Respiration NCLEX

The nurse is assessing a newly admitted medical client and notes there is a depression in the lower portion of the client's sternum. This client's health record should note the presence of what chest deformity?A. A barrel chest B. A funnel chest C. A pigeon chest D. Kyphosis

B: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax

A nurse is concerned that a client may develop post-operative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?A. Ineffective airway clearance B. Impaired gas exchange C. Decreased cardiac output D. Impaired spontaneous ventilation

B: Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis

The nurse is caring for a client receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the client were experiencing oxygen toxicity? A. Bradycardia and a frontal headache B. Dyspnea and substernal pain C. Peripheral cyanosis and restlessness D. Hypotension and tachycardia

B: Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.

A 79-year-old client suddenly develops pulmonary edema. The physician prescribes furosemide, 40mg IV, and use of a nonrebreather mask. The nurse is aware that the mask will provide the client an oxygen concentration of: A. 60% to 80% B. 80% to 100% C. 36% D. 44%

B: The nonrebreather mask delivers oxygen concentrations of 80% to 100%. It's reserved for emergency situations. A partial rebreather mask delivers concentrations of 60% to 80%. A nasal cannula delivers oxygen at flow rates of 1 to 6 L/minute. A flow rate of 4L/minute delivers an oxygen concentration of 36%; a rate of 6L/minute delivers an oxygen concentration of 44%.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?A. Diphragmatic breathing B. Use of accessory muscles C. Pursed-lip breathing D. Controlled breathing

B: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy

A nurse is caring for a client receiving oxygen via a nasal cannula. Which actions should the nurse implement? Select all that apply. A. Adjust the flow meter to the ordered oxygen flow rate. B. Reassess nares, cheeks, and ears for signs of pressure very 2 hours. C. Loop the tubing over the client's ears and adjust it firmly under the chin. D. Ensure hygiene includes applying an oil-based lubricant to the client's nares. E. Alternate the position of the prongs curving upward versus downward every 2 hours.

A, B: Adjusting the flow meter to the ordered oxygen flow rate ensures that the client is receiving the prescribed dose of oxygen. Reassessing the client's skin for signs of pressure every 2 hours ensures that tissue irritation or capillary compression does not occur from the nasal prongs or tubing. The tubing should be snug enough to keep the nasal prongs from becoming displaced but loose enough not to compress or irritate tissue. Looping the tubing over the client's ears and adjusting it firmly under the chin provide the correct placement of the tubing; however, the tubing should be secured gently not firmly under the chin. The use of an oil-based lubricant, a volatile, flammable material, should be avoided in the presence of oxygen. A water-based lubricant should be used. Placing he nasal prongs curving upward does not follow the natural curve of the nasal passage, which can cause tissue injury. The nasal prongs should always be curving downward to follow the natural curve of the nares.

Which outcome best reflects achievement of the goal, "The client will expectorate lung secretions with no signs of respiratory complications?"A. Absence of adventitious breath sounds. B. Deep breathing and coughing nonproductively. C. Drinking 3,000mL of fluid in the last 24 hours. D. Expectorating sputum three times between 1500 and 2300.

A: Adventitious breath sounds are abnormal breath sounds that occur when pleural linings are inflamed or when air passes through narrowed airways or through airways filled with fluid. The absence of abnormal sounds is desirable. To expectorate secretions, coughing must be productive, not nonproductive. A nonproductive cough is dry, which means that no respiratory secretions are raised and spat out (expectorated) because of coughing. Drinking fluid is an intervention that will liquefy respiratory secretions, thus facilitating their expectoration. However, just drinking fluid will not ensure that the secretions will be expectorated. Although spitting out sputum reflects achievement of the goal in relation to expectorating lung secretions, it does not address the absence of respiratory complications, which is the ultimate goal of decreasing stasis of respiratory secretions.

The nurse interviewing a client who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the client about taking? A. ACE inhibitors B. Aspirin C. Bronchodilators D. Cardiac glycosides

A: Common causes of cough include asthma, gastrointestinal reflux disease, infection, aspiration, and side effects of medications, such as angiotensin converting enzyme (ACE) inhibitors. The other medications listed are not associated with causing a cough.

The nurse is performing a respiratory assessment of an adult client and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal sounds on what basis?A. Their location over a specific area of the lung. B. The volume of the sounds. C. Whether they are heard on inspiration or expiration. D. Whether or not they are continuous breath sounds.

A: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Normal breath sounds are heard on both inspiration and expiration, and are continuous. They are not distinguished solely on the basis of volume

A nurse is teaching a client with recurrent rhinosinusitis and instructs the client to take the following medication at the first sign of symptoms: A. guaifenesin B. acetaminophen C. oxymetazoline nasal spray D. naproxen

A: The client should take a decongestant or expectorant (e.g, guaifenesin) at the first sign of recurrence of rhinosinusitis to promote drainage of the sinus cavities and prevent bacterial infection. Medications that the client may take later in the illness for pain relief include acetaminophen and nonsteroidal antiinflammatory drugs, such as naproxen. Over-the-counter nasal sprays cause rebound congestion and should be used minimially.

The ED nurse is assessing a client complaining of dyspnea. The nurse auscultates the client's chest and hears wheezing throughout the lung fields. What might this indicate?A. The client has a narrowed airway. B. The client has pneumonia. C. The client needs physiotherapy. D. The client has a hemothorax.

A: Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy

A client comes to the clinic with a cold and wants something to help relieve the symptoms. What should the nurse include in educating the client about the uncomplicated common cold? (Select all that apply). A. Tell the client to take prescribed antibiotics to decrease the severity of symptoms. B. Inform the client about the symptoms of secondary infection. C. Suggest that the client take adequate fluids and get plenty of rest. D. Inform the client that the virus is contagious for 2 days before symptoms appear and during the first part of the symptomatic phase. E. Inform the client that taking an antihistamine will help to decrease the duration of the cold.

B, C, D: Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Management consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and the use of expectorants as needed. The nurse instructs the client about methods to treat symptoms of the common cold and provides both verbal and written information to assist in the prevention and management of URIs.

A client's oxygen saturation via pulse oximetry indicates inadequate oxygenation. Which should the nurse do first?A. Notify the primary health-care provider. B. Encourage breathing deeply. C. Raise the head of the bed. D. Administer oxygen.

C: A nurse can implement this immediate, independent action. Nurses are permitted to treat human responses. Raising the head of the bed facilitates the dropping of the abdominal organs by gravity away from the diaphragm, which permits the greatest lung expansion. Notifying the primary health-care provider is premature. The client's needs must be met first. Although encouraging deep breathing might be done eventually, it is not the priority at this time. This may or may not help. Inadequate oxygenation can be caused by a variety of problems other than shallow breathing. Obtaining and setting up the equipment take time that can be used for other more appropriate interventions first; oxygen is a medication and necessitates an order from a health care provider.

A client diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? A. Surgery to remove the tonsils and adenoids B. Medications to assist the client with sleep at night C. Continuous positive airway pressure D. Bi-level positive airway pressure

C: Continuous positive airway pressure (CPAP) provides positive pressure to the airways throughout the respiratory cycle. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the client must be breathing independently.

A pediatric client is seen in the ER with a nonproductive cough, clear nasal drainage, and congestion. The child is diagnosed with nasopharyngitis. What information should the nurse include in the discharge instructions? A. Inform the parents to complete the entire prescription of antibiotics. B. Recommend that the parents avoid sending the child to day care. C. Educate the parents on comfort measures for the child. D. Instruct the parents to restrict the child to clear liquids for 24 hours.

C: Nursing care for nasopharyngitis is primarily supportive. Keeping the child comfortable during the course of the illness is all the parents can do. Nasal congestion can be relieved using normal saline drops and a bulb suction. Acetaminophen can also be given for discomfort or a mild fever. Nasopharyngitis is a viral illness and does not require antibiotic therapy. Children who attend day care are more prone to catching viral illnesses, bu tit is not the nurse's place to tell the parents not to send their child to day care. Often families do not have a choice about using day care. There is no reason to restrict the child to clear liquids. Many children have a decreased appetite during a respiratory illnesses, so the most important thing is to keep them hydrated.

The nurse is caring for a 22-month-old male who has had repeated bouts of otitis media. The nurse is educating the parents about otitis media. Which of the following statements from the parents indicates they need additional teaching?A. "If I quit smoking, my child may have less chance of getting an ear infection." B. "As my child gets older, he should have fewer ear infections, because his immune system will be more developed." C. "My child will have fewer ear infections if he has his tonsils removed." D. "My child may need a speech evaluation."

C: Removing children's tonsils may not have any effect on their ear infection. Children who have repeated bouts of tonsillitis can have ear infections secondary to the tonsillitis, but there is no indication in this question that the child has a problem with tonsillitis. Repeated exposure to smoke damages the cilia in the ear, making the child more prone to ear infections. Children experience fewer ear infections as their immune system is maturing. Children who have repeated ear infections are at a higher risk of having decreased hearing during and between infections. Hearing loss directly affects a child's speech development.

A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order?A. Non-rebreather B. Tracheostomy collar C. Venturi mask D. Face tent

C: The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these high flow methods to do not match the precision of a Venturi mask that a COPD client would need.

A physician diagnoses a school-age child with strep throat and pharyngitis. The child's parent asks the nurse what treatment the child will need. Which is the nurse's best response?A. "Your child will be sent home on bedrest and should recover in a few days without any intervention." B. "Your child will need to have the tonsils removed to prevent further strep infections." C. "Your child will need oral penicillin for 10 days and should feel better in a few days." D. "Your child will need to be admitted to the hospital for 5 days of intravenous (IV) antibiotics."

C: The child will need a 10-day course of penicillin to treat the strep infection. It is essential that the nurse always tell the family that, although the child will feel better in a few days, the entire course of antibiotics must be completed. The child may need bedrest. However, the child does need antibiotics to treat the strep infection. The child does not need the tonsils removed; the child has pharyngitis and strep throat. Surgical removal of the tonsils is done only following recurrent bouts of infection. Strep throat can be treated at home with oral penicillin and does not require IV antibiotics and hospitalization.

While assessing an acutely ill client's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?A. Eupnea B. Apnea C. Biot's respiration D. Cheyne-Stokes

C: The nurse will document that the patient is demonstrating a Biot's respiration pattern. Biot's respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biot's respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne-Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute. Bradypnea is a slower-than-normal rate (<10 breaths per minute), with normal depth and regular rhythm, and no apnea

A client with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath?A. Total lung capacity B. Forced vital capacity C. Tidal volume D. Residual volume

C: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.

A primary health care provider's order reads, "6 L oxygen via face mask." The client who has been extremely confused since being in the unfamiliar environment of the hospital, becomes agitated and repeatedly pulls off the mask. Which should the nurse do? A. Tighten the strap around the hand. B. Reapply the mask every time the client pulls it off. C. Provide an explanation of why the oxygen is necessary. D. Request that the order for oxygen be changed to a nasal cannula.

D: Agitated, confused clients generally tolerate a nasal cannula better than a face mask. A nasal cannula is less intrusive than a mask. Masks are oppressive and may cause a client to feel claustrophobic. Tightening the strap around the head is unsafe because it can compress the capillaries under the strap, which may interfere with tissue perfusion and result in pressure ulcers. Reapplying the mask every time the client pulls it off may increase the client's agitation and is impractical. Providing an explanation of why the oxygen is necessary will probably be ineffective because an agitated client often does not understand cause and effect.

A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform which of the following? A. Apply a cold pack to the affected area. B. Apply a mustard poultice to the forehead. C. Perform postural drainage. D. Increase fluid intake.

D: For a client diagnosed with acute sinusitis, the nurse should instruct the client that hot packs, increasing fluid intake, and elevating the head of the bed can promote drainage. Applying a mustard poultice will not promote sinus drainage. Postural drainage is used to remove bronchial secretions.

A client is admitted to the hospital with shortness of breath. The physician orders a stat hemoglobin and hematocrit level to be drawn. The client is questioning why he needs to have blood drawn when he is having trouble breathing. What is the best response by the nurse?

D: Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. More hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. If the client has been tachypneic during exertion, or even at rest, because oxygen demand is higher than the available oxygen content, then an increase in hemoglobin may decrease the respiratory rate to normal levels.

A client comes to the ER and is admitted with epistaxis. Pressure has been applied to the client's midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate what treatment to control the bleeding? A. Irrigation with a hypertonic solution B. Nasopharyngeal suction C. Normal saline application D. Silver nitrate application

D: If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used. Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation with a hypertonic solution is not used to treat epistaxis.