NCLEX questions #6 Respirations

The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is 128 mEq/L. The nurse should be alert for which findings? (Select all that apply.)

Answers: a. +1 reflexes to the patella b. Nausea e. Weakness in the hands and feet f. Headache Response Feedback: The client is hyponatremic. All are signs of hyponatremia except muscle twitching and facial redness.

A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of respiratory compromise for this client. What will the nurse include in this client's plan of care? (Select all that apply.)

Answers: a. Raise the head of the bed to no less than a 45 degree angle c. Have the client use and incentive spirometer 10 every hour while awake e. Ask the client to take deep breaths and cough five times every hour while awake Response Feedback: As long as the client is not on a fluid restriction, offer no less than 2000 mL of fluid to keep the body well hydrated and keep respiratory secretions loose. Ambulation is key for this client. Sitting at the side of the bed is not a replacement for ambulating. Having the client sit up helps expand the lungs. Taking deep breaths, through coughing or incentive spirometry, helps expand the lungs and decrease atelectasis.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.

Answers: a. Respirations that are abnormally deep d. Respirations that are increased in rate Response Feedback: Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug?

a. "Compress the inhaler while slowly breathing in through your mouth." Response Feedback: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration.

Which fluid will the nurse select to administer with the prescribed blood transfusion?

a. Normal Saline Response Feedback: Normal saline solution is the only solution that is compatible with blood.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection to remove a cancerous tumor. Which are the expected assessment findings? Select all that apply.

a. Occlusive dressing in place over the chest tube insertion site b. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation c. Drainage system maintained below the client's chest f. 50 mL of drainage in the drainage collection chamber Response Feedback: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the primary health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The postoperative nurse is reviewing the use of an incentive spirometer. Which instructions will the nurse include in the client's teaching plan? (Select all that apply.)

a. Sit in an upright position c. Hold breath for 5 seconds after inhaling on the spirometer d. Place mouth securely around the mouthpiece of the spirometer Response Feedback: After the spirometer is used the nurse can encourage deep coughing. The client should exhale through pursed lips. The remaining steps are correct.

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate?

b. "That isn't done because people often would develop pneumonia from the constricting effect on the lung." Response Feedback: Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 1, 2, and 4 are incorrect.

The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate will the nurse document?

b. 16 Response Feedback: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

b. An increase in blood pressure and increased respirations Response Feedback: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

b. Pain, especially with inspiration Response Feedback: Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

The nurse instructs a client with chronic obstructive pulmonary disease (COPD) to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

b. Promote Carbon Dioxide elimination Response Feedback: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?

b. Tuberculin skin test Response Feedback: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?

c. Sodium Response Feedback: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?

c. The client is probably hyperventilating Response Feedback: The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an inaccurate analysis. No conclusion can be made about a client's fluid volume status from the information provided.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

c. pH 7.25 PaCO2 50 Response Feedback: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Paco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mmol/L), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

c. Respiratory alkalosis, compensated Response Feedback: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at 1845. The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at 1915 and notes there is less than 50 mL left in the IV bag. What is the nurse's next action?

d. Auscultate the client's lungs Response Feedback: The client may show signs of fluid overload, such as crackles. Other respiratory signs are dyspnea and increased rate. Assess the client's reaction to the fluid bolus first and then proceed with notifying the charge nurse and the health care provider.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

d. Metabolic alkalosis Response Feedback: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume?

d. Sitting up and leaning on an overbed table Response Feedback: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.