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A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse should take which action after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour?

Refrigerate the specimen.

The nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux tuberculin skin test. Which action by the nurse is the priority?

Report the findings.

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?

Respiratory distress

The nurse is reinforcing discharge teaching with a client diagnosed with tuberculosis (TB) and has been on medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made?

"I should not be contagious after 2 to 3 weeks of medication therapy."

A nursing student prepares to instruct a client to expectorate a sample of sputum that will be sent to the laboratory for Gram stain, culture, and sensitivity and describes the procedure to the licensed practical nurse (LPN), who is the primary nurse. The LPN corrects the student if which incorrect description is provided?

"I will have the client take a shallow breath before coughing."

The nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the client's bed in which position to effectively perform this procedure? Refer to figure.

1 (Semifowlers)

The nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention should be included? Select all that apply.

Rest Local heat Analgesics

The nurse is collecting respiratory data from an adult client and is auscultating for normal breath sounds. The nurse should expect to hear bronchial breath sounds in which anatomical area? Refer to figure.

Tubular structure below trach

A client with pneumonia is admitted to the hospital, and the health care provider writes prescriptions for the client. Which prescription should the nurse complete first?

Obtain a culture and sensitivity of sputum.

The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. (Refer to audio.) The nurse determines that these breath sounds usually are caused by which?

Opening of small airways that contain fluid

The nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse should reinforce instructing the client to do which during this process?

Perform Valsalva's maneuver.

A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action?

Place the client in high-Fowler's position.

The nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure?

Places the stethoscope on the client's gown

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which arterial blood gas supports this diagnosis?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the nurse take?

Ventilate the client manually.

The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. Which would be the next immediate nursing action?

Ventilate the client with a resuscitation bag

The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter?

10 seconds

A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage. Which type of drainage is expected?

Bloody

The nurse has finished suctioning a client. The nurse should use which parameters to best determine the effectiveness of suctioning?

Breath sounds are clear

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?

A man who is an inspector for the U.S. Postal Service

The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client?

Abdominal distention

A client has undergone fluoroscopy-assisted aspiration biopsy of a lung lesion. The nurse determines that the client is experiencing complications from the procedure if the nurse makes which observation?

Absence of breath sounds in the right upper lobe

The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause?

Accumulation of secretions in the client's lungs

A client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions should be done? Select all that apply.

Administer humidified oxygen. Instruct on the use of the incentive spirometer. Monitor vital signs and pulse oximetry frequently.

The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure?

Administer pain medication 15 to 30 minutes before the procedure.

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply.

Apply suction for up to 10 to 15 seconds. Hyperoxygenate the client before suctioning. Apply intermittent suction while rotating and withdrawing the catheter. Advance the catheter until resistance is met and then pull the catheter back 1 cm.

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which best action to ensure accurate readings on the oximeter?

Ask the client to limit motion in the hand attached to the pulse oximeter.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Aspiration of gastric contents occurs when suctioning

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action?

Assess the client.

A client arrives in the emergency department with a bloody nose. Which is the initial nursing action?

Assist the client to a sitting position with the head tilted slightly forward.

The nurse is assisting in preparing a list of instructions for an adult client who is being discharged following a tonsillectomy. Which instructions should the nurse include in the list? Select all that apply.

Avoid hot fluids. Avoid rough foods. Rest for the next 24 hours.

The nurse is assessing a client who has frequent episodes of asthma. Which assessment finding is most closely associated with asthma?

Bilateral wheezing

A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes which sign/symptom?

Breath sounds greater on the right than the left

The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications?

Changing the client's position every 2 hours

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement?

Check the amount of suction pressure being applied.

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?

Check the client for spontaneous breathing.

The nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection?

Chills and night sweats

The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate?

Continue to monitor, because this is an expected finding.

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation?

Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out

The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse signs and symptoms indicating acute pulmonary edema?

Frothy sputum

A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. Which recommendation by the nurse is therapeutic? Select all that apply.

Get plenty of rest. Take antipyretics for fever. Increase intake of liquids.

The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis?

High-grade fever

The nurse is caring for a client with a wet suction chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which action?

Immerse the end of the tube in sterile saline.

The nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer?

Cough

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs with suctioning

The nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. Which action should the nurse implement?

Cover the insertion site with sterile Vaseline gauze.

The nurse is discussing signs of severe airway obstruction with a group of nursing students. Which sign should the nurse emphasize as one that indicates severe airway obstruction?

Cyanosis

A client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation?

Directly observed therapy

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?

Disconnect the suction source from the catheter.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take?

Discontinue suctioning until the client is stabilized and monitor vital signs.

The nurse is assisting a health care provider with the insertion of a wet-suction chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse plans to take which appropriate action?

Document the accurate functioning of the tube.

A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which signs and symptoms?

Dyspnea

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience?

Dyspnea

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply.

Dyspnea on exertion Presence of a productive cough Difficulty breathing while talking

The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis? Select all that apply.

Early onset cough Purulent mucous production Mild episodes of dyspnea

The nurse is collecting data on a client with chronic airflow limitation (CAL) and notes that the client has a "barrel chest." The nurse interprets that this client has which forms of CAL?

Emphysema

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which information about this type of tube?

Enables the client to speak

The nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a Pao2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client?

Ineffective oxygen and carbon dioxide exchange

The nurse is checking the chest tube drainage system of a postoperative client who had a right upper lobectomy. The closed drainage system has 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water-seal chamber. One hour following the initial data collection, the nurse notes that the bubbling in the water-seal chamber is now constant, and the client appears dyspneic. Based on these findings, which action should the nurse do first?

Inspect chest tube connections.

While assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder?

Knifelike pain that worsens on inspiration

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?

Lateral position

A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure?

Left side-lying with the head of the bed elevated at 45 degrees

A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hour?

Lorazepam (Ativan)

A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated?

Lowering the head of the bed to a flat position

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees

The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles?

Mask

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. Which action should the nurse take?

Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.

A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit?

Nasal obstruction

The nurse is reading the results of a Mantoux tuberculin skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. Which interpretation should the nurse make of these results?

Negative

The nurse is reading the results of a tuberculin skin test for a client who has no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets the data as which result?

Negative

The nurse is caring for the client who is at risk for lung cancer because of an extremely long history of heavy cigarette smoking. The nurse tells the client to report which frequent early symptom of lung cancer?

Nonproductive hacking cough

A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse should perform which action?

Notify the registered nurse.

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action?

Notify the registered nurse.

Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply.

Position on the side until fully recovered Encouraging coughing and deep breathing Monitoring pulse oximetry readings frequently Encouraging the use of an incentive spirometer

The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. Which nursing action would be immediate?

Reattach the chest tube to the drainage system.

The nurse is assigned to assist in caring for a client with a chest tube drainage system. In planning for the client, the nurse makes certain that what equipment is available, in the event that the drainage system needs to be changed?

Rubber-shod clamps

The nurse is assisting in caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse monitors the portable wound suction for which types of drainage expected in the immediate postoperative period?

Serosanguineous

The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax?

Shortness of breath

The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation?

Shortness of breath

The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement?

Shortness of breath and tracheal deviation

The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume?

Sitting on the side of the bed, leaning on an overbed table

The nurse is monitoring the respiratory status of a client who has suffered a fractured rib. The nurse monitors the client and understands that which sign/symptom is unrelated to the rib fracture?

Slow, deep respirations

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?

Stridor

The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention?

Suction the client.

The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion should the nurse make?

The chest tube is functioning as expected.

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly?

The client breathes out slowly through the mouth.

The nurse reads a client's tuberculin skin test as positive. The nurse notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse's response is based on the understanding that which statement is true for this client?

The client has been exposed to tuberculosis

The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client?

The client is breathing through the nose.

A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, which interpretation should the nurse make?

The client should be repeating the sequence 10 to 20 times in each session.

The nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique?

The client's exhalation is twice as long as inhalation.

The nurse is assisting a client, who underwent radical neck surgery, to get out of bed. How does the nurse provide support to this client, who is afraid to move the head?

The nurse places a hand behind the client's head.

A client reports the chronic use of nasal sprays. The nurse reinforces instructions to this client about which piece of information related to chronic use of nasal sprays?

The protective mechanism of the nose may be damaged.

The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene?

The student suctions the client's tracheotomy tube for 15 seconds.

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination?

The system is functioning as expected.

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse analyzes this finding as indicative of which outcome?

The system is functioning as expected.

A client has a closed-chest tube drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. How does the nurse interpret this finding?

The tube is patent.

The nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. Which statement represents the nurse's accurate interpretation of this finding?

This finding requires further data collection.

A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason?

To expel mucus from the airways

A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which sign or symptom observed by the nurse clearly indicates that the pneumothorax is rapidly worsening?

Tracheal deviation to the right

The nurse is admitting a client to the nursing unit who is suspected of having tuberculosis (TB). The nurse plans to admit the client to which type of room?

Venting to the outside, six air exchanges per hour, and ultraviolet light

The nurse is assisting a health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan to ensure that which is done as a final measure to determine correct tube placement?

Verify placement by a chest x-ray.

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?

pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L