NCLEX Review

What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply A. Polyps B. Gag reflex C. Shotty nodes D. Poor dentition E. Gum retraction

B, D, E 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 chronically ill, older client tells the home care nurse that the daughter with whom the client lives seems run-down and disinterested in her own health, as well as the health of her children, who are 5, 7, and 12 years old. The client tells the nurse that the daughter coughs a good deal and sleeps a lot. Why is it important that the nurse pursue the daughter's condition for potential case findings? A. Tuberculosis has been rising dramatically in the general population. B. Older adults with chronic illness are more susceptible to tuberculosis. C. There is a high incidence of tuberculosis in children less than 12 years of age. D. Death from tuberculosis has been generally on the decrease in the United States (Canada).

B. Older adults with chronic illness are more susceptible to tuberculosis. The client's chronic illness and older age increase vulnerability; the daughter's condition should be explored in greater detail. Tuberculosis is only one of many potential causes of the daughter's clinical condition. Children who have not yet reached puberty and adolescence have the lowest incidence of tuberculosis. Morbidity and mortality resulting from tuberculosis are increasing, not decreasing.

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? A. Tolerance of the child B. Sensitivity of the bacteria C. Selectivity of the bacteria D. Preference of the healthcare provider

B. Sensitivity of the bacteria

Which parameter describes the maximum volume of air that the lungs can contain? A. Vital capacity B. Total lung capacity C. Inspiratory capacity D. Functional residual capacity

B. Total lung capacity

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? A. Except with rare blood disorders, hemoglobin seldom affects oxygenation status. B. There are many other factors that affect oxygenation status more than hemoglobin does. C. A low hemoglobin level causes reduced oxygen-carrying capacity. D. Hemoglobin reflects the body's clotting ability and may or may not affect oxygenation status.

C. A low hemoglobin level causes reduced oxygen-carrying capacity. Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. Higher levels of hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. Hemoglobin does not reflect clotting ability.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? A. Red blood cell count B. Sputum culture C. Arterial blood gas D. Total hemoglobin

C. Arterial blood gas Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs

Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? A. Administering oxygen B. Using an incentive spirometer C. Having the client breathe into a paper bag D. Administering an IV containing bicarbonate ions

C. Having the client breathe into a paper bag

After abdominal surgery, a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by what method? A. Postural Drainage B. Pursed-lip breathing C. Incentive Spirometry D. Sustained Exhalation

C. Incentive Spirometry Incentive Spirometry expands collapsed alveoli and enhances surfactant activity, thereby preventing atelectasis.

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? A. Relieve bronchial spasms B. Increase depth of respirations C. Loosen pulmonary secretions D. Expel carbon dioxide from the lungs

C. Loosen pulmonary secretions 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.

The nurse is caring for a client with trauma in the emergency unit. Which action should the nurse perform as the highest priority? A. Applying dry dressing B. Evaluating chest expansion C. Providing adequate oxygen supply D. Applying direct pressure on bleeding site

C. Providing adequate oxygen supply The highest priority intervention is to establish a patent airway by providing adequate oxygen supply, thereby reducing the brain injury and progression to anoxic brain death.

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

C. Respirations

A school-aged child with cystic fibrosis has recurrent episodes of bronchitis, and the parents ask the nurse why this happens. What reason should the nurse include in the reply? A. Associated heart defects cause heart failure and respiratory depression. B. Neuromuscular irritability causes spasm and constriction of the bronchi. C. Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria. D. The increased salt content in saliva irritates the mucous membranes, resulting in inflammation of the nasopharynx.

C. Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.

Which client would have relatively smaller tidal volumes due to limited chest wall movement? A. A client with asthma B. A client with pneumonia C. A client with pulmonary fibrosis D. A client with phrenic nerve paralysis

D. A client with phrenic nerve paralysis Some respiratory conditions such as phrenic nerve paralysis may limit the diaphragm or chest wall movement and may result in smaller tidal volumes. In this condition, the lungs do not fully inflate, and the gas exchange may be impaired. Exacerbations of asthma may cause expiration to become an active labored process. Pneumonia may result in decreased lung compliance due to an accumulation of fluid in the lungs. As the lung tissue becomes less elastic or distensible, the client with pulmonary fibrosis may have decreased lung compliance.

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

D. Diminished breath sounds Because atelectasis [1] [2] involves collapsing of alveoli distal to the bronchioles, breath sounds are diminished in the lower lobes.

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? A. Decreases chest pain B. Conserves energy C. Increases oxygen saturation D. Promotes elimination of CO2

D. Promotes elimination of CO2

A nurse in the postanesthesia unit is caring for a client who had a thyroidectomy. Which client response is most important for the nurse to monitor? A. Urinary retention B. Signs of restlessness C. Decreased blood pressure D. Signs of respiratory obstruction

D. Signs of respiratory obstruction The first and most important observation should be for respiratory obstruction. If this occurs, treatment must be instituted immediately.

Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply. A. Burns B. Skin cancer C. Osteomyelitis D. Diabetic ulcers E. Myocardial infarction

A, C, D Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue's oxygen concentration. Burns, osteomyelitis, and diabetic ulcers are treated by hyperbaric oxygen therapy.

A client is admitted to the intensive care unit with acute pulmonary edema. Which diuretic does the nurse anticipate will be prescribed? A. Furosemide B. Chlorothiazide C. Spironolactone D. Acetazolamide

A. Furosemide Furosemide acts on the loop of Henle by increasing the excretion of chloride and sodium, is available for intravenous administration, and is more effective than chlorothiazide, spironolactone, and acetazolamide.

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? A. Initiate oxygen via a nasal cannula B. Administer the prescribed morphine C. Prepare the client for endotracheal intubation D. Place a nitroglycerin tablet under the client's tongue

A. Initiate oxygen via nasal cannula

A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates, and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant? A. Tachycardia B. Hypotension C. Respiratory arrest D. Central nervous system depression

A. Tachycardia Epinephrine stimulates beta- and alpha-receptors; its actions include increasing heart rate and blood pressure and inducing bronchodilation.