NU 322 Respiratory Exam (ticket to test)

The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2 level at or above what percent?

90%

On auscultation, which finding suggests a right pneumothorax?

Absence of breath sounds in the right thorax

Constant bubbling in the water seal of a chest drainage system indicates which problem?

Air leak

A nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize?

Chronic inhalation of indoor toxins can cause lung damage.

Which is the most important risk factor for development of chronic obstructive pulmonary disease (COPD)?

Cigarette smoking

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?

Encourage the patient to take approximately 10 breaths per hour, while awake.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

Hypoxia

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive?

Influenza

A client being seen in the emergency department has labored respirations. Auscultation reveals inspiratory and expiratory wheezes. Oxygen saturation is 86%. The client was nonresponsive to an albuterol (Ventolin) inhaler and intravenous methylprednisolone (Solu-Medrol). The nurse administers the following prescribed treatment first:

Oxygen therapy through a non-rebreather mask

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?

The nursing assistant is pouring a glass of water to wet the client's mouth.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak.

You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?

"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."

The nurse is completing a client's health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases?

"Do you currently smoke, or have you ever smoked?"

A client newly diagnosed with COPD tells the nurse, "I can't believe I have COPD; I only had a cough. Are there other symptoms I should know about"? Which is the best response by the nurse?

"Other symptoms you may develop are shortness of breath upon exertion and sputum production."

A client has been placed on a ventilator, and the spouse begins to cry during the initial visit. What is the best therapeutic statement for the nurse to communicate?

"Tell me what you are feeling."

Which of the following factors contribute to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Select all that apply.

-Inflamed airways obstruct airflow. -Mucus secretions block airways. -Overinflated alveoli impair gas exchange.

The nurse is assessing a client whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this client?

A barrel chest

The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem?

Air leak

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the client is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the client's blood?

An arterial blood gas (ABG) study

When assessing for substances that are known to harm workers' lungs, the occupational health nurse should assess their potential exposure to which of the following?

Asbestos

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

Assessing the client's respiratory status, orientation, and skin color

The nurse inspects the thorax of a patient with advanced emphysema. What does the nurse expect the chest configuration to be for this patient?

Barrel chest

Which assessment finding would be most consistent with advanced emphysema?

Barrel-shaped chest

The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?

Blood gases

What finding by the nurse may indicate that the client has chronic hypoxia?

Clubbing of the fingers

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

Impaired gas exchange

A client is admitted to a health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

Impaired gas exchange related to airflow obstruction

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?

Iodine allergy

A client is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe?

It lubricates the movement of the thorax and lungs.

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following?

Lungs are clear on auscultation.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Measuring and documenting the drainage in the collection chamber

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition?

Pneumothorax

The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids?

Presence of a cough and gag reflex

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?

Progressive loss of lung function associated with chronic disease

A client has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the client discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize?

Provide emotional support to the client and family

Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)?

Pulse oximetry

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to

Purse the lips when exhaling air from the lungs.

In which position should the client be placed for a thoracentesis?

Sitting on the edge of the bed

When developing a preventative plan of care for a patient at risk for developing chronic obstructive pulmonary disease (COPD), which of the following should be incorporated?

Smoking cessation

A client is being sent home with oxygen therapy. The nurse instructs that

Smoking or a flame is dangerous near oxygen.

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Swallow reflex

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-Medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer:

albuterol (Proventil).

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:

assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

continue to take antibiotics for the entire 10 days.

Which is a late sign of hypoxia?

cyanosis

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as

pleural effusion.

The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub