

A A barrel chest is caused by hyperinflation of the lungs due to a disease process, such as COPD. It can also be associated with the normal aging process. The anterior/posterior to transverse diameter is equal, and the ribs, normally in a downward slope, lay horizontal. The client might sit in a tripod position to obtain adequate oxygen exchange.

A nurse is teaching a newly licensed nurse about nipple inspection. Which of the following should the nurse include as an example of an expected variation of the nipple?

A client's nipple has remained inverted since childhood.

A nurse is auscultating breath sounds of a client who has pneumonia and hears bronchial crackles. In which of the following areas of the chest is the nurse auscultating?

A is correct. Bronchial breath sounds are heard to the right and left of the trachea and larynx. They can only be heard on the anterior chest.

The nurse is providing teaching to a client who has a new diagnosis of asthma and reports of smoking history of 20 years. Which of the following statements to the nurse make one counseling the client about her tobacco use? A. "Smoking is linked to various forms of cancer." B. "There are no risks associated with exposure to secondhand smoke." C. "It might take several attempts to finally stop smoking." D. "Smoking will cause you to die years earlier than if you didn't smoke." E. "There are pharmacologic therapies that can help a person stop smoking."

A. "Smoking is linked to various forms of cancer." C. "It might take several attempts to finally stop smoking." E. "There are pharmacologic therapies that can help a person stop smoking."

A nurse is caring for a client with a chest tube and is assessing the drainage. Which of the following findings should the nurse document? (Select all that apply.)

Amount Color Consistency

Charge nurse Is observing a newly licensed nurse perform an anterior chest auscultation on a client. Which of the following actions should the charge nurse intervene? A. The nurse asks the client to cough before beginning the auscultation. B. The nurse is auscultating through the client's gown. C. The nurse places the stethoscope on the intercostal spaces. D. The nurse moves down the chest in a ladder sequence.

B. The nurse is auscultating through the client's gown.

What should you include in a breast assessment for a female client?

Breast contour Axillae Areola condition