Evolve Adaptive Quiz: Med-Surg, Respiratory

A 6-year-old child with acute spasmodic bronchitis who is receiving humidified air removes the mask, and while bathing the child the nurse notes increasing respiratory distress. What is the most appropriate nursing intervention? 1 Stopping the bath and replacing the mask 2 Performing postural drainage and clapping the chest 3 Placing the child in the orthopneic position and calling the practitioner 4 Suctioning the child's nasal passages and waiting for the dyspnea to subside

1

A chest tube with an attached closed-drainage system is inserted into a client who was stabbed in the chest. Which is an important nursing intervention when caring for this client? 1 Observe for fluid fluctuations in the water-seal chamber. 2 Obtain a prescription for morphine to minimize agitation. 3 Apply a thoracic binder to prevent excessive tension on the tube. 4 Clamp the tubing securely to prevent a rapid decline in pressure.

1

A client has a closed chest drainage system in place. What should the nurse do to determine the amount of chest tube drainage? 1 Refer to the date and time markings on the outside of the collection chamber. 2 Aspirate the drainage from the collection chamber. 3 Replace the existing system with a new one to access the drainage in the existing system. 4 Clamp the chest tube and empty the fluid from the collection chamber.

1

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? 1 Remove the air that is present in the intrapleural space 2 Drain serosanguineous fluid from the intrapleural compartment 3 Permit the development of positive pressure between the layers of the pleura 4 Provide access for the instillation of medication into the pleural space

1

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client? 1 Edema of the left leg 2 Mobility of the left leg 3 Positive left-sided Babinski reflex 4 Presence of left arterial peripheral pulse

1

A client who had thoracic surgery is admitted to the postanesthesia care unit. What should the nurse do after the chest tube is attached to a disposable plastic water-seal drainage system? 1 Ensure the security of the connections from the client to the drainage unit. 2 Empty the drainage container and measure and record the amount once a day. 3 Verify that there is vigorous bubbling in the wet suction control compartment. 4 Check that the fluid level in the water-seal compartment increases with expiration.

1

A client who has a history of emphysema is transported back to the nursing unit after a radical neck dissection for cancer of the tongue. The client is receiving oxygen and an intravenous infusion. Within the first hour, the client has 50 mL of sanguineous drainage in the portable wound drainage system. Which initial action should the nurse take? 1 Inspect the dressing 2 Increase the oxygen flow rate 3 Notify the healthcare provider 4 Place the client in the supine position

1

A client who just returned from surgery reports shortness of breath and chest pain. Which should the nurse initially administer? 1 Supplemental oxygen 2 Intravenous morphine 3 Endotracheal intubation 4 Sublingual nitroglycerin

1

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, what should the nurse do? 1 Hyperoxygenate with 100% oxygen before and after suctioning 2 Suction two or three times in quick succession to remove secretions 3 Use the technique of short, pushing movements when applying suction 4 Apply suction for no more than 10 seconds while inserting the catheter

1

A client with chest trauma is admitted in the emergency department. Which intervention takes priority? 1 Ensure patent airway. 2 Monitor the cardiac rhythm. 3 Release dressing in tension pneumothorax. 4 Anticipate intubation for respiratory distress.

1

A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? 1 Increases the cardiac workload 2 Interferes with usual respirations 3 Produces an elevation in temperature 4 Decreases the amount of oxygen used

1

A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? 1 Ketoacidosis 2 Somogyi phenomenon 3 Hypoglycemic reaction 4 Hyperosmolar nonketotic coma

1

A client's arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? 1 A 65-year-old with pulmonary fibrosis 2 A 24-year-old with uncontrolled type 1 diabetes 3 A 45-year-old who has been vomiting for 3 days 4 A 54-year-old who takes sodium bicarbonate for indigestion

1

A nurse is caring for a 6-year-old child with sickle cell anemia. What is the priority nursing intervention to prevent thrombus formation? 1 Encouraging fluids 2 Encouraging bed rest 3 Administering oxygen 4 Administering prescribed anticoagulants

1

A nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment? 1 Increased breath sounds 2 Increased respiratory rate 3 Crepitus detected on palpation of the chest 4 Constant bubbling in the drainage collection chamber

1

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider? 1 Collect drainage 2 Ensure adequate suction 3 Maintain negative pressure 4 Sustain a continuance of the water seal

1

A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1 A 59-year-old who had a knee replacement 2 A 60-year-old who has bacterial pneumonia 3 A 68-year-old who had emergency dental surgery 4 A 76-year-old who has a history of thrombocytopenia

1

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? 1 Atrial fibrillation 2 Forearm laceration 3 Migraine headache 4 Respiratory infection

1

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)? 1 Aspirating gastric contents 2 Getting an opioid overdose 3 Experiencing an anaphylactic reaction 4 Receiving multiple blood transfusions

1

After a long history of recurrent thrombophlebitis with extensive varicose veins of the lower extremities, surgical intervention is suggested to the client. When asked about the procedure, what should the nurse explain that this surgery involves? 1 Removing the dilated superficial veins 2 Bypassing the varicosities with artificial veins 3 Stripping the cholesterol deposits from the veins 4 Creating fistulas between superficial and deep veins

1

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

During the second stage of labor the nurse discourages the client from holding her breath longer than 6 seconds while pushing with each contraction. Which complication does this prevent? 1 Fetal hypoxia 2 Perineal lacerations 3 Carpopedal spasms 4 Maternal hypertension

1

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? 1 Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. 2 Arrange for a supply of heparin for the client to take to the rehab center. 3 Explain to the client that anticoagulant therapy will no longer be needed. 4 Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.

1

The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema? 1 Palpate around the tube insertion sites for crepitus 2 Auscultate the breath sounds for crackles and atelectasis 3 Observe the client for the presence of a barrel-shaped chest 4 Compare the length of inspiration with the length of expiration

1

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis? 1 pH: 7.28; PCO2: 28; HCO3: 18 2 pH: 7.30; PCO2: 54; HCO3: 28 3 pH: 7.50; PCO2: 49; HCO3: 32 4 pH: 7.52; PCO2: 26; HCO3: 20

1

The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis? 1 Spiral (helical) computed tomographic angiography (CTA) 2 D-dimer and arterial blood gas (ABG) laboratory tests 3 Ventilation-perfusion (V/Q) scan 4 Pulmonary angiography

1

The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. What should the nurse do? 1 Assess for obstructions in the chest tube 2 Increase the amount of continuous suction 3 Add sterile water to the water-seal chamber 4 Make preparations to remove the chest tube

1

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? 1 Notify the primary healthcare provider immediately 2 Apply a warm, moist compress to the incision site 3 Increase the intravenous fluid rate by 20 mL/hr 4 Monitor vital signs more frequently

1

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? 1 Cerebral palsy 2 Cystic fibrosis 3 Muscular dystrophy 4 Multiple sclerosis

2: Cystic fibrosis

The parents of a child with spasmodic croup ask why their child is receiving humidified oxygen. What effect of humidified oxygen should the nurse include in the explanation? 1 It helps prevent drying of membranes. 2 It provides a mode of giving inhalant drugs. 3 It increases the surface tension of the respiratory tract. 4 It provides an environment free of pathogenic organisms.

1

What does the A of the mnemonic "ABCDE" of primary nursing survey stand for? 1 Airway 2 Exposure 3 Disability 4 Circulation

1

Which parameter does the nurse assess first while assessing a client with severe trauma? 1 Airway 2 Disability 3 Breathing 4 Circulation

1

While caring for a client who had an open reduction and internal fixation of the hip, the nurse encourages active leg and foot exercises of the unaffected leg every 2 hours. What does the nurse explain that these exercises will help to do? 1 Prevent clot formation 2 Reduce leg discomfort 3 Maintain muscle strength 4 Limit venous inflammation

1

The nurse is caring for a client after a right pneumonectomy for cancer. As part of the assessment, the nurse palpates the client's trachea. What is the rationale for this assessment? 1 A mediastinal shift may have occurred. 2 Subcutaneous emphysema may be present. 3 Tracheal edema may lead to an obstructed airway. 4 The cuff of the endotracheal tube may be underinflated.

1 After a pneumonectomy, the mediastinum may shift toward the remaining lung, or the remaining lung may shift toward the empty space, depending on the pressure within the empty space. Either of these shifts will cause the trachea to move from its usual midline position; this is known as a mediastinal shift. Subcutaneous emphysema is found by palpation over the lungs and chest areas. Tracheal edema cannot be assessed through palpation. The cuff of the endotracheal tube cannot be assessed through palpation of the trachea.

A client enters the emergency department reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention? 1 Assess vital signs. 2 Insert a saline lock. 3 Place client on oxygen. 4 Draw blood for troponins.

1 Assessment is the first step of the nursing process, and vital signs provide vital information about the client's cardiopulmonary status. Although inserting a saline lock may be done, it is not the priority. Although placing the client on oxygen may be done, it is not the priority. Administration of oxygen may alter the client's baseline vital sign results. Although drawing blood for troponins may be done, it is not the priority.

The nurse assists in the care of four older clients whose clinical features are mentioned below. Which client may have dementia? Client 1 Psychomotor Behavior: normal. Attention: normal. Perception: misperceptions absence. Client 2 Psychomotor Behavior: hypokinetic. Attention: impaired attention. Perception: difficult to distinguish between reality and perceptions Client 3 Psychomotor Behavior: hyperkinetic. Attention: inattentive. Perception: hallucinations Client 4 Psychomotor Behavior: psychomotor retardation. Attention: easily distractible. Perception: illusions present

1 Client 1 has normal psychomotor behavior. The attention of the client is also featured to be normal. Moreover, misperceptions are absent. Therefore, client 1 may likely have dementia. Hypokinetic psychomotor behavior, impaired attention, and a difficulty in distinguishing between reality and perceptions may signify delirium. Hyperkinetic behavior and inattention with hallucinations may also signify delirium. Psychomotor retardation, easily distractible attention, and illusions may be caused by depression.

The nurse is teaching a nursing student about the use of magnetic resonance imaging (MRIs). Which statement of the nursing student indicates effective learning? 1 "Clients with claustrophobia can have an MRI." 2 "Clients who are allergic to iodine should not have an MRI." 3 "Clients with pacemakers can have an MRI." 4 "Clients with surgical clips can go through an MRI."

1 Clients with a fear of closed spaces may develop anxiety; a closed MRI can be used, but the nurse should provide relaxation techniques or other modes to cope. MRIs do not involve the use of iodine or iodized products, so any clients allergic to iodine can still undergo the procedure. The magnetic field of an MRI may cause dysfunctions in pacemaker activity. Clients with surgical clips should remove all metal accessories before an MRI.

The parents of a sick infant talk with a nurse about their baby. One says, "I'm so upset; I didn't realize that our baby was ill." What major indication of illness in an infant should the nurse explain to the parent? 1 Grunting respirations 2 Excessive perspiration 3 Longer periods of sleep 4 Crying immediately after feedings

1 Grunting and rapid respirations are signs of respiratory distress in an infant. Grunting is a compensatory mechanism by which the infant attempts to keep air in the alveoli to increase arterial oxygenation; increased respirations increase oxygen and carbon dioxide exchange. Sweating in infants usually is scant because of immature function of the exocrine glands; profuse sweating is rarely seen in a sick infant. Longer periods of sleep are not necessarily a sign of illness, nor is crying immediately after feedings.

After the removal of a cast from a fractured arm, an 82-year-old client is to receive physical therapy. In an older adult, how is mild exercise expected to affect respirations? 1 Increase to 24 breaths per minute 2 Become progressively more difficult 3 Decrease in rate as their depth increases 4 Become irregular but remain within normal rates

1 In an older client, respirations are expected to increase to 24 breaths per minute and are a response to the need for oxygen at the cellular level because of the increased metabolic rate associated with exercise. Becoming progressively more difficult should not occur with mild exercise unless the client has cardiac disease. The rate of respirations will increase with mild exercise; because of inflexibility of the chest in the older adult, the depth will increase only minimally. Irregular respirations are not an expected response to exercise; this indicates a problem.

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1 Encouraging a fluid intake of 3 L daily 2 Suctioning via the tracheostomy every hour 3 Applying an occlusive dressing over the surgical site 4 Using cotton balls to cleanse the stoma with peroxide

1 Increased fluids help to liquefy secretions, enabling the client to clear the respiratory tract by coughing. Suctioning frequently will irritate the mucosal lining of the respiratory tract, which can result in more secretions. An occlusive dressing will block air exchange; the tracheostomy is now the client's airway. The use of cotton balls around a tracheostomy introduces the risk of aspiration of one of the cotton fibers; gauze should be used.

A registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning? 1 Administering sodium polystyrene sulfonate 2 Avoiding potassium restriction 3 Monitoring glucose levels hourly 4 Providing potassium-sparing diuretics

1 Increased potassium levels indicate hyperkalemia and are observed in clients with adrenal insufficiency. Administering potassium binding and excreting resin, such as sodium polystyrene sulfonate, can reduce the potassium levels. Potassium restriction should be initiated immediately to reduce the potassium levels. Monitoring glucose is required in a client with hypoglycemia, not hyperkalemia. Providing potassium-sparing diuretics may further lead to increase in potassium levels. Therefore, these diuretics should be avoided.

After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly? 1 Inhales deeply through the mouthpiece, relaxes, and then exhales. 2 Inhales deeply, seals the lips around the mouthpiece, and exhales. 3 Uses the incentive spirometer for 10 consecutive breaths per hour. 4 Coughs several times before inhaling deeply through the mouthpiece.

1 Inhaling deeply through the mouthpiece, relaxing, and then exhaling are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil. Inhaling deeply, sealing the lips around the mouthpiece, and exhaling are incorrect techniques; inhalation should occur through the mouthpiece. The breaths should not be taken in succession; they should be spaced by several normal breaths to avoid fatigue. Coughing is done after deep breathing.

A nurse is teaching breathing exercises to a client with emphysema. What is the reason the nurse should include in the teaching as to why these exercises are necessary to promote effective use of the diaphragm? 1 The residual capacity of the lungs has been increased. 2 Inspiration has been markedly prolonged and difficult. 3 The client has an increase in the vital capacity of the lungs. 4 Abdominal breathing is an effective compensatory mechanism and is spontaneously initiated.

1 Loss of elasticity causes difficult exhalation, with subsequent air trapping. Clients who have emphysema are taught to use accessory abdominal muscles and to breathe out through pursed lips to help keep the air passages open until exhalation is complete. Expiration is difficult because of air trapping and poor elasticity. There will be decreased vital capacity. Diaphragmatic breathing is a learned mechanism that is beneficial.

Which medication does the nurse anticipate will be prescribed to relieve anxiety and apprehension in a client with pulmonary edema? 1 Morphine 2 Phenobarbital 3 Hydroxyzine 4 Chloral hydrate

1 Morphine binds with the same receptors as natural opioids. However, it has a rapid onset, lowers the blood pressure, decreases pulmonary reflexes, and produces sedation. Phenobarbital has a slower onset than morphine and does not affect respirations and blood pressure to the same extent as morphine. Hydroxyzine generally is used to control anxiety associated with less acute situations. Chloral hydrate is a hypnotic that is not appropriate for the acute situation described.

Which statement regarding anesthetic drugs in pediatric clients requires correction? 1 During general anesthesia, the upper air obstruction risk is less in pediatrics. 2 Pediatric clients are more affected by anesthesia than adults. 3 Cardiac abnormalities are more common in pediatric clients receiving anesthesia. 4 The central nervous system of pediatric clients is more sensitive to the effects of anesthetics.

1 Neonates have a respiratory structure that is small in diameter, and they have a high metabolic rate. Because of this, the chance of upper air obstruction during general anesthesia is quite high. In pediatric clients, drug accumulation and toxicity also increases because the child's liver and kidney functions are immature. Thus children are more affected by anesthesia than adults. A child's cardiac system is not fully developed, which causes problems with the excretion and metabolism of anesthetics and leads to cardiac abnormalities. Because the blood brain barrier is underdeveloped in pediatric clients, the central nervous system becomes more affected by anesthetics.

To prevent potential aspiration, what technique should a nurse use when cleaning a tracheostomy tube that has a non-disposable inner cannula? 1 Apply precutdressing around the insertion site with the flaps pointing upward. 2 Replace the tube with a sterile obturator. 3 Use sterile cotton balls to cleanse the outer cannula. 4 Remove the tube after the high-volume, low-pressure cuff has been deflated.

1: Apply precutdressing around the insertion site with the flaps pointing upward

The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB). What is the rationale for the nurse's teaching? 1 Prolonged exhalation to decrease air trapping 2 Shortened inhalation to reduce bronchial swelling 3 Increased respiratory rate to improve arterial oxygenation 4 Decreased use of diaphragm to increase amount of inspired air

1 Pursed-lip breathing works to decrease dyspnea and the respiratory rate through prolonging exhalation and prevention of alveolar collapse. PLB does not increase the length of inhalation and does not increase the respiratory rate. Use of the diaphragm occurs with diaphragmatic, or abdominal, breathing.

Audio recording of breath sounds / lung sounds that is 0.10 seconds long 1 Stridor 2 Rhonchi 3 Wheezes 4 Coarse crackles

1 Stridor is a continuous musical or crowing sound of constant pitch, which is caused by partial obstruction of the larynx or trachea. It is associated with croup or epiglottitis. Rhonchi are continuous rumbling, snoring, or rattling sounds that occur due to obstruction of large airways with secretions. Wheezes are continuous high-pitched squeaking or musical sounds that result from rapid vibration of bronchial walls. Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds associated with pulmonary edema or pneumonia with severe congestion. They sound like air is blowing through a straw underwater and are caused by air passing through an airway intermittently occluded by mucus, unstable bronchial walls, or folds of mucosa.

A pregnant client is admitted to the high-risk unit with abdominal pain and heavy vaginal bleeding. What is the nurse's priority intervention? 1 Starting oxygen therapy 2 Administering an opioid 3 Elevating the head of the bed 4 Drawing blood for laboratory tests

1 The client is hemorrhaging and has decreased cardiac output. Oxygen is necessary to prevent further maternal and fetal compromise. Administering an opioid will sedate an already compromised fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Although blood should eventually be drawn for laboratory tests, it is not the priority.

A nurse is suctioning a client's airway. Which nursing action will limit hypoxia? 1 Apply suction only after catheter is inserted 2 Limit suctioning with catheter to half a minute 3 Lubricate the catheter with saline before insertion 4 Use a sterile suction catheter for each suctioning episode

1 The negative pressure from suctioning removes oxygen as well as secretions; suction should be applied only after the catheter is inserted and is being withdrawn. Limiting suctioning with catheter to half a minute is too long; suctioning should be limited to 10 seconds. Lubrication will facilitate insertion and minimize trauma; it will not prevent hypoxia. The use of a sterile catheter helps prevent infection, not hypoxia.

A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. How will the nurse's behavior be interpreted? 1 The nurse is negligent and can be sued for malpractice. 2 The nurse is practicing under guidelines of the nurse practice act. 3 The nurse is protected for these actions, in most states (Canada: provinces/territories), by Good Samaritan legislation. 4 The nurse is treating a health problem that can and should be addressed by a primary healthcare provider

1 The nurse at the scene of an accident should function in a responsible and prudent manner; the use of a soiled cloth on an open wound is not prudent, nor is the independent transfer of an accident victim from the scene. Although a nurse practice act defines nursing, it does not provide detailed standards for practice; the nurse's action was not prudent. The nurse's action was not what a reasonably prudent nurse would do, and therefore the nurse is not protected by Good Samaritan legislation. The nurse's intervention was not prudent and placed the client in jeopardy; the nurse was not practicing medicine but attempting to provide first aid.

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? 1 Assess the client's lungs. 2 Assess the client for pain. 3 Obtain details of smoking habits. 4 Ask about the onset of breathlessness.

1 The nurse should assess the client's lungs to gather objective data that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client's chest excursion. The nurse should review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes breathlessness; however, the client's statement is subjective data. All subjective data must be supported by measurable objective data.

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse conclude is causing these clinical findings? 1 Hypokalemia 2 Hyponatremia 3 Hyperglycemia 4 Hypercalcemia

1 These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose. Clinical manifestations of hyponatremia include nausea, malaise, and changes in mental status. Clinical manifestations of hyperglycemia include weakness, dry skin, flushing, polyuria, and thirst. Clinical manifestations of hypercalcemia include lethargy, nausea, vomiting, paresthesias, and personality changes.

A client with tongue occlusion has loss of gag reflex and alterations in level of consciousness. The blood gas test shows oxygen saturation as 40mm Hg and carbon dioxide saturation as 75 mm Hg. Which type of support provides immediate relief to the client? 1 Tracheotomy 2 Laryngeal repair 3 Abdominal thrust maneuver 4 Autotitrating positive airway pressure

1 Upper airway obstruction may occur with tongue occlusion, which is associated with loss of gag reflex and alterations in the level of consciousness. The client suffering from severe hypoxia (O2 saturation of 40mm Hg) and who is hypercapnic (CO2 saturation of 75 mm Hg) requires an emergency tracheotomy for relief within 2 minutes. Laryngeal repair is performed to prevent laryngealstenosis and to cover exposed cartilage. The abdominal thrust maneuver clears upper airway obstruction caused by a foreign body. Autotitrating positive airway pressure resets the pressure throughout the breathing cycle in a client with severe sleep apnea.

The nurse is caring for a client who is postoperative day 2 from an open cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions will be appropriate for this client? Select all that apply. 1 Encourage turning, coughing, and deep breathing exercises 2 Perform frequent breath sounds assessment 3 Decrease by mouth fluid intake 4 Offer a high-potassium diet 5 Obtain a chest x-ray

1 & 2 1: Encourage turning, coughing, and deep breathing exercises 2: Perform frequent breath sounds assessment

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply. 1 Sharp chest pain 2 Acute onset of dyspnea 3 Pain in the residual limb 4 Absence of the popliteal pulse 5 Blanching of the affected extremity

1, 2

A female client reports excessive hair growth on the face and chest. The nurse suspects ovarian dysfunction. Which findings support this assessment? Select all that apply. 1 Deepened voice 2 Enlarged clitoris 3 Capillary fragility 4 Changes in fat distribution 5 Increased thyroid gland activity

1, 2 The excessive growth of hair on the face and chest in women may be due to hirsutism. It is associated with an endocrine gland dysfunction. However, if accompanied by a deepened voice and enlargement of the clitoris, it may indicate ovarian dysfunction. Capillary fragility and changes in the distribution of fat may be associated with Cushing's disease. Hyperthyroidism can cause symptoms of softness or smoothness of the skin texture.

The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The client notifies the nurse that the catheter got tangled up in bedclothes and came out. What should the nurse do first? 1 Inspect the catheter 2 Notify the healthcare provider 3 Clamp the remaining device 4 Assess respiratory status

1: Inspect the catheter

The nurse plans interventions for a client with smoke inhalation based on a negative chest x-ray and arterial blood gases that show a PO2 of 85 mm Hg, a PCO2 of 45 mm Hg, and a pH of 7.35. Which interventions should the nurse anticipate will be prescribed? Select all that apply. 1 Coughing 2 Deep breathing 3 Bronchodilators 4 Humidified oxygen 5 Bronchial suctioning

1, 2, & 4 1: Coughing 2: Deep breathing 4: Humidified oxygen

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. 1 Confusion 2 Hypocapnia 3 Tachycardia 4 Constricted pupils 5 Slow respiratory rate

1, 2, 3

What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Select all that apply. 1 The test involves the administration of a contrast medium. 2 Clients should have their hydration levels assessed. 3 Clients are instructed to lie still on a hard table. 4 Clients are served shellfish before the test. 5 A client's serum creatinine level is evaluated after the test.

1, 2, 3

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). Which recommendations are essential for the nurse to include? Select all that apply. 1 "Wear a large-brimmed hat." 2 "Take your temperature daily." 3 "Balance periods of rest and activity." 4 "Use a strong soap when washing the skin." 5 "Expose the skin to the sun as often as possible."

1, 2, 3 A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. SLE can cause alopecia, and hair care recommendations include the use of mild protein shampoos and avoidance of harsh treatments, like permanents or highlights, and use of large-brimmed hat for skin protection. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not recommended. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.

A 1-year-old child is found to have nutritional iron-deficiency anemia. What nursing interventions are most important in the care of an infant with iron-deficiency anemia? Select all that apply. 1 Conserving the infant's energy 2 Protecting the infant from infection 3 Teaching the parents about nutrition 4 Telling the parents to offer small, frequent feedings 5 Instructing the parents to increase the amount of milk offered

1, 2, 3 Conservation of energy is important because anemic children are usually fatigued. There is an inadequate amount of red blood cells (RBCs) and hemoglobin to carry oxygen to body cells. Anemic children are prone to infection. Parents should know which foods are high in iron. Iron promotes the formation of RBCs. The time and amount of feedings are not as important as the quality of foods that are offered. Usually anemia results from drinking unfortified milk and little else; there should be an increase in the variety and quality of the foods offered.

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. 1 Crackles 2 Atelectasis 3 Hypoxemia 4 Severe dyspnea 5 Increased pulmonary wedge pressure

1, 2, 3, 4

During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions. 1. Elevate the head of the bed to 45 degrees 2. Apply oxygen via nasal cannula 3. Reduce the flow rate of the transfusion 4. Administer furosemide (Lasix) per provider prescription 5. Document findings in the client record

1, 2, 3, 4, 5 These symptoms represent circulatory overload. First, the nurse's priority is to facilitate gas exchange by elevating the head of the bed, then applying oxygen. Next, the transfusion rate should be slowed to reduce further circulatory overload and client compromise, followed by the administration of a diuretic to reduce circulating volume. Lastly, the findings and interventions should be documented accordingly.

A nurse is suctioning a client's tracheostomy. Place the nursing actions in order of priority when performing this procedure. 1. Auscultate the lungs and check the heart rate. 2. Prepare by turning suction on to between 80 and 120 mm Hg pressure. 3. Hyperoxygenate using 100% oxygen. 4. Don sterile gloves. 5. Guide the catheter into the tracheostomy tube using a sterile-gloved hand.

1, 2, 3, 4, 5 he status of the client should be ascertained as a baseline before starting the procedure. The suction should be turned on to check its adequacy before beginning. Because oxygen will be lost during suctioning, the client should be oxygenated using 100% oxygen before initiating the procedure. Then the nurse should don sterile gloves to protect the client from infection and guide the catheter into the tracheostomy tube without using negative pressure.

A nurse witnesses a client collapse during a home care visit. Place the basic life support actions in the order they should be performed by the nurse. Correct 1. Use physical and auditory stimulation to attempt to elicit a response. Correct 2. Direct the client's spouse to call the emergency management system. Correct 3. Listen and observe for spontaneous breaths. Correct 4. Palpate to determine the presence of a carotid pulse. Correct 5. Perform 30 chest compressions. Correct 6. Open the airway with the head tilt-chin lift method and give two breaths.

1, 2, 3, 4, 5, 6 Stimulation is required to determine if the person is actually unresponsive. Immediate activation of the emergency management system shortens response time and decreases mortality rate. Observing the rise of the chest and listening and feeling for the presence of breathing will determine if further action is needed. Palpation of the pulse determines if cardiac compression is needed. Begin 30 chest compressions to a depth of 2 inches (5 cm); this compresses the heart and pushes blood into the circulation. Opening the airway results in spontaneous breathing or prepares the person for two rescue breaths if needed. If two rescue breaths are given, they are alternated with chest compressions; rate is 30 compressions to two rescue breaths for a single rescuer, and 15 compressions to two rescue breaths for two rescuers.

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply. 1 Fever 2 Tachypnea 3 Hypertension 4 Abdominal rigidity 5 Increased bowel sounds

1, 2, 4

The primary healthcare provider is preparing to instill medication into the pleural space via thoracentesis. Which interventions does the nurse consider to be appropriate when performing a thoracentesis? Select all that apply. 1 Verify breath sounds. 2 Encourage deep breaths. 3 Observe for signs of pneumonia. 4 Ensure a chest x-ray is performed after the procedure. 5 Instruct the client to cough during the procedure.

1, 2, 4 Breath sounds should be verified in all lung fields after thoracentesis to rule out lung collapse. The client is encouraged to perform deep breaths to help expand the lungs. A chest x-ray should be obtained after the procedure to check for pneumothorax. Observing for signs of hypoxia and a pneumothorax is essential, but the signs of pneumonia may not be useful after thoracentesis. The client should be instructed not to talk or cough during the procedure because it may cause injury to the lungs.

Which order of steps would the nurse teach the client to follow while performing expansion breathing? 1. Sit in an upright position with knees slightly bent. 2. Place hands on each side of lower ribcage, just above the waist. 3. Exhale, first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the base of lungs. 4. Take a deep breath through your nose, using shoulder muscles to expand your lower ribcage outward during inhalation.

1, 2, 4, 3 While performing expansion breathing, the client should sit in an upright position with slightly bent knees because it decreases tension on the abdominal muscles and respiratory resistance and discomfort. Then the client should place hands on each side of the lower ribcage, just above the waist. A deep breath through the nose is taken, using shoulder muscles to expand the lower ribcage outward during inhalation. The client then exhales by first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the lungs.

The nurse is assessing a client with hyperthyroidism. Which clinical indicators are consistent with this diagnosis? Select all that apply. 1 Emotional lability 2 Dyspnea on exertion 3 Abdominal distention 4 Decreased bowel sounds 5 Hyperactive deep tendon reflexes

1, 2, 5 Lability of mood is a psychological/emotional manifestation related to excess thyroid hormones. Dyspnea with or without exertion can occur as the body attempts to meet oxygen demands related to the increased metabolic rate associated with hyperthyroidism. Hyperactive reflexes are a neurologic manifestation related to excessive production of thyroid hormones. Abdominal distention is associated with hypothyroidism; it is related to constipation and weight gain. Bowel sounds increase, not decrease, as a result of hyperperistalsis associated with the elevated metabolic rate. Hypoactive bowel sounds are related to hypothyroidism.

A client had thoracic surgery. The nurse should monitor for which clinical manifestations that may indicate acute pulmonary edema? Select all that apply. 1 Crackles 2 Cyanosis 3 Chest pain 4 Bradypnea 5 Frothy sputum

1, 2, 5 1: Crackles 2: Cyanosis 5: Frothy Sputum

The primary healthcare provider has prescribed a stat chest x-ray exam and electrocardiogram for a client with a history of heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. Which immediate actions will the nurse take? Select all that apply. 1 Instruct a staff member to get the electrocardiogram machine. 2 Call for a portable stat chest x-ray. 3 Have a staff member notify the nursing supervisor of the change in client status. 4 Notify the healthcare provider of the change in the oxygen saturation. 5 Tell the certified nursing assistant to get a prescription from the healthcare provider to increase the oxygen. 6 Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula.

1, 2, 6

A client presents to the emergency room with coughing and sudden wheezing. The nurse notes the client is progressing quickly into respiratory distress. The nurse identifies that the client is experiencing what problem? 1 An acute asthma attack 2 Acute bronchitis 3 Left-sided heart failure 4 Cor pulmonale

1: An acute asthma attack

A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary, and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning. Correct 1. Assess client's vital signs and lung sounds Incorrect 2. Insert the catheter without applying suction Incorrect 3. Activate the ventilator suction hyperoxygenation setting Correct 4. Rotate the catheter while suction is applied

1, 3, 2, 4 1: Assess client's vital signs and lung sounds 3: Activate the ventilator suction hyperoxygenation setting 2: Insert the catheter without applying suction 4: Rotate the catheter while suction is applied

A client is diagnosed with hyperthyroidism and is experiencing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? Select all that apply. 1 Use tinted glasses. 2 Use warm, moist compresses. 3 Elevate the head of the bed 45 degrees. 4 Tape eyelids shut at night if they do not close. 5 Apply a petroleum-based jelly along the lower eyelid.

1, 3, 4 Tinted glasses decrease light impacting on the eyes and protect eyes that are photosensitive. Elevating the head of the bed 45 degrees will promote a decrease in periorbital fluid. Taping the eyelids shut at night if they do not close reduces the risk of corneal dryness, which can lead to infection or injury. Cool, moist compresses are used to relieve irritation; warm compresses cause vasodilation, which may aggravate tissue congestion. Artificial tears are used to moisten the eyes, not a petroleum-based jelly.

A client with chronic obstructive pulmonary disease will be taking long-term oral corticosteroid therapy. After the nurse conducts a teaching session, which statements by the client indicates that the nurse should follow up? Select all that apply. 1 "My urine may become discolored." 2 "I need to avoid crowds in enclosed areas." 3 "I will lose weight while on this medication." 4 "The medication should be taken between meals." 5 "When I'm feeling better, I can stop taking this medication." 6 "I will not take aspirin or ibuprofen while on this medication."

1, 3, 4, 5 1: "My urine may become discolored." 3: "I will lose weight while on this medication." 4: "The medication should be taken between meals." 5: "When I'm feeling better, I can stop taking this medication."

Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. 1 Dyspnea 2 Dry cough 3 Diaphoresis 4 Mild chest pain 5 High temperature

1, 3, 5

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Select all that apply. 1 Lips 2 Sclera 3 Mouth 4 Sacrum 5 Nail beds 6 Shoulders

1, 3, 5 Prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best evaluated in lips, mouth, nail beds, and skin (in extreme conditions). Sclera is the site of assessment for jaundice, while shoulders are assessed to confirm the condition of erythema.

The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply. 1 Sudden chest pain 2 Flushing of the face 3 Elevation of temperature 4 Abrupt onset of shortness of breath 5 Pain rating increase from 2 to 8 in the hip

1, 4

When reviewing the results of a toddler's complete blood count, a nurse concludes on the basis of decreased hemoglobin and hematocrit levels that the child has iron-deficiency anemia. Which other laboratory findings are indicative of iron-deficiency anemia? Select all that apply. 1 Microcytic red blood cells 2 Hyperchromic red blood cells 3 Low total iron-binding capacity 4 Slightly reduced reticulocyte count 5 Increased erythrocyte sedimentation rate

1, 4 In iron-deficiency anemia the red blood cells are microcytic, with a decreased mean corpuscular volume. The reticulocyte count is within the expected range or slightly reduced. The red blood cells are hypochromic, not hyperchromic. The total iron-binding capacity is increased in children with iron-deficiency anemia as the body attempts to absorb more iron. An increased erythrocyte sedimentation rate (ESR) indicates an inflammatory process. The ESR is not related to iron-deficiency anemia.

The nurse is caring for a client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? Select all that apply. 1 Dry cough 2 Chest pain 3 Hemoptysis 4 Shortness of breath 5 Fever greater than 100.4° F (38° C)

1, 4, & 5 1: Dry cough 4: Shortness of breath 5: Fever greater than 100.4° F (38° C)

What are the clinical manifestations during the fulminant stage in a client with inhalation anthrax? Select all that apply. 1 Septic shock 2 Harsh cough 3 Mild chest pain 4 Pleural effusion 5 Body temperature of 104 °F

1, 4, 5 Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. Manifestations such as septic shock, pleural effusion, and body temperature above 103°F indicate the fulminant stage of inhalation anthrax. The prodromal stage is the early stage of inhalation anthrax; clinical manifestations include a harsh cough and mild chest pain.

A client comes to the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response? 1 "Cover your cough with your forearm." 2 "Dispose of used paper tissues in a paper bag." 3 "Encourage your roommate to get the flu vaccine." 4 "Move out of your apartment until you are over the cold."

1: "Cover your cough with your forearm."

During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response? 1 "You seem concerned about your diagnosis." 2 "You are feeling guilty about your smoking." 3 "There have been advances in lung cancer therapy." 4 "Trust your healthcare provider, who is very competent in treating cancer."

1: "You seem concerned about your diagnosis."

Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) should be administered in which manner? 1 1 to 2 L via nasal cannula to keep SaO2 above 90%. 2 1 to 2 L via nasal cannula to maintain SaO2 at or above 95%. 3 3 L via mask to maintain SaO2 at 95%. 4 Do not give oxygen because it may suppress hypoxic drive in client.

1: 1 to 2 L via nasal cannula to keep SaO2 above 90%.

A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client? 1 Air will move from the lung into the pleural space. 2 The heart and great vessels shift toward the affected side. 3 There is greater negative pressure within the chest cavity. 4 Collapse of the other lung will occur if not treated immediately.

1: Air will move from the lung into the pleural space

The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique? 1 Arterial oxygen saturation 2 Partial pressure of oxygen in arterial blood 3 Partial pressure of arterial carbon dioxide 4 Partial pressure of oxygen in venous blood

1: Arterial oxygen saturation

Which would the nurse consider to be a potential respiratory system-related complication of surgery? 1 Atelectasis 2 Hyperthermia 3 Wound dehiscence 4 Hypovolemic shock

1: Atelectasis

A client with terminal cancer 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 concludes the client is experiencing? Correct1 Bargaining 2 Frustration 3 Depression 4 Rationalization

1: Bargaining

A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level? 1 Cannula 2 Catheter 3 Venturi mask 4 Rebreather mask

1: Cannula

Which condition can cause a client's partial pressure of end-tidal carbon dioxide (PETCO2) to be 50 mmHg? 1 Hypoventilation 2 Tracheal extubation 3 Pulmonary embolism 4 Total airway obstruction

1: Hypoventilation

A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority? 1 Immediately contact the primary healthcare provider 2 Document the amount of sputum 3 Monitor vital signs every hour 4 Increase the frequency of coughing and deep breathing

1: Immediately contact the primary healthcare provider

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs? 1 Increased restlessness 2 No secretions when client is suctioned 3 PaO2 of 93 4 Skin warm and dry

1: Increased restlessness

A client sustains a stab wound to the chest, and a chest tube is inserted. Later the client's chest tube appears to be obstructed. Which is the most appropriate nursing action? 1 Instruct the client to cough 2 Clamp the tube immediately 3 Prepare for chest tube removal 4 Arrange for a stat chest x-ray film

1: Instruct the client to cough

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take? 1 Instruct the client to splint the wound with a pillow when coughing. 2 Place the client in the supine position and inspect the site of the incision. 3 Assess the intensity of the pain and administer the prescribed analgesic. 4 Call the healthcare provider immediately and then check for wound dehiscence.

1: Instruct the client to splint the wound with a pillow when coughing.

Which statement appropriately describes tidal volume? 1 It is the volume of air inhaled and exhaled with each breath. 2 It is the amount of air remaining in the lungs after forced expiration. 3 It is the additional air that can be forcefully inhaled after normal inhalation. 4 It is the additional air that can be forcefully exhaled after normal exhalation.

1: It is the volume of air inhaled and exhaled with each breath.

The nurse is providing care during the immediate postoperative period for a client who had a radical neck dissection. What is the best method to assess for stridor? 1 Listen with a stethoscope over the trachea 2 Determine the client's ability to do neck exercises 3 Listen with a stethoscope over the base of the lungs 4 Determine the client's ability to cough and deep breathe

1: Listen with a stethoscope over the trachea

After a lateral crushing chest injury, obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. Which complication associated with this injury should the nurse assess in this client? 1 Mediastinal shift 2 Tracheal laceration 3 Open pneumothorax 4 Pericardial tamponade

1: Mediastinal shift

A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, what should the nurse do? 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

A nurse observes a client with acute bronchitis and emphysema sitting up in bed, appearing anxious and dyspneic. What should the nurse do first? 1 Provide oxygen at 2 L per minute 2 Encourage deep breathing and coughing 3 Administer the prescribed sedative and encourage rest 4 Suggest breathing into a paper bag for several minutes

1: Provide oxygen at 2 L per minute

A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. What should a nurse do first? 1 Raise the head of the bed. 2 Apply oxygen. 3 Assess breath sounds. 4 Call the primary healthcare provider requesting a STAT chest x-ray.

1: Raise the head of the bed

A serious train accident occurs in the community. At the scene of the accident, a triage nurse is identifying and labeling victims according to triage acuity principles. With what color tag should the nurse label a client who is experiencing respiratory distress? 1 Red 2 Black 3 Green 4 Yellow

1: Red

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum? 1 Sooty 2 Frothy 3 Yellow 4 Tenacious

1: Sooty

A client who had a laryngectomy for cancer of the larynx is being transferred from the postanesthesia care unit to a surgical unit. Which is the most important equipment that the nurse should place in the client's room? 1 Suction supplies 2 Writing materials 3 Tracheostomy set 4 Incentive spirometer

1: Suction Supplies

A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency while the client is in the postanesthesia care unit, what should the nurse do? 1 Suction as needed 2 Apply an ice collar 3 Maintain a high-Fowler position 4 Encourage expectoration of secretions

1: Suction as needed

A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measured when the client follows these directions? 1 Tidal volume 2 Vital capacity 3 Expiratory reserve 4 Inspiratory reserve

1: Tidal volume

A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon awakening in the morning. What should the nurse suggest to the client? 1 Use a humidifier in the bedroom. 2 Sleep with two or more pillows. 3 Cough regularly even if the cough does not produce sputum. 4 Cough and deep breathe each night before going to sleep.

1: Use a humidifier in the bedroom

A client has a laryngectomy. The avoidance of which activity identified by the client indicates that the nurse's teaching about activities and the stoma is understood? 1 Water sports 2 Strenuous exercises 3 Sleeping with pillows 4 High-humidity environment

1: Water sports

After assessing a client's breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse's suspicion? 1 Wheezing 2 Rhonchi 3 Pleural friction rub 4 Low-pitched crackles

1: Wheezing

A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention? 1 Increasing physical activities 2 Performing postural drainage 3 Maintaining dietary restrictions 4 Administering prescribed pancreatic enzymes

2

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? 1 Clamp the chest tubes when suctioning. 2 Palpate the surrounding area for crepitus. 3 Change the dressing daily using aseptic technique. 4 Empty the drainage chamber at the end of the shift.

2

A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client? 1 Take a baby aspirin every day 2 Ambulate early and frequently 3 Sit for prolonged periods of time 4 Place a warm soak on the legs daily

2

A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? 1 Bradycardia 2 Restlessness 3 Constricted pupils 4 Clubbing of the fingers

2

A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first? 1 Prepare to intubate the client. 2 Increase the oxygen flow rate per facility protocol. 3 Decrease the tension of oxygen in the plasma. 4 Have the arterial blood gases redone to verify accuracy.

2

A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention? 1 Administer oral fluids. 2 Encourage deep breathing. 3 Increase the oxygen flow rate. 4 Perform nasotracheal suctioning.

2

A client with a 10-year history of emphysema is admitted in acute respiratory distress. During assessment, what does the nurse expect to identify? 1 Chest pain on inspiration 2 Prolonged expiration with use of accessory muscles 3 Signs and symptoms of respiratory alkalosis 4 Decreased respiratory rate

2

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? 1 Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. 2 Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. 3 Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. 4 Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.

2

A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery? 1 Constipation 2 Muscle spasms 3 Hypoactive reflexes 4 Increased specific gravity

2

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1 Limit the client's fluid intake. 2 Teach the client how to exercise the legs. 3 Encourage use of the incentive spirometer. 4 Maintain the knee gatch position at an angle.

2

A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? 1 Metabolic alkalosis 2 Myocardial hypoxia 3 Decreased catecholamine secretion 4 Increased parasympathetic nervous system stimulation

2

A nurse is monitoring a client with severe preeclampsia who is receiving an infusion of magnesium sulfate. Assessment reveals a pulse rate of 55 beats/min, a respiratory rate of 10 breaths/min, and a flushed face. What are the next nursing actions? 1 Continuing the infusion and notifying the primary healthcare provider 2 Stopping the infusion and starting an infusion of dextrose and water 3 Continuing the infusion and documenting the findings in the clinical record 4 Decreasing the rate of the infusion and obtaining blood for a magnesium level

2

A nurse uses abdominal-thoracic thrusts (Heimlich maneuver) when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts to expel a foreign object in the larynx? 1 Tidal 2 Residual 3 Vital capacity 4 Inspiratory reserve

2

A toddler with cystic fibrosis has been hospitalized with bacterial pneumonia. The nurse determines that the child has no known allergies. What does the nurse conclude is the reason that the healthcare provider selected a specific antibiotic? 1 Tolerance of the child 2 Sensitivity of the bacteria 3 Selectivity of the bacteria 4 Preference of the healthcare provider

2

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, what should the nurse do? 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

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? 1 Stimulating crying 2 Suctioning the airway 3 Using an Ambu bag with oxygen support 4 Placing the infant in the reverse Trendelenburg position

2

During the immediate postpartum period, the client with heart disease may experience increased cardiac output with tachycardia. This knowledge should motivate the nurse who is caring for this client to monitor her for what? 1 Irregular pulse 2 Labored breathing 3 Hypovolemic shock 4 Increased vaginal bleeding

2

The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding? 1 Productive coughing 2 Return of breath sounds 3 Increased pleural drainage in the chamber 4 Constant bubbling in the water-seal chamber

2

The nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client's condition? 1 Bacillus anthracis 2 Bordetella pertussis 3 Streptococcus pneumoniae 4 Mycobacterium tuberculosis

2

The nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction? 1 Deep breathing 2 Hoarse quality to the voice 3 Pink-tinged, frothy sputum 4 Rapid abdominal breathing

2

The nurse is providing postoperative care for a client who had an extensive surgical revision of the head of the pancreas. To decrease the risk of hemorrhage at the operative site, what action should the nurse take? 1 Keep the client in the supine position. 2 Maintain patency of the nasogastric tube. 3 Replace fat-soluble vitamins as necessary. 4 Administer prescribed tube feedings to the client slowly.

2

The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How does the nurse describe this assessment finding? 1 Respiratory stridor 2 Subcutaneous emphysema 3 Bilateral 2+ pitting edema 4 Chest distention

2

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client? 1 Apnea 2 Bradypnea 3 Tachypnea 4 Hyperpnea

2

The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement? 1 "I will try to avoid smoking." 2 "I will maintain complete bed rest." 3 "I'll control the temperature in my home." 4 "I'll need to clean my mouth several times a day."

2

What is an appropriate nursing intervention for a neonate with respiratory distress syndrome (RDS)? 1 Avoid handling the infant to conserve energy 2 Position the infant to promote respiratory efforts 3 Assess the infant for congenital birth defects to enable early treatment 4 Set the incubator thermostat 10° F (12° C) below body temperature to prevent shivering

2

What is the priority nursing action when caring for a client with disseminated intravascular coagulation? 1 Monitor for Homans sign. 2 Avoid giving intramuscular injections. 3 Take temperatures via the rectal route. 4 Apply sequential compression stockings.

2

Which clinical manifestation can a client experience during a fat embolism syndrome (FES)? 1 Nausea 2 Dyspnea 3 Orthopnea 4 Paresthesia

2

Which part of the respiratory system is referred to as Angle of Louis? 1 Hilum 2 Carina 3 Alveoli 4 Epiglottis

2

A client is admitted to the surgical unit with superficial wounds of both wrists, the result of a suicide attempt. When the nurse enters the room, the client says, "I suppose you're going to ask me about my suicide attempt." What is the best response by the nurse? 1 "Do you want to talk about it?" 2 "Tell me how you feel about it." 3 "It's best not to dwell on it right now." 4 "Why do you think I'd ask you about it?"

2 "Tell me how you feel about it" moves the emphasis from facts to feelings; it focuses on the client without setting the direction for communication. "Do you want to talk about it?" is a rhetorical question, because the client has already brought up the topic. Also, it will elicit a yes or no response that limits discussion. "It's best not to dwell on it right now" denies the client's feelings and cuts off further communication. "Why do you think I'd ask you about it?" is a direct question that the client will probably be unable to answer.

A client has a leaking thoracic duct following a radical neck surgery. What does the nurse expect the postoperative plan of care to include? 1 A gastrostomy tube, a high-fat diet, and bed rest 2 A chest tube, total parenteral nutrition (TPN), and bed rest 3 A rectal tube, a low-fat diet, and increased activity 4 A nasogastric tube, a moderate-fat diet, and increased activity

2 A chest tube drains the leaking chyle from the thoracic area; TPN provides nutrition, boosts immune defenses, and decreases thoracic duct flow. Bed rest is recommended because lymphatic flow increases with activity. A gastrostomy tube is not used because the client can eat and drink; a high-fat diet is contraindicated, but bed rest is recommended. A rectal tube has no relationship to the drainage of chyle from the thoracic area; a low-fat diet and bed rest are recommended. The nasogastric tube does not drain fluid from the thoracic area; a low-fat diet and bed rest are recommended. A low-fat diet of medium-chain triglycerides will reduce the production and flow of chyle.

A client at 32 weeks' gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone 12 mg is prescribed. What should the nurse tell the client about why the medication is being given? 1 Cervical dilation is increased. 2 Fetal lung maturity is accelerated. 3 The risk of a precipitous birth is reduced. 4 The potential for maternal hypertension is minimized.

2 A steroid such as betamethasone or dexamethasone administered to the mother crosses the placenta and promotes lung maturity in the fetus. Steroids do not cause an increase in cervical dilation, reduce the risk of precipitous birth, or minimize the potential for maternal hypertension.

What nursing intervention is the priority in the period immediately after an emaciated 13-year-old child's admission to the hospital for starvation resulting from anorexia nervosa? 1 Ensuring that rest and nutrition needs are met 2 Correcting the child's fluid and electrolyte imbalances 3 Obtaining more data about the child's diet and exercise program 4 Completing an assessment of the child's physical and mental status

2 Anorexic children are usually severely malnourished and have severe fluid and electrolyte imbalances. Unless these imbalances are corrected, cardiac irregularities and death may occur. Rest and nutrition, information on diet and exercise, and assessment of physical and mental status are important, but none is the priority at this time.

What is the priority goal for a client with asthma who is being discharged from the hospital with prescriptions for inhaled bronchodilators? 1 Is able to obtain pulse oximeter readings 2 Demonstrates use of a metered-dose inhaler 3 Knows the healthcare provider's office hours 4 Can identify the foods that may cause wheezing

2 Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack; this is an important skill to have before discharge. Pulse oximetry is rarely conducted in the home; home management usually includes self-monitoring of the peak expiratory flow rate. Although knowing the healthcare provider's office hours is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance. Not all asthma is associated with food allergies

A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. When caring for this client, what should the nurse do? 1 Administer opioids frequently 2 Assess for signs of pneumonia 3 Give medication to suppress coughing 4 Limit fluid intake to prevent pulmonary edema

2 Clients with pleuritic disease are prone to developing pneumonia because of impaired lung expansion, air exchange, and drainage. Opioids are contraindicated because opioids depress respirations. Coughing should not be suppressed; it enhances lung expansion, air exchange, and lung drainage. Oral fluids should be encouraged; pulmonary edema does not develop unless the client has severe cardiovascular disease.

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care? 1 Use calamine lotion for pruritus. 2 Keep skin lubricated with lotion. 3 Apply warm soaks to inflamed areas. 4 Take frequent baths to remove scaly lesions.

2 With scleroderma, the skin becomes dry because of interference with the underlying sweat glands. Pruritus, inflamed areas, and skin lesions are not associated with scleroderma.

A client is admitted for an exacerbation of emphysema. The client has a fever, chills, and difficulty breathing on exertion. What is the priority nursing action based on the client's history and present status? 1 Checking for capillary refill 2 Encouraging increased fluid intake 3 Suctioning secretions from the airway 4 Administering a high concentration of oxygen

2 Fluids will replace fluid loss from fever and decrease viscosity of secretions. Capillary refill relates to peripheral tissue perfusion. There are no data to suggest that secretions are blocking the airway; there is no support that suctioning is needed. High concentrations of oxygen generally are not administered to clients with chronic obstructive pulmonary disease (COPD); traditionally, the reason given for this was that clients with COPD become desensitized to carbon dioxide as a respiratory stimulus so that reduced oxygen levels act as the stimulus and high concentrations of oxygen levels may actually depress respirations. The newer theory suggests that the hypoxic drive is valid for a small number. The majority of cases involve the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia.

A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? 1 Curing the condition permanently 2 Raising mucous secretions from the chest 3 Limiting pulmonary secretions by decreasing fluid intake 4 Convincing the client that the condition is emotionally based

2 In addition to dilation of bronchi, treatment is aimed at expectoration of mucus. Mucus interferes with gas exchange in the lungs. Curing the condition permanently is an unrealistic goal; asthma is a chronic illness. Increased fluid intake helps liquefy secretions. Asthma has a psychogenic factor, but this is not the only cause; it may occur as an allergic response to an antigen, such as dust.

A client tells the nurse, "All my friends experiment with drugs. I like the high I get when I huff paint. Nothing bad is going to happen to me." What is the best response by the nurse? 1 "Inhalants can cause a mild state of intoxication." 2 "Huffing paint can damage your lungs, kidneys, and liver." 3 "Withdrawal problems will start if you continue huffing paint." 4 "Limiting the type of inhalant used decreases respiratory irritation."

2 Inhaled toxins become systemic and cause damage to major organs such as the lungs, liver, and kidneys. Inhalants tend to produce euphoria, not just a mild state of intoxication. Huffing paint will not produce major withdrawal symptoms. All toxic substances that are inhaled become systemic and cause damage to major organs such as the lungs, liver, and kidneys.

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? 1 Stridor 2 Crackles 3 Wheezes 4 Friction rubs

2 Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are not heard with heart failure, but with asthma. Friction rubs are not heard with heart failure, but with pleurisy.

A client with Lyme disease presents with dyspnea, dizziness, and facial paralysis. Which medication may be included in the prescription? 1 Amoxicillin 2 Ceftriaxone 3 Doxycycline 4 Erythromycin

2 Lyme disease is a systemic infectious disease caused by the spirochete Borrelia burgdorferi and results from the bite of an infected deer tick, also known as the blacklegged tick. Stage II of Lyme disease is characterized by dizziness, dyspnea, and facial paralysis, and may be treated with ceftriaxone. Amoxicillin, doxycycline, and erythromycin are prescribed to treat localized stage I of Lyme disease.

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care? 1 Lessens the client's chest discomfort 2 Restores negative pressure in the pleural space 3 Drains accumulated fluid from the pleural cavity 4 Prevents subcutaneous emphysema in the chest wall

2 Negative pressure is exerted by gravity drainage or by suction through the closed system. Though the discomfort may be lessened as a result of the insertion of the chest tube, this is not the primary purpose. There is an accumulation of air, not fluid, when a pneumothorax occurs in a client with COPD. Subcutaneous emphysema in the chest wall is associated most commonly with clients receiving air under pressure, such as that received from a ventilator; subcutaneous emphysema can also occur with a chest tube.

The nurse in the postanesthesia care unit is caring for a client who had a left-sided pneumonectomy. Which goal is priority? 1 Replace blood loss 2 Maintain ventilatory exchange 3 Maintain closed chest drainage 4 Replace supplemental oxygenation

2 Oxygen and carbon dioxide exchange is essential for life and is the priority. Blood replacement is not the priority. Closed chest drainage is unnecessary with a left-sided pneumonectomy because there is no lung to reinflate. Supplemental oxygenation is not the priority.

Oxygen therapy is prescribed for a client being cared for in the coronary care unit. The nurse implements safety precautions. Which information should the nurse consider when planning care for this client? 1 Oxygen is flammable. 2 Oxygen supports combustion. 3 Oxygen has unstable properties. 4 Oxygen converts to an alternate form of matter.

2 Oxygen is necessary for the production of fire. Oxygen does not burn; it supports combustion. Flammability, unstable properties, and conversion to an alternate form of matter are irrelevant regarding the need for safety precautions.

In addition to Pneumocystis jiroveci, a client with acquired immunodeficiency syndrome (AIDS) also has an ulcer 4 cm in diameter on the leg. Considering the client's total health status, what is the most critical concern? 1 Skin integrity 2 Gas exchange 3 Social isolation 4 Nutritional status

2 P. jiroveci, now believed to be a fungus, causes pneumonia in immunosuppressed hosts; it can cause death in 60% of the clients. The client's respiratory status is the priority. Although skin integrity, social isolation, and nutritional status are concerns, the client's respiratory status is the priority.

A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made, and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care? 1 Place in a warm, dry environment. 2 Maintain standard and contact precautions. 3 Administer prescribed antibiotic immediately. 4 Allow parents and siblings to room in with the infant.

2 RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Standard and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive cool, humidified oxygen by nasal cannula or mask or in a croup tent. Because RSV is extremely contagious, the number of visitors should be limited. Uninfected children should not be allowed near the infant, and as few personnel as possible should care for the infant. Antibiotics are not effective against RSV, and their use is contraindicated.

A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a laryngectomy is scheduled. What is the most important piece of equipment that the nurse should place at the client's bedside postoperatively? 1 Tracheostomy set 2 Suction equipment 3 Humidified oxygen 4 Cold-steam vaporizer

2 Suction equipment is essential because respiratory complications can occur subsequent to edema of the glottis or to injury to the recurrent laryngeal nerve. A tracheostomy set is unnecessary because a permanent stoma is surgically created and a laryngectomy tube is in place. However, an additional sterile laryngectomy tube should be kept at the bedside. Oxygen may not be necessary unless there is a complication. Although a cold-steam vaporizer may promote moist mucous membranes, it usually is unnecessary; also, it is rarely used in a hospital because of the possibility of the growth and transmission of microorganisms.

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. 1 "Do you experience a morning headache?" 2 "Have you ever smoked elicit street drugs?" 3 "What do you do when you get short of breath?" 4 "Are you able to maintain a typical activity pattern?" 5 "What equipment helps you manage your respiratory problems?"

2 & 5 2: "Have you ever smoked elicit street drugs?" 5: "What equipment helps you manage your respiratory problems?"

The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. What should the nurse do? 1 Notify the healthcare provider immediately of the findings. 2 Administer the prescribed oxygen. 3 Record the observations and continue to observe the client. 4 Administer the prescribed antianxiety medication.

2 The cardiovascular and nervous systems of older adults are less flexible than those in a younger age group; postoperative hypoxia responds to oxygen. Notifying the healthcare provider is unnecessary because it is a common reaction of older adults to anesthesia, which may be alleviated by oxygen. Although necessary, recording the observations will not help the client adapt. An anxiolytic may increase agitation.

A client has a laryngectomy and radical neck dissection for cancer of the larynx. Two tubes from the area of the incision are connected to portable wound drainage systems. Inspection of the neck reveals moderate edema even though the drainage systems are functioning. Which clinical indicator should the nurse assess in the client? 1 Crackles 2 Restlessness 3 Loss of the gag reflex 4 Cloudy wound drainage

2 The client has a high risk for airway obstruction from the edema; restlessness and dyspnea indicate cerebral hypoxia. Crackles come from the alveoli, part of the lower airway; the surgery involves the upper airway. There is no evidence of abdominal distention. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed, and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Cloudy drainage may indicate infection; however, this is not an immediate postoperative complication.

An obese client leads a sedentary lifestyle and complains of leg pain when walking long distances. A nurse leader is teaching the client different exercises that can relieve the pain and can be performed while working in an office or doing daily activities. Which of Gardner's leadership tasks is the leader nurse following? 1 Managing 2 Explaining 3 Motivating 4 Affirming values

2 The nurse leader is performing the explaining element of Gardner's leadership tasks. Explaining includes teaching and interpreting information to promote client functioning and well-being. Managing involves assisting the client with planning, priority setting, and decision making while ensuring the organizational systems work on the client's behalf. Motivating is inspiring clients to achieve their vision. Assisting clients in sorting out and articulating personal values in relation to health problems falls under the affirming values task.

A nurse is caring for a newborn with a diaphragmatic hernia and impaired gas exchange. What does the nurse identify as the cause of the infant's decreased gas exchange? 1 Incarcerated hernia 2 Decreased oxygen intake 3 Increased basal metabolic rate 4 Excessive respiratory secretions

2 The presence of abdominal viscera in the thoracic cavity impinges on the lungs and affects their ability to expand, thus limiting the amount of air that can enter the lungs and alveoli. In addition, these newborns tend to have underdeveloped lungs. An incarcerated hernia, although a medical emergency, does not impair gas exchange on a long-term basis. The basal metabolic rate is not increased with a diaphragmatic hernia. Excessive secretions do not occur with a diaphragmatic hernia.

A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse? 1 "I will ask the primary healthcare provider to clarify the diagnostic procedure." 2 "Tell me more about the conversation you had with your healthcare provider." 3 "The procedure will be fast so that you will experience minimal discomfort." 4 "Your perception of the diagnostic test is incorrect."

2 The response "Tell me more about the conversation you had with your healthcare provider" is the best response. Exploration and collection of data are important parts of the therapeutic process; anxiety, fear, and depression can influence understanding of the procedure. Instructing the client to ask the healthcare provider to clarify the procedure is not the priority; at this point, the nurse should collect more data and then may have to refer. The response "The procedure will be fast so that you will experience minimal discomfort" is false reassurance. The response "Your perception of the diagnostic test is incorrect" will put the client on the defensive.

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? 1 Fatigue related to weight loss secondary to COPD 2 Imbalanced nutrition: less than body requirements, related to fatigue 3 Imbalanced nutrition: less than body requirements, related to COPD 4 Ineffective breathing pattern, related to alveolar hypoventilation

2 The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.

A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy? 1 "No, try to be in your sense of reality." 2 "Yes, today is the day that you just mentioned." 3 "You should try improving your awareness level." 4 "Try to recall your past memories associated with the day."

2 Validation therapy an approach to communication with a confused client with dementia. In this approach, the nurse accepts the description of the time and place as stated by the client. Therefore, the statement "Yes, today is the day that you just mentioned" represents the use of validation therapy. Asking the client to reorient himself or herself to reality and asking him or her to improve his or her awareness level are examples of the reality orientation approach. Reminiscence is an approach that asks the client to recall his or her past experience.

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply. 1 Weight loss 2 Unusual fatigue 3 Dependent edema 4 Nocturnal dyspnea 5 Increased urinary output

2, 3, 4

Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? Select all that apply. 1 Elevated levels of partial arterial oxygen 2 Elevated levels of eosinophils 3 Elevated levels of neutrophils 4 Elevated levels of red blood cells 5 Elevated levels of peripheral capillary oxygen saturation

2, 3, 4 Elevated levels of eosinophils, neutrophils, and red blood cells are often related to the excessive production of erythropoietin in response to a chronic hypoxic state and indicates possible chronic obstructive pulmonary disease. Elevated levels of partial arterial oxygen and peripheral capillary oxygen saturation are not associated with chronic obstructive pulmonary disease. However, elevated levels of partial arterial oxygen indicate possible excessive oxygen administration. Decreased levels of peripheral capillary oxygen saturation indicate possible impaired ability of hemoglobin to release oxygen to tissues.

Which preoperative and postoperative care points should be included when providing education and intervention to a client scheduled for a septoplasty? Select all that apply. 1 Teach the client about hot compresses. 2 Encourage the client to quit smoking before surgery. 3 Observe the surgical site for edema. 4 Teach the client about post-surgery activities that are restricted. 5 Assess the client's respiratory status. 6 Encourage the client to take aspirin before the surgery.

2, 3, 4, & 5 2: Encourage the client to quit smoking before surgery. 3: Observe the surgical site for edema. 4: Teach the client about post-surgery activities that are restricted 5: Assess the client's respiratory status.

A nurse is caring for several postoperative clients. For which clinical manifestations of a pulmonary embolus should the nurse monitor these clients? Select all that apply. 1 Apathy 2 Dyspnea 3 Hemoptysis 4 Bronchial wheezes 5 Feeling of impending doom

2, 3, 5

During chest assessment of a client with idiopathic pulmonary fibrosis, the nurse hears short, discontinuous, high-pitched sounds that sound like hair being rolled between the fingers just behind the ear in the bilateral lower lobes. Which respiratory disorders may also manifest these sounds as a pathophysiological sign? Select all that apply. 1 Croup 2 Atelectasis 3 Cystic fibrosis 4 Bronchospasm 5 Pulmonary edema

2, 5 The short, discontinuous, high-pitched sounds that sound like hair being rolled between fingers just behind the ear in the bilateral lower lobes indicate fine crackles. These sounds may be auscultated in clients with pulmonary disorders such as idiopathic pulmonary fibrosis, atelectasis, and pulmonary edema. Croup is a respiratory disorder characterized by a continuous musical or a crowing sound of a constant pitch. Cystic fibrosis is characterized by continuous rumbling, snoring, and rattling sounds from secretions obstructing large airways. Bronchospasms are characterized by continuous high-pitched, squeaking, or musical sounds caused by rapid vibration of bronchial walls.

A nurse is caring for a client who underwent surgery for laryngeal cancer. Which nursing action may help to communicate effectively with the client? Select all that apply. 1 Asking the client open-ended questions 2 Providing the client with praise and encouragement 3 Collaborating with a speech and language pathologist 4 Using a high-pitched tone of voice to speak with the client 5 Asking the client to make noise when immediate attention is required

2, 3, 5 Following a surgery for laryngeal cancer, a client may not be able to talk because of removal of the vocal cords. Praising or encouraging the client may help to motivate the client to communicate more effectively. Collaborating with a speech and language pathologist can help to make the client aware of different ways to effectively communicate. Asking the client to make noise may help the client avoid accidents and may help to alert the nurse if the client needs attention. Open-ended question should not be asked because the client may not be able to explain things. Asking simple questions requiring an answer of yes or no may be more useful. After laryngeal surgery clients may not be able talk but can hear properly. Therefore a normal tone of voice should be used.

A client has a hysterectomy, salpingo-oophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations indicating that the client may be experiencing a pulmonary embolus should the nurse assess the client? Select all that apply. 1 Flushed face 2 Increased temperature 3 Severe abdominal pain 4 Decreased oxygen saturation level 5 Sudden onset of shortness of breath

2, 4 , 5

The nurse is studying the stages that characterize the progression of chemical pneumonia in young children following ingestion of a hydrocarbon. Which symptoms does the nurse correctly list as occurring in the third stage postingestion, between 72 to 96 hours? Select all that apply. 1 Sweating 2 Stupor 3 Multiple organ failure 4 Coagulation abnormalities 5 Pain in right upper quadrant

2, 4, 5

A nursing student is learning about Erikson's theory of psychosocial development. Which statement made by the client indicates the Identity versus Role Confusion stage? Select all that apply 1 "I fear that this relationship will not last, just like the previous one." 2 "I like to dress like a boy even though my parents want me to dress like a girl." 3 "When I look back at my life, I feel that I have not been able to be a good mother." 4 "I want to get a clear skin like my best friend, so I am visiting the skin specialist today." 5 "I do not want to become an engineer like my parents want me to be; I dream of becoming a pilot."

2, 4, 5 According to Erikson's theory of psychosocial development, in the Identity versus Role Confusion stage, an individual may pass through dramatic physiological changes. A client who says that she likes to dress like a boy but her parents want her to dress like a girl is in the Identity versus Role Confusion stage. A client who wants clear skin like his or her best friend is also in this stage. A client who wants to become a pilot instead of an engineer is also in the Identity versus Role Confusion stage. A client who fears that his or her relationship will not last like his or her previous one is in the Intimacy versus Isolation stage. An older adult who feels that she has not been able to be a good mother is in the Integrity versus Despair stage.

What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply. 1 Polyps 2 Gag reflex 3 Shotty nodes 4 Poor dentition 5 Gum retraction

2, 4, 5 The nurse should place a tongue blade along the side of the client's pharynx behind the tonsil and stimulate the gag reflex. Using a good light source, the nurse should inspect the interior of the mouth for poor dentition and gum retraction. These findings may indicate the presence of a respiratory disorder. Polyps may result from a long-term infection of the oral mucosa. The nurse should observe for the presence of polyps during an inspection of the nose. The presence of small, mobile nontender or shotty nodes is not a sign of the pathologic condition.

A client is to continue oxygen therapy at home when discharged. Which client statement indicates the need for further instruction by the nurse? 1 "I will use only grounded electrical equipment." 2 "I have a new woolen blanket to keep me warm." 3 "I have told my family they cannot smoke in the house." 4 "I will keep a pitcher of water near me so I drink enough."

2: "I have a new woolen blanket to keep me warm."

A nurse is teaching a client about self-management techniques for smoking cessation. Which statement made by the client indicates the need for further teaching? 1 "I should list the reasons why I should stop smoking." 2 "I should visit all the places where I started smoking." 3 "I should remove all ashtrays and lighters." 4 "I should try replacing tobacco with sugarless mints and gum."

2: "I should visit all the places where I started smoking."

The nurse is teaching a student nurse about the preventive measures to be taken to prevent injury in clients who are receiving anticoagulant therapy. Which statement indicates the need for further teaching? 1 "I will handle the client gently and carefully." 2 "I will assess intravenous sites at least every 6 hours for bleeding." 3 "I will use a lift sheet when moving and positioning the client in bed." 4 "I will use the smallest gauge needle when injections or venipunctures are necessary."

2: "I will assess intravenous sites at least every 6 hours for bleeding."

After surgery for cancer of the posterior pharynx, a client is receiving gavage feedings through a nasogastric tube. A family member asks why this is necessary. What is the nurse's best response? 1 "Tube feedings prevent aspiration of food into the lungs." 2 "Tube feedings promote healing by reducing the risk for infection." 3 "Let me show you how to do a gavage. It will make you less anxious." 4 "You seem concerned about the gavage. You probably will not have to do this at home."

2: "Tube feedings promote healing by reducing the risk for infection."

A client tells the nurse that the client's chest tube is scheduled to be removed soon. Before it is removed, what is the nurse aware of? 1 The drainage system will be disconnected from the chest tube. 2 A chest x-ray will be performed to determine lung re-expansion. 3 An arterial blood gas will be obtained to determine oxygenation status. 4 The client will be sedated 30 minutes before the procedure.

2: A chest x-ray will be performed to determine lung re-expansion.

A client is brought to the emergency department after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. What client reaction should cause a nurse the most concern? 1 Ischemia 2 Asphyxia 3 Lactic acidosis 4 Increased blood pressure

2: Asphyxia

A nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. What does the nurse conclude is the probable cause of the severe dyspnea? 1 Abdominal distention or pressure Correct2 Bronchial obstruction or pleural effusion 3 Fluid retention as a result of renal failure 4 Anxiety associated with pain on inspiration

2: Bronchial obstruction or pleural effusion

A client is diagnosed with emphysema. What long-term problem should the nurse monitor in this client? 1 Localized tissue necrosis 2 Carbon dioxide retention 3 Increased respiratory rate 4 Saturated hemoglobin molecules

2: Carbon dioxide retention

A client is diagnosed with thrombophlebitis. The client states, "I am worried about getting a clot in my lungs that will kill me." Which should be the nurse's initial response? 1 Clarify the misconception 2 Discuss the client's concerns 3 Explain measures to prevent pulmonary emboli 4 Teach recognition of early symptoms of pulmonary emboli

2: Discuss the client's conerns

A client develops increased respiratory secretions because of radiation therapy to the lung, and the healthcare provider prescribes postural drainage. What client assessment leads the nurse to determine that the postural drainage is effective? 1 Is free of crackles 2 Has a productive cough 3 Is able to expectorate saliva 4 Can breathe deeply through the nose

2: Has a productive cough

A nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula? 1 Has an upper respiratory infection 2 Has many visitors while sitting in a chair 3 Has a nasogastric tube for gastric decompression 4 Has dry oral mucous membranes from mouth breathing

2: Has many visitors while sitting in a chair

The client with emphysema complains of increased shortness of breath and becomes anxious. The healthcare provider prescribes oxygen at 1 L/min via nasal cannula. The nurse understands that this prescription is appropriate for what reason? 1 High concentrations of oxygen cause alveoli to rupture. 2 High concentrations of oxygen eliminate the respiratory drive. 3 The client does not need any more than 1 L/min. 4 The oxygen at 1 L/min should be enough to diminish the anxiety.

2: High concentrations of oxygen eliminate the respiratory drive.

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? 1 Apply negative pressure while inserting the suction catheter. 2 Hyperoxygenate with 100% oxygen before and after suctioning. 3 Suction two to three times in succession to effectively clear the airway. 4 Use rapid movements of the suction catheter to loosen secretions.

2: Hyperoxygenate with 100% oxygen before and after suctioning.

A client appears anxious, exhibiting 40 shallow respirations per minute. The client complains of feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. What does the nurse conclude that the client's complaints probably are related to? 1 Eupnea 2 Hyperventilation 3 Kussmaul respirations 4 Carbon dioxide intoxication

2: Hyperventilation

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. Which type of lung sounds will the nurse hear? 1 Snorting sounds during the inspiratory phase 2 Moist rumbling sounds that clear after coughing 3 Musical sounds more pronounced during expiration 4 Crackling inspiratory sounds unchanged with coughing

2: Moist rumbling sounds that clear after coughing

A nurse who is caring for a client after head and neck surgery is concerned with the client's anger and depressive episodes about the effects of surgery. Which action indicates the client is reaching acceptance? 1 Smiling and becoming more extroverted 2 Performing self-care of the tracheal stoma 3 Ambulating in the hall and sitting in the lounge 4 Allowing a family member to participate in care

2: Performing self-care of the tracheal stoma

While assessing a client, the nurse finds increased vibrations over the chest wall. What condition can be inferred from this finding? 1 Atelectasis 2 Pneumonia 3 Orthopnea 4 Pneumothorax

2: Pneumonia

A client with obstructive airway disease reports to the nurse about experiencing spasms of coughing. What suggestion should the nurse provide to help the client successfully manage this problem? 1 Limit the intake of highly seasoned foods. 2 Postpone the planned vacation to go skiing. 3 Use aerosolized cleaning products when dusting. 4 Perform mild physical exercise when breathing difficulties occur.

2: Postpone the planned vacation to go skiing

The nurse is caring for a client who is hyperventilating. The nurse recalls that the client is at risk for what? 1 Respiratory acidosis 2 Respiratory alkalosis 3 Respiratory compensation 4 Respiratory decompensation

2: Respiratory alkalosis

A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client? 1 The client may need up to 60% oxygen flow via Venturi mask. 2 The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula. 3 The client should receive humidified oxygen delivered by a face mask. 4 The client's respiratory treatment plan should have oxygen eliminated from it.

2: The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula

During a follow-up visit, a nurse finds that the client has a slow rate of healing after laryngeal cancer surgery. The nurse also finds that the client is at risk of developing lung cancer. What would be the reason behind the nurse's suspicion? 1 The client leans forward while coughing. Correct2 The client smokes four cigarettes per day. 3 The client avoids showering and swimming. 4 The client uses a non-oil-based ointment to lubricate the stoma.

2: The client smokes four cigarettes per day

A client who is homeless is hospitalized for alcohol withdrawal. When considering the type of personal protective equipment that is needed for the client's care, what condition does the nurse recall that homeless persons are at risk for? 1 Prostatitis 2 Tuberculosis 3 Osteoarthritis 4 Diverticulosis

2: Tuberculosis

A nurse is caring for a client who had a pneumonectomy. Which is the priority nursing assessment? 1 Pulse oximetry 2 Ventilatory exchange 3 Closed chest drainage 4 Approximation of the incision

2: Ventilatory Exchange

A 67-year-old client has tested positive for influenza A. The client also has asthma. Which drug would the nurse recommend be avoided in this client? 1 Ribavirin 2 Zanamivir 3 Oseltamivir 4 Amantadine

2: Zanamivir

A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114 mm Hg. What should the nurse do first? 1 Page the on-call healthcare provider and continue to monitor the blood pressure. 2 Administer ibuprofen and have the client rest quietly for 20 minutes. 3 Elevate the head of the bed, provide reassurance, and reassess the blood pressure. 4 Place the client in the supine position, administer oxygen, and notify the healthcare provider.

3

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? 1 Bradycardia 2 Flushed face 3 Unilateral chest pain 4 Decreased blood pressure

3

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? 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slow rate of breathing

3

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? 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slowed rate of breathing

3

A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do? 1 Raise the drainage system to bed level and check its patency 2 Clamp the tube when moving the client from the bed to a chair 3 Mark the time and fluid level on the side of the drainage chamber 4 Secure the chest catheter to the wound dressing with a sterile safety pin

3

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what? 1 Providing more oxygen to lung tissue 2 Forcing pressure into lung tissue, which improves gas exchange 3 Opening collapsed alveoli and keeping them open 4 Opening collapsed bronchioles, which allows more oxygen to reach lung tissue

3

A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test? 1 Check the client's blood glucose levels. 2 Obtain informed consent from the client. 3 Assess if the client is allergic to shellfish. 4 Instruct the client to remove his or her dentures.

3

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? 1 Vesicular 2 Bronchial 3 Crackles 4 Rhonchi

3

A nurse caring for a client who has had a hysterectomy is concerned about the client's risk for postoperative thrombosis. The nurse remembers that the majority of pulmonary emboli begin as deep vein thromboses in what area? 1 Calf 2 Thoracic cavity 3 Pelvis and thighs 4 Extremities and abdomen

3

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk? 1 Asthma 2 Anemia 3 Endocarditis 4 Reye syndrome

3

A nurse is caring for a toddler in acute respiratory distress precipitated by laryngotracheobronchitis. The child has a temperature of 103° F (39.4° C). What is the priority nursing intervention? 1 Delivering humidified oxygen 2 Initiating measures to reduce fever 3 Monitoring respiratory status continuously 4 Providing support to diminish apprehension

3

A nurse on the disaster management team is caring for survivors of an earthquake. The nurse understands that some survivors may have chest trauma and may need a needle decompression to relieve the air or fluid trapped in the chest. Following the initial assessment, which client would the nurse treat first? 1 Client A with muffled, distant heart sounds, neck vein distention 2 Client B with paradoxic movement of chest wall, respiratory distress 3 Client C with cyanosis, air hunger, violent agitation, tracheal deviation away from affected side 4 Client D with hyperresonance to percussion, diminished or absent breath sounds on the affected side

3

After a tonsillectomy, which finding alerts the nurse to suspect the initial stage of hemorrhage? 1 Noisy snoring 2 Asking for water 3 Frequent swallowing 4 Gradual onset of pallor

3

Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? 1 Administering oxygen 2 Using an incentive spirometer 3 Having the client breathe into a paper bag 4 Administering an IV containing bicarbonate ions Reassurance decreases

3

Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? 1 Relax in a reclining position 2 Sit upright with legs extended 3 Walk around at least every hour 4 Sit in any position that relieves pressure on the legs

3

Following surgery in the inguinal area, the client reports pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. Which is the priority nursing action? 1 Auscultate the chest 2 Obtain the vital signs 3 Elevate the head of the bed 4 Position the client on the right side

3

The healthcare provider prescribes isosorbide dinitrate 10 mg for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. How will the nurse respond? 1 "It prevents excessive blood clotting." 2 "It suppresses irritability in the ventricles." 3 "It improves oxygen supply to heart tissue." 4 "The inotropic action increases the force of contraction of the heart."

3

The nurse is caring for a client who had a wedge resection of a lobe of the lung and now has a chest tube with a three-chamber underwater drainage system in place. Which main purpose of the third chamber of the underwater drainage system should the nurse consider when planning care? 1 Acts as a drainage container 2 Provides an airtight water seal 3 Controls the amount of suction 4 Allows for escape of air bubbles

3

The nurse is providing postoperative care to a client with cancer of the lung who had a lobectomy. The client has a chest tube attached to suction. Which assessment finding includes a complication? 1 Clots in the tubing during the first postoperative day 2 Bloody fluid in the drainage-collection chamber on the first postoperative day 3 Subcutaneous emphysema on the second postoperative day 4 Decreased bubbling in the water-seal chamber on the third postoperative day

3

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest? 1 It prevents the further aggregation of platelets. 2 It enhances the peripheral circulation in the deep vessels. 3 It decreases the potential for further dislodgment of emboli. 4 It maximizes the amount of blood available to damaged tissues.

3

What is the underlying rationale for why a nurse assesses a client with emphysema for clinical indicators of hypoxia? 1 Pleural effusion 2 Infectious obstructions 3 Loss of aerating surface 4 Respiratory muscle paralysis

3

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

Which assessment finding is considered the earliest sign of decreased tissue oxygenation? 1 Cyanosis 2 Cool, clammy skin 3 Unexplained restlessness 4 Retraction of interspaces on inspiration

3

Which statement is true about the disaster triage tag system? 1 Yellow tags are given to "walking wounded clients." 2 Clients who are in shock are given a black tag. 3 Clients with airway obstruction, who require immediate attention, are given a red tag. 4 Green tags are given to clients who require treatment within 30 minutes to 2 hours of admission.

3

Which type of breathing pattern alteration is manifested with hypercarbia? 1 Eupnea 2 Tachypnea 3 Hypoventilation 4 Kussmaul's respiration

3

While caring for a group of clients injured in a fire, the nurse finds that there is a need for airway maintenance, electrical therapies, and specialized resuscitation. Which invasive assessment trained team and management skills certification is required in this situation? 1 Basic Life Support (BLS) 2 Certified Emergency Nurse (CEN) 3 Advanced Cardiac Life Support (ACLS) 4 Pediatric Advanced Life Support (PALS)

3

A client's breath has a sweet, fruity odor. Which condition is likely affecting this client? 1 Gum disease 2 Uremic acidosis 3 Diabetic acidosis 4 Infection inside a cast

3 A client with diabetic acidosis has a sweet, fruity odor to the breath. Gum disease is marked by halitosis. A stale urine smell indicates uremic acidosis. An infection inside a cast is accompanied by a musty odor of the casted body part.

A client is informed that he has developed a healthcare-associated upper respiratory tract infection and asks the nurse what this means. How should the nurse reply? 1 "You developed an infection that requires antibiotics." 2 "This is a highly contagious infection requiring isolation." 3 "You acquired the infection after being admitted to the hospital." 4 "An infection you had before beginning treatment has flared up."

3 A healthcare-associated infection (formerly called nosocomial infection) is contracted during the course of receiving treatment. Although developing an infection that requires antibiotics may occur, this response does not explain a healthcare-associated infection. The need for precautions relates to the type of infection, not to the situation in which it was acquired. A preexisting infection is unrelated to a healthcare-associated infection.

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? 1 Cyanosis 2 Bradycardia 3 Mental confusion 4 Distended neck veins

3 Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution 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 A high-particulate filtration mask that meets Centers for Disease Control (CDC) performance criteria (Canada: Public Health Agency of Canada [2013] Canadian Tuberculosis Standards, 7th edition) for a tuberculosis respirator must be worn to protect healthcare providers from exposure to the Mycobacterium tuberculosis organism. Airborne transmission-based precautions do not require a gown unless contact with respiratory secretions is anticipated. The client should be placed in a private room with negative pressure and multiple full air exchanges per hour vented to the outside environment. A surgical mask with a face shield is inadequate to prevent transmission of the tuberculosis microorganism.

Which diagnostic test is performed under general anesthesia to detect non-Hodgkin lymphoma and requires the client to sign an informed consent form? 1 A thoracentesis 2 A bronchoscopy 3 A mediastinoscopy 4 Computed tomography (CT)

3 A mediastinoscopy is a surgical procedure that requires the client to sign an informed consent form. This procedure is performed under general anesthesia and is used to detect non-Hodgkin lymphoma. A thoracentesis is a diagnostic procedure used to obtain a specimen of pleural fluid for diagnosis, to remove pleural fluid, or to instill medication. A bronchoscopy is used to diagnose a condition, to biopsy, to collect a specimen, or to suction mucous plugs, and remove foreign objects. Computed tomography (CT) is performed to diagnose lesions difficult to assess via conventional X-ray studies.

A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information? 1 The client's pneumonia is continually improving. 2 Oxygen concentrations up to 44% can be obtained. 3 Mechanical ventilation may be required next. 4 Nasal cannula may be used while the client is eating.

3 A nonrebreathing mask is used when the client requires higher oxygen concentrations and the condition is worsening. If the nonrebreathing mask does not improve oxygen saturation, the next steps to improving gas exchange and oxygenation are intubation and mechanical ventilation. Oxygen concentrations up to 90% can be achieved. Nasal cannula would not be advised, as the client requires more oxygen than can be delivered through this method.

What emergency equipment should the nurse ensure is readily available at the bedside after a client has surgery for a malignant lesion on a vocal cord? 1 Crash cart with bed board 2 Airway and rebreathing mask 3 Tracheostomy set and oxygen 4 Ampule of sodium bicarbonate

3 Acute respiratory obstruction can result from edema. A cardiac arrest is not expected after this type of surgery. Airway and rebreathing mask will be ineffective because obstruction is beyond the oropharynx. Acidosis is not expected after this type of surgery.

The registered nurse (RN) is caring for a client with renal calculi. Which healthcare professional is most suitable to be delegated the task of administering urinary alkalinizer by mouth to the client? 1 Certified technician 2 Patient care associate 3 Licensed practical nurse 4 Unlicensed assistive personnel

3 Administering oral medications such as urinary alkalinizer can be safely delegated to a licensed practical nurse (LPN) or licensed vocational nurse (LVN) as per guidelines. Certified technician is a licensed assistive personnel whose scope of practice is limited for administering medications. The scope of practice of the patient care associate and unlicensed assistive personnel is limited to performing basic care, feeding, and hygiene.

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client? 1 Prevent dyspnea 2 Prevent cyanosis 3 Increase oxygen concentration to heart cells 4 Increase oxygen tension in the circulating blood

3 Administration of oxygen increases the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although administering oxygen will increase oxygen tension in the circulating blood, it is not specific to heart cells, which are hypoxic when there is a myocardial infarction from a coronary occlusion.

A nurse administers albuterol to a child with asthma. For what common side effect will the nurse monitor the child? 1 Flushing 2 Dyspnea 3 Tachycardia 4 Hypotension

3 Albuterol produces sympathetic nervous system side effects such as tachycardia and hypertension. Pallor, not flushing, is a common side effect. Dyspnea is not a common side effect; this medication is given to decrease respiratory difficulty. Hypertension, not hypotension, is a common side effect.

A nurse is assigned to care for a newly admitted client. The nurse performs a physical assessment and reviews the admission form and the primary healthcare provider's prescriptions. What should the nurse identify as the priorities in this client's plan of care? 1 Intake and output 2 Diet and nutrition 3 Hygiene and comfort 4 Body mechanics and posture

3 Because the client's condition is terminal, the nursing priority should be directed toward providing basic care and comfort. Although intake and output, diet and nutrition, and body mechanics and posture are important aspects of nursing care, provision of comfort is the priority when caring for a dying client.

On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? 1 Muscle twitching 2 Mental instability 3 Deep and rapid respirations 4 Tachycardia and cardiac dysrhythmias

3 Deep, rapid respirations are an adaptation to a decreased serum pH. Carbonic acid dissociates in the lungs to hydrogen ions and carbon dioxide, which helps increase the serum pH. Muscle twitching results from low serum calcium (hypocalcemia), not compensated metabolic acidosis. Mental confusion does not occur in compensated acidosis; confusion can occur in uncompensated metabolic acidosis. Tachycardia and cardiac dysrhythmias are associated with hyperthyroidism, not compensated metabolic acidosis.

A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? 1 Report of pain when taking deep breaths 2 Client is observed splinting the fracture site 3 Diminished breath sounds on the affected side 4 Bowel sounds are auscultated in the lower chest

3 Fractured ribs may penetrate the pleura and lung, allowing air to fill the pleural space and collapse the lung, causing diminished breath sounds. This is a complication of fractured ribs. Reports of pain when taking deep breaths is an expected response to tissue trauma caused by a fractured rib. Observing the client splinting the fracture site is an expected response to tissue trauma caused by a fractured rib. Bowel sounds auscultated in the lower chest suggest rupture of the diaphragm, not fractured ribs.

A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period, what is the priority nursing action? 1 Irrigating the T-tube every hour 2 Changing the dressing every two hours 3 Encouraging coughing and deep breathing 4 Promoting an adequate fluid and food intake

3 In an abdominal cholecystectomy, the incision is high, causing pain when the client is deep breathing. Self-splinting results in shallow breathing, which does not aerate or expand the lungs adequately, particularly the lower right lobe, leading to pneumonia. The client should be encouraged to deep breathe and cough, while splinting the incision with a pillow to help decrease the pain, yet expanding the lungs to decrease atelectasis or pneumonia. The T-tube is never irrigated; it drains by gravity until the edema in the operative area subsides; the primary healthcare provider then removes the tube. The nurse does not change the dressing in the immediate postoperative period; the client's respiratory status takes priority. The client will ingest nothing by mouth immediately after surgery.

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. What type of respirations does the nurse expect the client to exhibit? 1 Dyspnea 2 Hyperpnea 3 Kussmaul breathing 4 Cheyne-Stokes breathing

3 Kussmaul breathing is an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide. Dyspnea is difficult breathing associated with subjective or objective distress in response to oxygen problems. Hyperpnea is a deep, rapid rate of breathing without a subjective sense of extra effort, usually as a response to strenuous effort. Cheyne-Stokes respirations are characterized by a waxing and waning of breathing that is usually associated with pathology of the respiratory center in the brain.

A nurse is teaching a postpartum client the characteristics of lochia and any deviations that should be reported immediately. Which client statement indicates that the teaching was effective? 1 "If I pass any clots, I'll notify the clinic." 2 "I'll call the clinic if my lochia changes from red to pink." 3 "I'll notify the clinic if my lochia starts to smell bad." 4 "If my vaginal discharge continues for 3 weeks, I'll call the clinic."

3 Lochia has a characteristic menstrual musky or fleshy smell. A foul-smelling discharge, along with fever and uterine tenderness, suggests an infection. Passing clots is a common occurrence. Lochia changing from red to pink is expected as lochia rubra progresses to lochia serosa. Although many women have a minimal discharge after 2 weeks, it is not uncommon for lochia alba to last 6 weeks.

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? 1 Loss of skin integrity caused by the burns 2 Potential infection as a result of the burn injury 3 Inadequate gas exchange caused by smoke inhalation 4 Decreased fluid volume because of the depth of the burns

3 Maintaining a patent airway is the priority; because of the proximity of the chest and face to the nose and mouth, inhalation burns also may have occurred. Although loss of skin integrity caused by the burns is important, it is not the priority at this time. Although potential for infection as a result of the burn injury is important, it is not the priority. Although fluid needs are important, the gas exchange is priority.

What is the priority nursing intervention for a client during the immediate postoperative period? 1 Monitoring vital signs 2 Observing for hemorrhage 3 Maintaining a patent airway 4 Recording the intake and output

3 Maintenance of a patent airway is always the priority, because airway obstruction impedes breathing and may result in death. Monitoring vital signs, observing for hemorrhage, and recording the intake and output is important; however, a patent airway is the priority.

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? 1 Malice 2 Tort law 3 Malpractice 4 Case law

3 Malpractice is the unskilled or faulty treatment by a professional that causes injury or harm to a client. It can result from a lack of professional knowledge or skill that can be expected in others in the profession, or from a failure to exercise reasonable care or judgment in the application of professional knowledge, experience, or skill. Malice is the desire or intent to inflict injury, harm, or suffering. Tort law is a wrongful act, not including a breach of contract of trust, that results in injury to another person and for which the injured person is entitled to compensation. Case law is law established by judicial decisions in particular cases instead of by legislative action.

A 5-year-old child is being given dactinomycin and doxorubicin therapy after nephrectomy for Wilms tumor. What will the nursing care include? 1 Administering aspirin for pain 2 Offering citrus juices with meals 3 Ensuring meticulous oral hygiene 4 Eliminating spicy foods from the diet

3 Oral hygiene is essential, especially during the administration of medications that have a negative effect on the oral mucosa. Although pain may be present, aspirin is avoided because doxorubicin is also being used, and a side effect of this medication is thrombocytopenia. Aspirin is contraindicated for children because it is associated with Reye syndrome. Citrus juice will aggravate stomatitis, which is a common side effect of dactinomycin. Spicy foods may aggravate the stomatitis that occurs with chemotherapy. However, usually any food that the child requests is permitted.

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the healthcare provider, which action should the nurse take? 1 Place the client on the unaffected side 2 Administer 60% oxygen via a Venturi mask 3 Give oxygen at 2 L per minute via nasal cannula 4 Prepare for intravenous (IV) administration of electrolytes

3 Oxygen is supplied to prevent anoxia, but not in high concentrations without a prescription. In an individual with emphysema, a low oxygen level, not high carbon dioxide level, may be the respiratory stimulus. Placing the client on the unaffected side might increase the risk for mediastinal shift and interfere with expansion of the unaffected lung. Although oxygen is administered to prevent hypoxia, this concentration is too high for a client with emphysema because it may precipitate carbon dioxide narcosis. Preparing for an IV administration of electrolytes requires prescriptions as to specific electrolytes.

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what? 1 Relieve bronchial spasms 2 Increase depth of respirations 3 Loosen pulmonary secretions 4 Expel carbon dioxide from the lungs

3 Postural drainage and percussion also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue? 1 Provide small, frequent meals 2 Encourage pursed-lip breathing 3 Schedule nursing activities to allow for rest 4 Encourage bed rest until energy level improves

3 Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small, frequent meals may decrease pressure on the diaphragm and facilitate breathing, this precaution does not address the client's fatigue. Although pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.

A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? 1 Client no longer is infected. 2 Tuberculin skin test is negative. 3 Sputum is free of acid-fast bacteria. 4 Client's temperature has returned to normal.

3 The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Treatment is over an extended period; eventually the client may not have an active disease, but still remains infected. Once an individual has been infected, the test will always be positive. The client's temperature returning to normal is not evidence that the disease cannot be transmitted.

A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? 1 Temperature 2 Blood pressure 3 Respirations 4 Urinary output

3 The nurse must be especially alert to any changes in respirations because morphine decreases the respiratory center function in the brain. An order for morphine should be questioned if the baseline respirations are less than 12 per minute. Neurologic status, along with pulse and blood pressure, would be a priority assessment after respiratory rate. Measurements of temperature and urinary output are part of the overall client assessment, but are not a priority with morphine.

During data collection, the nurse inspects the client's nose and concludes that the client has an infection. Which finding supports the nurse's conclusion? 1 Bloody discharge 2 Watery discharge 3 Thick mucosal discharge 4 Purulent and malodorous discharge

3 The presence of thick mucosal discharge could indicate an infection. The client may have bloody discharge due to trauma or dryness. Watery discharge could be secondary to allergies or from cerebrospinal fluid. Purulent and malodorous discharge could indicate the presence of a foreign body.

A client gives birth to an 8-lb (3529-g) baby. Ten minutes after the birth, the placenta has not yet separated. What is the nurse's priority action at this time? 1 Applying fundal pressure 2 Administering a second dose of oxytocin 3 Continuing to assess the client for signs of separation 4 Preparing a consent form for manual removal of the placenta

3 The third stage of labor (from birth to expulsion of the placenta) may last as long as 30 minutes and still be within acceptable limits. Applying fundal pressure is an outmoded procedure that can cause eversion of the uterus. Oxytocin is not administered before the expulsion of the placenta. It is too early to seek consent for manual removal at this time.

The healthcare provider prescribes an intravenous medication for a client who has been admitted for a chronic obstructive pulmonary disease exacerbation. When preparing to initiate an intravenous line, the nurse applies the tourniquet to select the site. When should the nurse release the tourniquet? 1 After cleaning the insertion site 2 As soon as the needle pierces the skin 3 When the needle enters the vein 4 After the device is secured with tape

3 The tourniquet causes the vein to become distended and makes entry into the vein easier. The tourniquet should be removed when the needle enters the vein. Removing the tourniquet after cleaning the insertion site and removing the tourniquet as soon as the needle pierces the skin do not assist the nurse in keeping the vein distended and visible for complete insertion. Keeping the tourniquet on until after the device is secured could cause damage by impairing circulation.

Which is the priority nursing action when providing care to a trauma client? 1 Monitoring vital signs 2 Maintaining vascular access 3 Assessing respiratory effort 4 Evaluating level of consciousness

3 When providing care during the primary survey of a trauma client, the priority action is assessing respiratory effort. The nurse prioritizes care by assessing the ABC's - airway, breathing, and circulation. Once this is completed, the nurse will monitor vital signs, maintain vascular access, and then evaluate level of consciousness.

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply. 1 Vomiting 2 Weight gain 3 Hemoptysis 4 Night sweats 5 Bilateral crackles

3 & 4 3: Hemoptysis 4: Night sweats

A nurse is caring for a client with a Venturi mask who is receiving 40% oxygen. What nursing actions are indicated? Select all that apply. 1 Keep the oxygen source higher than the client's airway. 2 Adjust the liter flow according to the oxygen saturation. 3 Prevent the client's blanket from covering the adaptor's orifices. 4 Ensure that the bag does not deflate completely during inspiration. 5 Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the mask.

3 & 5 3: Prevent the client's blanket from covering the adaptor's orifices 5: Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the mask

A client who had a total laryngectomy is using a pad and pencil to communicate. The client becomes frustrated and writes, "When can I learn how to speak again?" Which is the best response by the nurse? 1 "Every client with a laryngectomy is different. It's difficult to say." 2 "It must be difficult for you, but be patient. These things take time." 3 "Perhaps I can have someone from the Laryngectomy Club come speak with you." 4 "I can provide you with more information after your incision has had time to heal."

3: "Perhaps I can have someone from the Laryngectomy Club come speak with you."

Which suggestion of the nurse would help the client prevent respiratory problems? 1 "You should start painting your house." 2 "You should engage in heavy physical activity." 3 "You should wear a mask while working in certain industries." 4 "You should move from a rural to an urban area."

3: "You should wear a mask while working in certain industries."

A nurse identifies 12 mm of induration at the site of a Mantoux test when a client returns to the health office to have it read. Which explanation of this result should the nurse give to the client? 1 Result is negative, and follow-up is not needed. 2 The disease is active, and medication is required. 3 Additional tests are needed, such as a chest x-ray. 4 Outcome is inconclusive, and the test will be repeated in six weeks.

3: Additional tests are needed, such as a chest x-ray

A client is diagnosed with cancer of the larynx and is scheduled for a total laryngectomy. What should the nurse initially include in the preoperative teaching plan? 1 Have a speech therapist visit 2 Give a detailed explanation of the surgery 3 Allow the client an opportunity to ask questions 4 Explain breathing exercises to be performed postoperatively

3: Allow the client an opportunity to ask questions

The nurse is interpreting responses to tuberculin skin testing in a 58-year-old client with end-stage kidney disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? 1 Presence of acid-fast bacilli in the sputum 2 A 6-mm area of induration at the test's injection site Correct3 An 11-mm area of induration at the test's injection site 4 Presence of reddened, flat areas at the test's injection site

3: An 11-mm area of induration at the test's injection site

A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? 1 An elevated pH, elevated PCO2 2 A decreased pH, elevated PCO2 Correct3 An elevated pH, decreased PCO2 4 A decreased pH, decreased PCO2

3: An elevated pH, decreased PCO2

A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's most immediate intervention at this time? 1 Prepare the client for emergency surgery. 2 Facilitate the client's verbal communication. 3 Assess the client's response to the interventions. 4 Maintain sterility of the ventilation system that is being used.

3: Assess the client's response to the interventions

What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath? 1 Scoliosis 2 Kyphosis 3 Clubbing 4 Kyphoscoliosis

3: Clubbing

Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L (25 mmol/L). Which action should the nurse take? 1 Obtain a prescription for a diuretic. 2 Have the client breathe into a rebreather bag. 3 Encourage the client to take deep, cleansing breaths. 4 Request a prescription for the administration of sodium bicarbonate.

3: Encourage the client to take deep, cleansing breaths.

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

After a laryngectomy a client is concerned about improving the ability to communicate. Which topic should the nurse include in a teaching plan for the client? 1 Sign language 2 Body language 3 Esophageal speech 4 Computer-generated speech

3: Esophageal Speech

A client responds well after extensive pulmonary surgery for lung cancer and is discharged. A week after discharge the home care nurse observes the client's downcast eyes and lack of interest in the environment. The client's family states that this behavior started a few days after discharge. How should the nurse interpret these findings? 1 Unusual, indicating mental illness 2 Normal, and no follow-up is required 3 Expected, but needs to be addressed 4 Serious, needing immediate acute care

3: Expected, but needs to be addressed

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion? 1 Excessive fluid intake 2 Inadequate chest expansion 3 Extension of cancerous lesions 4 Irritation from the bronchoscopy

3: Extension of cancerous lesions

The nurse is watching the technician obtain a 12-lead ECG. In which area should the nurse make sure the technician places the V1 lead? 1 Halfway between V2 and V4 2 Fourth intercostal space, left sternal border 3 Fourth intercostal space, right sternal border 4 Fifth intercostal space, left midclavicular line

3: Fourth intercostal space, right sternal border

A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have? 1 Crepitus 2 Sinusitis 3 Fracture of the nose 4 Upper respiratory tract infection

3: Fracture of the nose

During a client's immediate postoperative period after a laryngectomy, what is a nursing priority? 1 Provide emotional support 2 Observe for signs of infection Correct3 Keep the trachea free of secretions 4 Promote a means of communication

3: Keep the trachea free of secretions

The nurse is caring for a client who has a lesion in the right upper lobe. A diagnosis of tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis? 1 Frothy sputum and fever 2 Dry cough and pulmonary congestion 3 Night sweats and blood-tinged sputum 4 Productive cough and engorged neck veins

3: Night sweats and blood-tinged sputum

Which disorder would the nurse state is related to the tonsils? 1 Rhinitis 2 Sinusitis 3 Pharyngitis 4 Pneumonia

3: Pharyngitis

During the assessment of a client who was admitted to the hospital because of a productive cough, fever, and chills, the nurse percusses an area of dullness over the right posterior lower lobe of the lung. Which medical diagnosis will the nurse most likely observe documented in the client's electronic records? 1 Pleurisy 2 Bronchitis 3 Pneumonia 4 Emphysema

3: Pneumonia

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments? 1 Level of consciousness and pupil size 2 Characteristics of pain and blood pressure Correct3 Quality of respirations and presence of pulses 4 Observation of abdominal contusions and other wounds

3: Quality of respirations and presence of pulses

When assessing a client with pleural effusion, what does the nurse expect to identify? 1 Moist crackles at the posterior of the lungs 2 Deviation of the trachea toward the involved side 3 Reduced or absent breath sounds at the base of the lung 4 Increased resonance with percussion of the involved area

3: Reduced or absent breath sounds at the base of the lung

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3: Respiratory acidosis

What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly? 1 Contains many small air bubbles 2 Bubbles vigorously on inspiration 3 Rises with inspiration and falls with expiration 4 Remains at a consistent level during the respiratory cycle

3: Rises with inspiration and falls with expiration

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" The nurse's response is based on what likely cause of the spontaneous pneumothorax? 1 Pleural friction rub 2 Tracheoesophageal fistula 3 Rupture of a subpleural bleb 4 Puncture wound of the chest wall

3: Rupture of a subpleural bleb

In which positions should the nurse place a client who has just had a right pneumonectomy? 1 Right or left side-lying 2 High-Fowler or supine 3 Supine or right side-lying 4 Left side-lying or low-Fowler

3: Supine or right side-lying

Which cartilage is also known as the Adam's apple? 1 Costal 2 Cricoid 3 Thyroid 4 Arytenoid

3: Thyroid

A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion? 1 Check the client's temperature. 2 Take the client's blood pressure. 3 Obtain the client's pulse oximetry. 4 Assess the client's respiratory status.

4

A nurse is caring for a client with a chest tube. How will complete lung expansion be determined before removal of the chest tube? 1 Return of usual tidal volume 2 Decreased adventitious sounds 3 Absence of additional drainage 4 Comparison of chest radiographs

4

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? 1 Fever and chest pain 2 Positive Homans sign 3 Loss of sensation in the operative leg 4 Tachycardia and petechiae over the chest

4

A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess in this client? 1 Aphasia 2 Dyspnea 3 Dysphagia 4 Hoarseness

4

A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding does the nurse expect when performing the admission assessment? 1 Weak, rapid pulse 2 Decreased blood pressure 3 Radiating anterior chest pain 4 Crackles at bases of the lungs

4

A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin? 1 Atenolol 2 Ferrous sulfate 3 Chlorpromazine 4 Acetylsalicylic acid

4

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? 1 Dull sound on percussion 2 Vocal fremitus on palpation 3 Rales with rhonchi on auscultation 4 Absence of breath sounds on auscultation

4

A client returns from a radical neck dissection with a tracheotomy and two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? 1 Cloudy wound drainage 2 Poor gag reflex 3 Decreased urinary output 4 Restlessness with dyspnea

4

A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? 1 Hypocapnia 2 Hyperkalemia 3 Generalized anemia 4 Respiratory acidosis

4

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information should the nurse provide about the purpose of the chest tube? 1 It checks for bleeding in the lung. 2 It monitors the function of the lung. 3 It drains fluid from the pleural space. 4 It removes air from the pleural space.

4

A client with a tentative diagnosis of lung cancer is scheduled for a mediastinoscopy with biopsy. Which is a priority nursing action? 1 Tell the client that chest tubes will be present after the procedure. 2 Explain that the procedure will allow visualization of lungs and chest cavity. 3 Inform the client that some pleural fluid will be removed during this procedure. 4 Advise the client to avoid eating or drinking anything for several hours before the test.

4

A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. How should the nurse interpret these findings? 1 Increased leukocyte development in response to infection 2 Decreased extracellular fluid volume secondary to infection 3 Decreased red blood cell proliferation because of hypercapnia 4 Increased erythrocyte production as a result of chronic hypoxia

4

A client's cells are deprived of oxygen during a cardiac arrest. What medication should the nurse be prepared to administer? 1 Regular insulin 2 Calcium gluconate 3 Potassium chloride 4 Sodium bicarbonate

4

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? 1 Client pushes the airway out. 2 Client has snoring respirations. 3 Client's respirations are 16 breaths per minute and unlabored. 4 Client's systolic blood pressure drops from 130 to 90 mm Hg.

4

A nurse is caring for a client who is admitted to the hospital with a severe head injury. Which action is priority? 1 Place the client in a supine position. 2 Prevent contractures and deformities. 3 Monitor the blood pressure frequently. 4 Maintain respiratory exchange and ventilation.

4

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? 1 Strip the chest tube periodically. 2 Administer the prescribed cough suppressant at the scheduled times. 3 Empty and measure the drainage in the collection chamber each shift. 4 Keep the drainage system lower than the level of the client's chest.

4

A nurse is providing education to a coworker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which information will be appropriate for the nurse to include? 1 The thoracentesis procedure uses the principle of positive pressure. 2 It is common for a sclerosing agent to be instilled at the end of the procedure. 3 Clients will have temporary increased dyspnea immediately after the procedure. 4 Rapid removal of large amounts of fluid may precipitate cardiovascular collapse.

4

An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? 1 Spinal stenosis 2 Buerger disease 3 Rheumatoid arthritis 4 Intermittent claudication

4

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? 1 Take the client's vital signs. 2 Inform the healthcare provider. 3 Turn the client to the unaffected side. 4 Check the tube to ensure that it is not kinked.

4

Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly? 1 Remains constant in the chest drainage chamber. 2 Is bubbling gently in the chest drainage chamber. 3 Is bubbling vigorously in the suction control chamber. 4 Rises in the tube of the water-seal chamber during inspiration.

4

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)? 1 Chest tube insertion 2 Aggressive diuretic therapy 3 Administration of beta-blockers 4 Positive end-expiratory pressure (PEEP)

4

Upon assessment the nurse discovers a client with heart failure has crackles in lower lung fields and dyspnea. Upon notifying the primary healthcare provider, the provider prescribes intravenous (IV) normal saline at 200 mL/hr and furosemide 120 mg orally stat. Which action should the nurse take next? 1 Place the normal saline on an infusion pump to control the amount, and give the furosemide. 2 Ask the healthcare provider why so much intravenous fluid is to be given to an older adult client, and give the furosemide as prescribed. 3 Decline to give the intravenous fluid, saying it could cause circulatory overload, and give the furosemide as prescribed. 4 Question the choice of solution, the amount to be given, and the dose of furosemide that has been prescribed.

4

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1 Administer sedatives around the clock 2 Turn client every four hours 3 Increase ventilator settings as needed 4 Suction as needed

4

Which complications does the nurse anticipate in the client who has blue-colored nail beds? 1 Thrombocytopenia 2 Polycythemia vera 3 Methemoglobinemia 4 Cardiopulmonary disease

4

Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? 1 Peak expiratory flow rate 2 Forced vital capacity 3 Forced mid-expiratory flow rate 4 Forced expiratory volume/forced vital capacity ratio

4

While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. What is the nurse's immediate action? 1 Place the client in the supine position 2 Spread a clamp in the insertion site to hold the site open 3 Obtain a sterile Vaseline gauze to cover the opening 4 Cover the opening with the cleanest material available

4

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? 1 Slow, deep respirations 2 Normal oral temperature 3 Dry, unproductive cough 4 Diminished breath sounds

4 Because atelectasis involves collapsing of alveoli distal to the bronchioles, breath sounds are diminished in the lower lobes. The client will have rapid, shallow respirations to compensate for poor gas exchange. Atelectasis results in an elevated temperature. Atelectasis results in a loose, productive cough.

A client with the diagnosis of inhalation anthrax is admitted to the intensive care unit. It is most important for the nurse to make a focused assessment of which body system? 1 Mental 2 Hydration 3 Neurologic 4 Respiratory

4 Because respiratory collapse is an early sign of inhalation anthrax, a client's respiratory status requires immediate assessment and continued monitoring. Development of a central nervous system problem, such as anthrax-related meningitis, is a late sign of inhalation anthrax. Although assessing hydration status is important for any client who is acutely ill, it is not a nursing assessment that is specific to anthrax. Neurologic adaptations are late signs of inhalation anthrax.

What condition would a nurse suspect in a client with abnormal respirations with alternating periods of apnea and rapid breathing? 1 Pectus carinatum 2 Pectus excavatum 3 Kussmaul breathing 4 Cheyne-Stokes respirations

4 Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep rapid breathing. Pectus carinatum is a prominent abnormal protrusion of the sternum. Pectus excavatum is an abnormal indentation of the lower sternum above the xiphoid process. Kussmaul breathing is a rapid and deep breathing abnormality.

A nurse is assessing the skin of a client with a cortisol deficiency. Which integumentary assessment finding will most likely be observed in this client? 1 Dry skin 2 Ulcerated skin 3 Generalized edema 4 Diminished axillary hair

4 Clients with cortisol deficiencies will have diminished axillary and pubic hair. Dry skin is associated with hypothyroidism. Ulcerated skin is a sign of peripheral neuropathy and peripheral vascular disease. Generalized edema is seen in clients with hypothyroidism due to mucopolysaccharide accumulation in the tissues.

Which pulmonary function test provides a more sensitive index of obstruction in smaller airways? 1 Forced vital capacity 2 Functional residual capacity 3 Forced expiratory volume in 1 second 4 Forced expiratory flow over the 25% to 75% volume of the forced vital capacity

4 Forced expiratory flow over the 25% to 75% volume of the forced vital capacity is the measure that provides a more sensitive index of obstruction in smaller airways. Forced vital capacity indicates respiratory muscle strength and ventilator reserve. Functional residual capacity is normal or decreased in restrictive pulmonary diseases and increased in obstructive pulmonary diseases. Forced expiratory volume in 1 second is reduced in certain obstructive and restrictive disorders.

During the infusion of dialysate during peritoneal dialysis, the client exhibits symptoms of severe respiratory difficulty. What should the nurse do? 1 Slow the rate of the client's infusion 2 Place the client in a low-Fowler position 3 Auscultate the client's lungs for breath sounds 4 Drain the fluid from the client's peritoneal cavity

4 Pressure from the dialysate may cause upward displacement of the diaphragm; the dialysate should be drained from the peritoneal cavity. Additional fluid, even at a decreased rate of infusion, will aggravate the respiratory difficulty. The client should already be in the semi-Fowler position. Auscultation is important, but it does not alleviate the respiratory difficulty.

The nurse is caring for a child with spasmodic croup. The nurse knows that which symptom requires immediate nursing intervention? 1 Irritability 2 Hoarseness 3 Barking cough 4 Rapid respiration

4 Rapid respiration may be a sign of impending airway obstruction. Unless irritability is accompanied by severe restlessness, symptomatic care should be given. Unless accompanied by signs of respiratory embarrassment, hoarseness needs no immediate intervention. A barking cough may sound ominous, but it is not a sign of respiratory compromise, as is rapid respiration.

A nurse is discussing sexuality with a teenage female who has cystic fibrosis. Which statement best reflects the teenager's understanding of healthy sexuality? 1 "I can never get pregnant." 2 "Having sex is not possible for me." 3 "My best protection is a diaphragm." 4 "I won't have sex unless I use a condom."

4 Stating that she will not have sex without a condom indicates that the teenager understands that she can have sexual intercourse even though she has cystic fibrosis and that, other than abstinence, condoms offer the best protection from sexually transmitted infections. Although fertility is inhibited by highly viscous cervical secretions, which act as a plug, blocking sperm entry, pregnancy is possible; in vitro fertilization may make pregnancy possible. A woman with cystic fibrosis can have sex. A diaphragm provides protection against pregnancy, but it does not protect the individual from sexually transmitted infections.

The nurse is assisting the primary healthcare provider, who is examining the client's skull radiograph. An abnormality in the endocrine gland situated in a depression of the sphenoid bone is suspected. Which hormone release is most probably affected? 1 Glucagon 2 Cortisol 3 Aldosterone 4 Corticotropin

4 The pituitary gland is the endocrine gland that is situated in a bony depression of the sphenoid bone. Corticotropin or adrenocorticotropic hormones are secreted by the anterior pituitary and could be affected by an abnormality in the pituitary. Glucagon is a hormone that is secreted by the pancreas. Cortisol and aldosterone are hormones secreted by the adrenal cortex. There is less likelihood that the release of glucagon, cortisol, or aldosterone might be affected by a suspected abnormality in the pituitary gland.

An adolescent child with sickle cell anemia is admitted to the pediatric unit during a vaso-occlusive crisis. What does the nurse identify as the reason that the crisis occurred? 1 Severe depression of the circulating thrombocytes 2 Diminished red blood cell (RBC) production by the bone marrow 3 Pooling of blood in the spleen with splenomegaly as a consequence 4 Blockage of small blood vessels as a result of clumping of RBCs

4 The red blood cells in sickle cell anemia are fragile. When hypoxia or dehydration occurs, the cells take on a crescent shape; they then clump together and occlude blood vessels. The platelet count is not severely depressed in vaso-occlusive crisis. Diminished RBC production by the bone marrow is an aplastic crisis resulting in severe anemia. Pooling of blood in the spleen that results in splenomegaly is known as a splenic sequestration crisis.

What breathing exercises should the nurse teach a client with the diagnosis of emphysema? 1 An inhalation that is prolonged to promote gas exchange. 2 Abdominal exercises to limit the use of accessory muscles. 3 Sit-ups to help strengthen the accessory muscles of respiration. 4 Diaphragmatic exercises to improve contraction of the diaphragm.

4 With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable to maximize exhalation. Prolonged exhalations are more desirable; clients with emphysema have an increased residual volume, which eventually causes a barrel chest. Abdominal exercises enhance, not limit, the accessory muscles of respiration that are needed as a compensatory mechanism for clients with emphysema. Sit-ups are too strenuous for clients with emphysema

After a bus accident, four clients are admitted to an emergency department. In what order should the clients be seen? 1. Client with chest pain resulting from ischemia 2. Client with closed extremity trauma 3. Client with abdominal pain 4. Client in cardiac arrest

4, 1, 3, 2

The nurse provides preoperative education to a client with extensive cancer of the upper right lobe of the lung who is scheduled for a lobectomy. The nurse concludes that the teaching was effective when the client makes which statement? 1 "The healthcare provider is going to use a laser to destroy all of the cancer cells. I will have oxygen in place to help me breathe after the surgery." 2 "I don't even need the lobe they are taking out. I still have three lobes in my left lung to help me breathe after the surgery." 3 "I know that my entire right lung will be removed. I will have chest tubes to help with drainage after surgery." 4 "The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery."

4: "The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery."

On a client's admission to a rehabilitation unit, the nurse gives the client, who is not immunocompromised, a purified protein derivative (PPD) of tuberculin to test for tuberculosis. Which client reaction indicates a positive response? 1 5-mm erythema with no induration 2 No erythema with 3-mm induration 3 7-mm erythema with 5-mm induration 4 5-mm erythema with 10-mm induration

4: 5-mm erythema with 10-mm induration

A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? 1 Distended neck veins 2 Paradoxical respirations 3 Increasing amounts of purulent sputum 4 Absence of breath sounds over the affected area

4: Absence of breath sounds over the affected area

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), what should the nurse do? 1 Initiate pulmonary hygiene to clear air passages of trapped mucus 2 Instruct to deep breathe slowly with inhalation longer than exhalation 3 Encourage continuous rapid panting to promote respiratory exchange Correct4 Administer oxygen at a low concentration to maintain respiratory drive

4: Administer oxygen at a low concentration to maintain respiratory drive

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? 1 Rhonchi 2 Wheezes 3 Fine crackles 4 Coarse crackles

4: Coarse crackles

What area of the body would you expect to hear this sound?....audio recording that is 0.21 seconds long 1 Nasal cavity 2 Trachea 3 Pharynx 4 Larynx

4: Larynx

Which diagnostic test may be used to distinguish vascular from nonvascular structures? 1 Chest X-ray 2 Pulmonary angiogram 3 Computed tomography 4 Magnetic resonance imaging

4: MRI, Magnetic Resonance Imaging

A client with a sucking chest wound has a large, tight dressing over the site. Which purpose of the dressing does the nurse consider when planning care for this client? 1 Protects the lung 2 Seals off major vessels 3 Prevents additional contamination of the wound 4 Maintains the appropriate pressure within the chest cavity

4: Maintains the appropriate pressure within the chest cavity

As a result of pulmonary tuberculosis, a client has a decreased surface area for gas exchange in the lungs. Which physiologic process does the nurse consider will be affected as a result? 1 Osmosis 2 Filtration 3 Active transport 4 Molecular diffusion

4: Molecular diffusion

Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? 1 Face tent 2 Venturi mask 3 Nasal cannula 4 Nonrebreather mask

4: Nonbreather mask

What is the major factor a nurse considers when anticipating the method of oxygen administration to be prescribed by the healthcare provider for a client? 1 Activity level 2 Facial anatomy 3 Mental capacity 4 Pathologic condition

4: Pathologic condition

A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? 1 Retrospective 24-hour calorie count 2 Elimination pattern during the last 30 days 3 Complete gynecological and sexual history 4 Presence of a cough and pulmonary secretions

4: Presence of a cough and pulmonary secretions

Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. What should the nurse instruct the client about the purpose of pursed-lip breathing? 1 Decreases chest pain 2 Conserves energy 3 Increases oxygen saturation 4 Promotes elimination of CO2

4: Promotes elimination of CO2

A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? 1 Obtain a new sterile drainage system. 2 Use two clamps to close the drainage tube. 3 Place the client in the high-Fowler position. 4 Reconnect the client's tube to the drainage system.

4: Reconnect the client's tube to the drainage system.

A nurse works with a large population of immigrant clients and is concerned about the debilitating effects of influenza. Which action by the nurse is the first line of defense against an emerging influenza pandemic? 1 Complying with quarantine measures 2 Instituting strict international travel restrictions 3 Seeking aid from the international public health community Correct4 Reporting surveillance findings to appropriate public health officials

4: Reporting surveillance findings to appropriate public health officials

During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the lungs. Which sound should the nurse document in the medical record? 1 Dull 2 Flat 3 Tympany Correct4 Resonance

4: Resonance

Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurse's first intervention? 1 Treat the victim for shock. 2 Start rescue breathing immediately. 3 Apply surface pressure to the foot wound. Correct4 Safely remove the victim from the immediate vicinity.

4: Safely remove the victim from the immediate vicinity

A client returns from surgery after a total laryngectomy with a laryngectomy tube in the permanent stoma. In which position should the nurse place this client to facilitate respirations and promote comfort? 1 Side-lying position 2 Orthopneic position 3 High-Fowler position 4 Semi-Fowler position

4: Semi-Fowler position

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 emphysema has a history of smoking two packs of cigarettes a day. What is the best approach for the nurse to help the client stop smoking? 1 Teach pursed-lip breathing. 2 Encourage the client to reduce emotional stress. 3 Obtain a referral to a smoking-cessation program in the community. 4 Suggest that the client limit smoking to one pack of cigarettes a day.

4: Suggest that the client limit smoking to one pack of cigarettes a day.

A nurse is caring for a client who had a bronchoscopy one hour ago. Which nursing action is most appropriate for assessing the return of the client's gag reflex? 1 Ask the client to say several words. 2 Give the client a small swallow of water. 3 Stroke the anterior third of the client's tongue. 4 Touch the client's pharynx with a tongue depressor.

4: Touch the client's pharynx with a tongue depressor.

A client reports having a bad cold and chest pain that worsens when the client takes deep breaths. Where should the nurse place the stethoscope to determine the presence of a pleural friction rub? Choose the appropriate location marked on the image.

Answer D is the lower-lateral chest, which is the area of greatest thoracic excursion.

Identify the maxillary sinuses.

Click on orange area horizontal to nose

Identify the area the nurse should palpate to determine tracheal position.

Click on trachea right before the trachea splits into 2 in between both sides of lungs

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? Client 1: Cystic Fibrosis Client 2: Bronchiectasis Client 3: Metabolic Acidosis Client 4: Pulmonary Edema

Client 1: Cystic Fibrosis Client 1 with cystic fibrosis may have increased anteroposterior diameter; that is, the anteroposterior chest diameter is equal to the lateral chest measurement and the slope of the ribs are more horizontal to the spine. Client 2 with bronchiectasis may have finger clubbing with increased depth, bulk, and sponginess of the distal portion of the finger. Client 3 with metabolic acidosis may have Kussmaul respirations that are regular, rapid, and deep. Client 4 with pulmonary edema may sit in a tripod position, which involves leaning forward with arms and elbows supported on an overbed table.

Which client would the nurse consider to have the highest risk of pneumonia? Client 1 received the pneumococcal vaccination in the last 3 months and thus has a lower risk of pneumonia. Client 2 received a pneumococcal vaccination in the last 2 years and may not have an elevated risk of pneumonia. Client 3 may have a lower risk of pneumonia due to receiving the pneumococcal vaccine a year ago.

Client 4, who is an older adult with chronic lung disease and has received the pneumococcal vaccination more than 5 years ago, has the highest risk of pneumonia. An infection may occur because older adults with chronic lung disease are at a higher risk of infection.

Which anatomic area is palpated if the nurse suspects aortic abnormalities? A: Left second intercostal space B: Lower left sternal border of 3rd intercostal space C: Tricuspid area at the 4th or 5th intercostal space D: Epigastric area at the tip of the sternum (xyphoid process)

D In case of the detection of aortic abnormalities, palpation of the epigastric area (which is located at the tip of the sternum) should be performed. The left second intercostal space is the pulmonic area. In this area, deeper palpation is required to feel the spaces in obese or heavily muscled clients. After the pulmonic area, the lower left sternal border of the third intercostal space is called the second pulmonic area. The tricuspid area is located at the fourth or fifth intercostal space along the sternum.

Fine Crackles

Fine crackles are short, discontinuous, high-pitched sounds like hair being rolled between fingers just behind the ear, heard just before the end of inspiration.

Rhonchi

Rhonchi are continuous rumbling, snoring, or rattling sounds that occur as a result of an obstruction of the large airways.

Flat Percussion

Soft high-pitched sounds of short duration heard over very dense tissue where air is not present

Dull Percussion

Sounds are of medium-intensity pitch and duration and are heard over areas of mixed, solid, and lung tissue.

Tympany Percussion

Sounds with drum-like, loud, or empty quality heard over a gas-filled stomach or intestines

Wheezes

Wheezes are continuous high-pitched squeaking or musical sounds that indicate airway obstruction.

Identify the area of pleural effusion.

The yellow color on Left side of lung