NCLEX EAQ Respiratory System

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? 1. Initiate oxygen via a nasal cannula 2. Administer the prescribed morphine 3. Prepare the client for endotracheal intubation 4. Place a nitroglycerin tablet under the client's tongue

1; Supplemental O2 supports the body while issue is identified. Can be administer without prescription in an emergency

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? 1. Decreases chest pain 2. Conserves Energy 3. Increases oxygen saturation 4. Promotes elimination of CO2

4; Pursed-lip breathing= increases positive pressure within alveoli and makes it easier to expel air. Promotes CO2 elimination, helps slow breathing, increase depth, but does not decrease chest pain, conserve energy, or increase o2 saturation

After percussing a client's posterior chest and hearing low-pitched hollow sounds over the whole chest, how will the nurse document the finding? 1. Dull 2. Flat 3. Tympanic 4. Resonance

4; Resonance= low pitched, hollow sounds normally heard over air-filled lungs during percussion. Dullness= medium-pitched "thud-like" sound that may be heard with problems like lung consolidation due to pneumonia. Flatness= high-pitched and short duration sound that might be heard over a pleural effusion. Tympanic sounds= high pitched and musical- may be heard over pneumothorax

Which statement describes a client's tidal volume? 1. Tidal volume is the volume of air inhaled and exhaled with each breath. 2. Tidal volume is the amount of air remaining in the lungs after forced expiration 3. Tidal volume is the additional air forcefully inhaled after normal inhalation 4. Tidal volume is the additional air forcefully exhaled after normal exhalation

1; Tidal volume= volume of air inhaled and exhaled with each breath. Residual volume= amount of air remaining in the lungs after forced expiration. Inspiratory reserve volume= additional air that can be inhaled after normal inhalation. Expiratory reserve volume= additional air that can be exhaled after normal exhalation

How would the nurse position a client to practice supraglottic swallowing after tracheostomy? 1. In bed 2. Upright 3. Lying down 4. Position of discomfort

2; Should be out of bed if possible. At risk for aspiration if supine. Comfort is the goal but upright is priority for safety

The nurse described a client's abnormal breathing sounds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear? 1. Vesicular 2. Bronchial 3. Adventitious 4. Bronchovesicular

3; Adventitious= abnormal breath sounds. Vesicular= relatively soft, low-pitched, gentles rustling sounds. Bronchial sounds= louder and higher pitched, resemble air blowing through a hollow pipe. Bronchovesicular sounds= medium pitch and intensity, heard over mainstem bronchi next to sternum and between scapulae posteriorly

A client presents with hemoptysis. The nurse recalls the clinical manifestation associated with which disease? 1. Anemia 2. Pneumonia 3. Tuberculosis 4. Leukocytosis

3; Hemoptysis is expectoration of blood- stained sputum derived from lungs, bronchi, or trachea- clinical manifestation of tissue erosion caused by tb. Anemia doesn't cause bleeding, but may be caused by bleeding. Pneumonia causes sputum as result of inflammation, but sputum is normally yellow- not bloody. Leukocytosis= increased wbc- does not cause hemoptysis.

Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? Select all that apply. One, Some, or all responses may be correct. 1. Type of employment 2. Presence of ear pain 3. History of tobacco use 4. Oral hygiene practices 5. Amount of alcohol intake

1,2,3,4,5; Employment determines chemical or environmental exposures that can increase risk. Ear pain and nagging cough can indicate head and neck cancer. Use of tobacco and alcohol= major risk factor. Poor oral hygiene= risk increase

Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. One, some, or all responses may be correct. 1. Facial edema 2. Septal deviation 3. Clear nasal drainage 4. Oxygen saturation 89% 5. Bilateral periorbital bruising

1,2,3,4,5; Facial edema and septal deviation indicate facial injuries. Clear nasal drainage indicate cerebrospinal fluid leak. O2 level of 89 indicates nonvisible injuries. "Raccoon eyes" indicates basilar skull fracture

After reviewing information about oxygenation for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy? 1. PaO2 of 72; SpO2 of 96 2. PaO2 of 60; SpO2 of 90 3. PaO2 of 55; SpO2 of 88 4. PaO2 of 70; SpO2 pf 92

3; PaO2 of 55 and SpO2 of 88 indicate hypoxemia and long term o2 therapy is needed.

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding? 1. Adventitious sounds 2. Fine crackling sounds 3. Vesicular breathing sounds 4. Diminished breath sounds

3; Vesicular= normal which the rest are adventitious

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco2 of 60 mmHg. These blood gas results require nursing attention because they indicate which condition? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3; normal ph=7.35-7.45, so 7.25 indicates acidosis. Normal respiratory function= 35-45 mmHg. So 60 mmHg is elevated meaning respiratory acidosis