EAQ N4510 Respiratory Summer '20

Client 1: Cystic fibrosis Client 2: Bronchiectasis Client 3: Metabolic acidosis Client 4: Pulmonary edema The nurse is caring for different clients in a healthcare setting who are diagnosed with respiratory disorders. Which client may have the anteroposterior chest diameter equal to the lateral chest and the slope of the ribs more horizontal to the spine? A. Client 1 B. Client 2 C. Client 3 D. Client 4

A

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. A. Crackles B. Atelectasis C. Hypoxemia D. Severe dyspnea E. Increased pulmonary wedge pressure

A, B, C, D

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care? A. Fibrotic B. Exudative C. Reparative D. Proliferative

B

The registered nurse is teaching a group of nursing students about the characteristics of the five percussion notes. Which statements made by a student nurse indicate effective learning? Select all that apply. A. "Resonance indicates the presence of trapped air." B. "Dullness can be percussed over a consolidated lung." C. "Hyperresonance is characteristic of normal lung tissue." D. "Tympanic notes over the lung usually indicate a large pneumothorax." E. "Flatness percussed over the lung fields indicates massive pleural effusion."

B, D, E

A client admitted in the emergency department has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia. Which condition of the client will be given the highest priority? A. Hypoglycemia B. Chest wall trauma C. Airway obstruction D. External hemorrhage

C

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? A. Hypertension B. Tenacious sputum C. Altered mental status D. Slow rate of breathing

C

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? A. Question the client about the confusion B. Change the method of oxygen delivery C. Percuss and vibrate the client's chest wall D. Discontinue or decrease the oxygen flow rate.

D

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? A. Chest tube insertion B. Aggressive diuretic therapy C. Administration of beta-blockers D. Positive end-expiratory pressure (PEEP)

D

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? A. Aspirating gastric contents B. Getting an opioid overdose C. Experiencing an anaphylactic reaction D. Receiving multiple blood transfusions

A

The nurse is collecting the health history of a client suspected to have a pulmonary disorder. Which questions should the nurse ask the client related to health perception and health management? Select all that apply. A. "Do you experience a morning headache?" B. "Have you ever smoked elicit street drugs?" C. "What do you do when you get short of breath?" D. "Are you able to maintain a typical activity pattern?" E. "What equipment helps you manage your respiratory problems?"

B, E

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? A. Hypertension B. Tenacious sputum C. Altered mental status D. Slowed rate of breathing

C

A client who is admitted with emphysema shows progressive respiratory failure and has a Paco2 of 60. To address the problems, the nurse expects to receive a prescription for: A. Mucolytics B. Bronchodilators C. Mechanical Ventilation D. Intermittent positive-pressure breathing (IPPB)

C

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. Which clinical indicator should the nurse assess first? A. Cyanosis B. Bradycardia C. Mental confusion D. Distended neck veins

C

The nurse instructed a client with asthma about the use of a peak flow meter at home. The client assesses the peak expiratory flow by using the peak flow meter. Which action performed by the client would be appropriate when the reading is in the yellow zone? A. Perform the peark expiratory flow again immediately B. Increase the prescribed drug therapy C. Use a prescribed reliever drug therapy D. Reassess the asthma plan and change the controller medication

C

What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath? A. Scoliosis B. Kyphosis C. Clubbing D. Kyphoscoliosis

C

Which assessment finding is considered the earliest sign of decreased tissue oxygenation? A. Cyanosis B. Cool, clammy skin C. Unexplained restlessness D. Retraction of interspaces on inspiration

C

the nurse finds that clinet becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? A. Class 1 B. Class 2 C. Class 3 D. Class 4

C

The nurse hears a series of long, discontinuous low-pitched sounds similar to blowing through a straw under water while auscultating the lungs of a client with chronic obstructive pulmonary disease. What should the nurse document in the client's assessment record based on this finding? A. Rhonchi B. Wheezes C. Fine crackles D. Coarse crackles

D

What does the nurse state is the cause of frequent upper respiratory tract infections in toddlers? A. Stress B. Unhealthy diet C. Lack of exercise D. Immature immune system

D

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? A. Administer sedatives around the clock B. Turn client every four hours C. Increase ventilator settings as needed D. Suction as needed

D