Respiratory

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing? 1 Atrial fibrillation 2 Sinus tachycardia 3 Ventricular fibrillation 4 First-degree atrioventricular block

2 Sinus tachycardia The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.

When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? 1 Slide slowly to the floor to prevent a fall and injury. 2 Sit on the edge of the bed while they hold the client upright. 3 Bend forward because this will increase blood flow to the brain. 4 Lie down quickly so the legs can be raised above the heart level.

2 Sit on the edge of the bed while they hold the client upright.

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" The nurse explains that the purpose of the chest tube is to do what? 1 Check for bleeding in the lung 2 Monitor the function of the lung 3 Drain fluid from the pleural space 4 Remove air from the pleural space

4 Remove air from the pleural space

The laboratory reports of a client with a history of congestive heart failure show a blood pH value more than 7.45. Which type of acid-base imbalance may most likely be found in the client? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

4 Respiratory alkalosis

Which clinical indicator should the nurse expect to identify when assessing a client with varicose veins? 1 Positive Homans sign 2 Pallor of the affected extremity 3 Continuous edema of the lower legs 4 Sensation of heaviness in calf muscles

4 Sensation of heaviness in calf muscles

When assessing a client with the diagnosis of left ventricular failure, what does the nurse expect to identify? 1 Crushing chest pain 2 Dyspnea on exertion 3 Jugular vein distention 4 Extensive peripheral edema

2 Dyspnea on exertion

When caring for a client with pneumonia, which nursing intervention is the highest priority? 1 Increase fluid intake. 2 Employ breathing exercises and controlled coughing. 3 Ambulate as much as possible. 4 Maintain a nothing-by-mouth (NPO) status.

2 Employ breathing exercises and controlled coughing.

A client with respiratory disorder complains of fatigue. Which nursing intervention will be beneficial for this client? 1 Assessing the degree of dyspnea 2 Encouraging adequate periods of rest 3 Instruction in effective breathing techniques 4 Monitoring for nasal flaring and sternal retractions

2 Encouraging adequate periods of rest

Which older client is likely at an increased risk for developing pneumonia due to not having been vaccinated? 1 Asian American 2 Hispanic 3 Native American 4 African American

2 Hispanic

In what position should the nurse place a client recovering from general anesthesia? 1 Supine 2 Side-lying 3 High Fowler 4 Trendelenburg

2 Side-lying (gag reflex not in tact and may throw up so put on side)

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing? 1 Atrial fibrillation 2 Sinus tachycardia 3 Ventricular fibrillation 4 First-degree atrioventricular block

2 Sinus tachycardia

What should a nurse do immediately when a client returns from the postanesthesia care unit following a subtotal thyroidectomy? 1 Inspect the incision. 2 Instruct the client not to speak. 3 Place a tracheostomy set at the bedside. 4 Place in the supine position for 24 hours.

3 Place a tracheostomy set at the bedside.

A client is admitted to the hospital with a severe head injury. What should the nurse identify as the priority nursing care for this client? 1 Placing the client in a supine position 2 Preventing contractures and deformities 3 Monitoring the blood pressure frequently 4 Maintaining respiratory exchange and ventilation

4 Maintaining respiratory exchange and ventilation

A nurse is teaching the parents of an infant with a cleft lip and palate how to prevent infection. What information should the nurse include about why the infant is predisposed to infection? 1 Waste products accumulate along the defect. 2 Circulation to the defective area is insufficient. Incorrect3 Inefficient feeding behaviors result in inadequate nutrition. 4 Mouth breathing dries the oropharyngeal mucous membranes.

4 Mouth breathing dries the oropharyngeal mucous membranes.

A nurse is caring for a client who had emergency surgery for a ruptured appendix. What action should the nurse take when the client manifests signs and symptoms of shock? 1 Prepare for a blood transfusion 2 Elevate the head of the bed 30 degrees 3 Administer 2 L oxygen via nasal cannula 4 Notify the health care provider immediately

4 Notify the health care provider immediately

Which preparations use toxoids but not live viruses? Select all that apply. 1 Rotarix 2 Varivax 3 M-M-R II 4 PEDIARIX 5 DAPTACEL

4 PEDIARIX 5 DAPTACEL

Which value is within the normal range of values for arterial blood gas? 1 7.44 2 7.26 3 7.56 4 7.66

1 7.44 The normal value range for arterial blood gas is between 7.35 and 7.45. Therefore, 7.44 is the normal value. For arterial blood gas levels, 7.26 is too low, and 7.56 and 7.66 are too high.

Which action should be the nurse's first priority for a client with major burns? 1 Assessing airway patency 2 Checking the client from head to toe 3 Administering oxygen as needed 4 Elevating the extremities if no fractures are noticed

1 Assessing airway patency

Which technique is not used to manage mild sleep apnea? 1 Polysomnography 2 Avoiding sedatives 3 A weight-loss program 4 Use of an oral appliance

1 Polysomnography

The nurse should place the client in which position to obtain an accurate reading of jugular vein distention? 1 Upright at 90 degrees 2 Supine position 3 Raised to 45 degrees 4 Raised to 10 degrees

3 Raised to 45 degrees

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply. 1 Fever 2 Stridor 3 Wheezing 4 Tachycardia 5 Hypotension

3 Wheezing 4 Tachycardia

Newborn suffering from respiratory distress: Cyanosis Weezing Crackles Retractions Tachypnea

Cyanosis Tachypnea Retractions

Which laboratory finding indicates metabolic alkalosis? 1 A pH value of more than 7.45 2 Potassium ions (K+) more than 5 mEq/L 3 Bicarbonate ion ( HCO3- ) levels less than 21 4 Partial pressure of carbon dioxide (PaCO2) more than 45 mm Hg

1 A pH value of more than 7.45

A registered nurse supervises a licensed practical nurse (LPN) who is caring for a client with hyperthermia. Which action by the LPN may indicate a need for further supervision? Select all that apply. 1 Advising the client to increase physical activities 2 Encouraging the client to increase oral fluid intake 3 Keeping bed linens wet to reduce the client's temperature 4 Removing the client's external coverings if temperature is subnormal 5 Administering acetaminophen as ordered by the health-care provider

1 Advising the client to increase physical activities 3 Keeping bed linens wet to reduce the client's temperature 4 Removing the client's external coverings if temperature is subnormal

The nurse is caring for a client with bomb blast injuries. Which are priority emergency assessments that need to be performed? Select all that apply. 1 Airway 2 Breathing 3 Circulation 4 Give comfort measures 5 Facilitate family presence 6 Exposure or environmental control

1 Airway 2 Breathing 3 Circulation 6 Exposure or environmental control

Which condition may cause respiratory alkalosis? 1 Asthma 2 Atelectasis 3 Poliomyelitis 4 Cystic fibrosis

1 Asthma

A nurse is caring for a client with a diagnosis of diabetic ketoacidosis. What information should the nurse include when teaching the client about the causes of diabetic acidosis? 1 Breakdown of fat stores for energy 2 Ingestion of too many highly acidic foods 3 Excessive secretion of endogenous insulin 4 Increased amounts of cholesterol in the extracellular compartment

1 Breakdown of fat stores for energy

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? 1 Skin breakdown 2 Aspiration pneumonia 3 Retention ileus 4 Profuse diarrhea

2 Aspiration pneumonia

A female client who has been sexually active for 5 years is found to have gonorrhea. The client is upset and asks the nurse, "What can I do to keep from getting another infection in the future?" Which statement by the client indicates that the teaching by the nurse was effective? 1 "I'll douche after each time I have sex." 2 "Having sex is a thing of the past for me." 3 "My partner has to use a condom all the time." 4 "I'll be using a spermicidal cream from now on."

3 "My partner has to use a condom all the time."

A client who is to begin continuous ambulatory peritoneal dialysis (CAPD) asks the nurse what this treatment entails. What information should the nurse include in the explanation? 1.Peritoneal dialysis is done in an ambulatory care clinic. 2.Hemodialysis and peritoneal dialysis are provided continuously. 3.The peritoneal membrane allows passage of toxins into the dialysate. 4.A quarter of a liter of dialysate is maintained inter- and intraperitoneally.

3.The peritoneal membrane allows passage of toxins into the dialysate.

A client reports frequent awakening at night, insomnia, and excessive daytime sleepiness. The client adds that his bed partner also complains about his loud snoring. What does the nurse anticipate including in the patient's teaching plan? 1 "Take a warm shower before bedtime." 2 "Take a sedative three or four hours before bedtime." 3 "Avoid alcoholic beverages for five to six hours before bedtime." 4 "Get fitted for an oral appliance that will bring the lower jaw and tongue forward."

4 "Get fitted for an oral appliance that will bring the lower jaw and tongue forward."

What is the most essential nursing care for a client who just had a cardiac catheterization? A. Maintain the semi-Fowler position. B. Monitor the apical pulse and blood pressure. C. Take the temperature hourly until it stabilizes. D. Encourage frequent coughing and deep breathing.

B. Monitor the apical pulse and blood pressure.

A nurse is caring for a client with a diagnosis of diabetic ketoacidosis. What information should the nurse include when teaching the client about the causes of diabetic acidosis? 1 Breakdown of fat stores for energy 2 Ingestion of too many highly acidic foods 3 Excessive secretion of endogenous insulin 4 Increased amounts of cholesterol in the extracellular compartment

1 Breakdown of fat stores for energy In the absence of insulin , which facilitates the transport of glucose into cells, the body breaks down proteins and fats to supply energy; ketones, a by-product of fat metabolism, accumulate, causing metabolic acidosis (pH below 7.35). The pH of food ingested has no effect on the development of acidosis. The opposite of excessive secretion of endogenous insulin is true. Cholesterol level has no effect on the development of acidosis.

What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. 1 Count the client's respirations. 2 Document the intensity of the client's pain. 3 Withhold the medication if the client reports pruritus. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose. 5 Discard the medication in the client's toilet before leaving the room if the medication is refused.

1 Count the client's respirations. 2 Document the intensity of the client's pain. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose. Pruritus is a common side effect that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration.

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply. 1 Crackles 2 Coughing 3 Orthopnea 4 Yellow sputum 5 Dependent edema

1 Crackles 2 Coughing 3 Orthopnea yellow sputum is infection not pulmonary edema

The nurse is caring for a 4-year-old child who has been hospitalized with an acute asthma exacerbation. Which finding requires action by the nurse? 1 Diminished breath sounds 2 Pulse rate of 110 beats/min 3 Pulse oximetry reading of 95% 4 Respiratory rate of 24 breaths/min

1 Diminished breath sounds

A client with chronic kidney disease is scheduled to begin peritoneal dialysis. When discussing the procedure, what does the nurse explain is the purpose of the dialysis? 1 Help do some of the work usually done by the kidneys 2 Prevent the client from developing complicating heart problems 3 Remove bad chemicals from the body so the disease will not get worse 4 Speed the client's recovery because the kidneys are not responding to other therapy

1 Help do some of the work usually done by the kidneys

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse suspect is causing these clinical findings? 1 Hypokalemia 2 Hyponatremia 3 Hyperglycemia 4 Hypercalcemia

1 Hypokalemia

When providing nursing care to children the nurse remembers that in the child, as in the adult, respiratory patterns are controlled by what? 1 Medulla 2 Cerebellum 3 Hypothalamus 4 Cerebral cortex

1 Medulla

A client with arthritis increases the dose of ibuprofen to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? Select all that apply. 1 Melena 2 Tachycardia 3 Constipation 4 Clay-colored stools 5 Painful bowel movements

1 Melena 2 Tachycardia

Which medication does the nurse anticipate will be prescribed to relieve anxiety and apprehension in a client with pulmonary edema? 1 Morphine 2 Phenobarbital 3 Hydroxyzine 4 Chloral hydrate

1 Morphine

A client suffering severe metabolic acidosis is comatose. Which nursing action would be appropriate? Select all that apply. 1 Providing mechanical ventilation 2 Administering sodium bicarbonate 3 Helping the client breathe into a paper bag 4 Using intermittent positive pressure breathing 5 Using continuous positive airway pressure (CPAP)

1 Providing mechanical ventilation 2 Administering sodium bicarbonate

After reviewing a client's medical records, a nurse suspects that the client has sleep apnea. Which medical diagnosis is related to sleep apnea? 1 Pulmonary edema 2 Increased hematocrit 3 Increased white blood cell count 4 Hemoglobin concentration of 20 g/dL or more

1 Pulmonary edema

Which nursing action would be appropriate for treating a client with respiratory alkalosis caused by hyperventilation secondary to anxiety? Select all that apply. 1 Sedating the client 2 Providing mechanical ventilation 3 Administering sodium bicarbonate 4 Helping the client breath into a paper bag 5 Instructing the client to breathe slowly to retain and accumulate carbon dioxide in the body

1 Sedating the client 4 Helping the client breath into a paper bag 5 Instructing the client to breathe slowly to retain and accumulate carbon dioxide in the body

What is the first thing that must occur in the respiratory system to compensate for increased alkalinity in the system? 1 Slowing down the respiratory rate 2 Increasing the carbonic acid level 3 Lowering the pH value of the blood 4 Raising carbon dioxide levels in the blood

1 Slowing down the respiratory rate When there is increased alkaline in the system, the respiratory system should be slowed down, in order to increase the carbon dioxide in the blood. This then raises the level of carbonic acid, resulting in lowering the pH level.

What is the most essential nursing care for a client who just had a cardiac catheterization? 1 Maintain the semi-Fowler position 2 Monitor the apical pulse and blood pressure 3 Take the temperature hourly until it stabilizes 4 Encourage frequent coughing and deep breathing

2 Monitor the apical pulse and blood pressur

A complete blood count is ordered for a 5-month-old infant with Tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results? 1 Anemia 2 Polycythemia 3 Agranulocytosis 4 Thrombocytopenia

2 Polycythemia The body responds to the chronic hypoxia caused by the heart defect by increasing the production of red blood cells (RBCs) in an attempt to increase the oxygen-carrying capacity of the blood. The RBC count will be increased because the body increases erythrocyte production in an attempt to make more cells available to carry oxygen. Agranulocytosis does not result from hypoxia; it occurs when the white blood cell count decreases to a very low level and neutropenia becomes pronounced. Thrombocytopenia (low platelet count) does not result from hypoxia; it occurs in disease processes in which platelet production is suppressed, platelet survival is decreased, or platelet destruction is increased.

Which test is used to diagnose sleep apnea? 1 Sonography 2 Polysomnography 3 Echocardiography 4 Plethysmography

2 Polysomnography

A male client with a diagnosis of antisocial personality disorder is admitted to the mental health hospital. What is the priority nursing intervention? 1 Encouraging interactions with others 2 Presenting a united, consistent staff approach 3 Assuming a nurturing, forgiving tone in disputes 4 Using seclusion when manipulative behaviors are exhibited

2 Presenting a united, consistent staff approach

How does the body compensate for metabolic alkalosis? 1 The kidneys retain bicarbonate to raise pH levels. 2 The lungs retain carbon dioxide to lower pH levels. 3 The lungs excrete carbon dioxide to raise pH levels. 4 The kidneys excrete increased amounts of bicarbonate to lower pH levels.

2 The lungs retain carbon dioxide to lower pH levels.

How does the body compensate for metabolic alkalosis? 1 The kidneys retain bicarbonate to raise pH levels. 2 The lungs retain carbon dioxide to lower pH levels. 3 The lungs excrete carbon dioxide to raise pH levels. 4 The kidneys excrete increased amounts of bicarbonate to lower pH levels.

2 The lungs retain carbon dioxide to lower pH levels. In metabolic alkalosis, the body must lower pH levels. The lungs do this by retaining carbon dioxide. The lungs excrete carbon dioxide to raise pH levels in metabolic acidosis, but not in metabolic alkalosis. In respiratory alkalosis, the kidneys excrete increased amounts of bicarbonate to lower pH levels. In respiratory acidosis, the kidneys retain increased amounts of bicarbonate to increase pH levels. (23-30 for bicarbonate levels)

A registered nurse is educating a licensed practical nurse (LPN) about the palliative procedure used to manage tetralogy of Fallot in infants. Which statement made by the LPN indicates effective teaching? 1 "It involves enlarging an atrial septal defect that is already present." 2 "It involves impeding the flow of blood from the right ventricle to the pulmonary circulation." 3 "It is a temporary procedure that creates an artificial connection between the pulmonary artery and the aorta." 4 "It involves repair of small defects with purse-string sutures and moderate to large defects with a Dacron, or polyester fiber, patch."

3 "It is a temporary procedure that creates an artificial connection between the pulmonary artery and the aorta."

The nurse should place the client in which position to obtain an accurate reading of jugular vein distention? 1 Upright at 90 degrees 2 Supine position 3 45 degrees 4 Raised to 10 degrees

3 45 degrees

Which client is most likely to report experiencing fatigue? 1 A client with peripheral edema 2 A client limiting vigorous activity 3 A client with increased oxygen demand 4 A client with increased body temperature

3 A client with increased oxygen demand

A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period, what is the priority nursing action? 1 Irrigating the T-tube every hour 2 Changing the dressing every two hours 3 Encouraging coughing and deep breathing 4 Promoting an adequate fluid and food intake

3 Encouraging coughing and deep breathing

Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals what? 1 A pH of 7.35 2 A potassium level of 4.6 mEq/L 3 An increased Paco2 of 55 mm Hg 4 An arterial O2 pressure of 80 mm Hg

3 An increased Paco2 of 55 mm Hg

A client is admitted to the emergency department after ingesting a tricyclic antidepressant in an amount 30 times the daily recommended dose. What is the immediate treatment anticipated by the nurse? 1 Administration of physostigmine as soon as possible 2 Closer monitoring to prevent further suicidal attempts 3 Gastric lavage with activated charcoal and support of physiological function 4 Intravenous administration of an anticholinergic in response to changes in vital signs

3 Gastric lavage with activated charcoal and support of physiological function

A client with asthma is pregnant. Which nursing intervention is advisable to ensure the safe delivery of the baby? 1 Have the client stop taking her medication 2 Advise the client to abort the pregnancy 3 Have the client continue the asthma treatment 4 Have the client reduce the dose of the medication

3 Have the client continue the asthma treatment

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client? 1 Prevent dyspnea 2 Prevent cyanosis 3 Increase oxygen concentration to heart cells 4 Increase oxygen tension in the circulating blood

3 Increase oxygen concentration to heart cells

What are the PRIORITY nursing interventions for a client with neutropenia in an emergency department? Select all that apply. 1 Monitor for rashes and pruritus. 2 Prepare an appropriate diet plan. 3 Obtain blood cultures immediately. 4 Teach hygiene measures to be followed. 5 Administer antibiotic STAT as prescribed.

3 Obtain blood cultures immediately. 5 Administer antibiotic STAT as prescribed.

A health care provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens? 1 After activity 2 Before meals 3 On awakening 4 Before a respiratory treatment

3 On awakening

When is the most appropriate time for the nurse to plan for chest percussion and postural drainage for a toddler with cystic fibrosis? 1 After suctioning 2 Before aerosol therapy 3 One hour before meals 4 Fifteen minutes after meals

3 One hour before meals Performing chest percussion and postural drainage 1 hour before meals will give the child an opportunity to rest before eating. The child should be encouraged to cough; if this is not effective, suctioning may be done after chest percussion and postural drainage.

A nurse instills an antibiotic ophthalmic ointment into a newborn's eyes. What condition does this medication prevent? 1 Herpetic ophthalmia 2 Retinopathy of prematurity 3 Ophthalmia neonatorum 4 Hemorrhagic conjunctivitis

3 Ophthalmia neonatorum Ophthalmia neonatorum is caused by gonorrheal and/or chlamydial infections present in the vaginal tract. It is preventable with the prophylactic use of an antibiotic ophthalmic ointment applied to the neonate's eyes.

An emergency tracheotomy is performed on a toddler in acute respiratory distress from laryngotracheobronchitis (viral croup). What early signs of respiratory distress indicate that it is necessary for the nurse to suction the tracheotomy? Select all that apply. 1 Stridor 2 Cyanosis 3 Restlessness 4 Increased pulse rate 5 Substernal retractions

3 Restlessness 4 Increased pulse rate Restlessness and increased pulse rate are early signs of hypoxia; suctioning is required to keep the airway patent. Stridor, cyanosis, and substernal retractions are late signs of hypoxia; suctioning should be performed before substernal retractions occur.

While preforming nasotracheal suctioning, the nurse notices that the client has blood pressure of 90/70 and a heart rate of 50 beats per minute. What is the priority nursing intervention in this situation? 1 Administering intravenous fluids to the client 2 Reporting to the primary healthcare provider 3 Stopping the suctioning procedure immediately 4 Administering 100% oxygen manually to the client

3 Stopping the suctioning procedure immediately

A client with asthma was taught about self-management with long-acting medication. Which action performed by the client indicates a need for correction? 1 Practicing yoga daily 2 Minimum intake of eight ounces of water daily 3 Taking the medication when an attack is triggered 4 Performing deep breathing exercise whenever possible

3 Taking the medication when an attack is triggered

Client complains of left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, what does the nurse expect to identify? 1 Dull sound on percussion 2 Vocal fremitus on palpation 3 Rales with rhonchi on auscultation 4 Absent breath sounds on auscultation

4 Absent breath sounds on auscultation

A licensed practical nurse (LPN) is providing palliative care to a client who has undergone surgery as a measure to treat lung cancer. A registered nurse teaches the LPN the interventions that need to be performed if ineffective airway clearance related to the surgery develops in the client. Which statement by the nurse indicates a need for further teaching? 1 "I'll promote coughing and deep breathing." 2 "I'll assist the client with frequent position changes." 3 "I'll encourage the client to use an incentive spirometer." 4 "I'll facilitate optimal breathing by placing the client in supine position."

4 "I'll facilitate optimal breathing by placing the client in supine position."

A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. What would be the best response from the nurse? 1 "I don't know. I will ask the health care provider for a prescription." 2 "Antibiotics are used to treat viruses, and you have a bacterial infection." 3 "Antibiotics are ineffective for treating the bacteria that cause upper respiratory infections." 4 "Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics."

4 "Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics."

A client complains of left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, what does the nurse expect to identify? 1 Dull sound on percussion 2 Vocal fremitus on palpation 3 Rales with rhonchi on auscultation 4 Absence of breath sounds on auscultation

4 Absence of breath sounds on auscultation

What is the primary cause of otitis media in young children? 1 Sinusitis 2 Recurrent tonsillitis 3 An inflamed mastoid process 4 An obstructed eustachian tube

4 An obstructed eustachian tube

A client who is to begin continuous ambulatory peritoneal dialysis asks the nurse what this entails. What information should the nurse include when answering the client's question? 1 Hemodialysis and peritoneal dialysis will be done together. 2 Peritoneal dialysis is performed in an ambulatory care clinic. 3 About a quarter of a liter of dialysate is maintained in the peritoneal cavity. 4 Constant contact is maintained between the dialysate and the peritoneal membrane.

4 Constant contact is maintained between the dialysate and the peritoneal membrane.

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? 1 Choking 2 Redness 3 Gagging 4 Cyanosis

4 Cyanosis

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? 1 Productive cough 2 Clubbing of the fingertips 3 Crackles at the height of inhalation 4 Diminished breath sounds on auscultation

4 Diminished breath sounds on auscultation

Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation? 1 Late cyanosis 2 Early tachypnea 3 Late use of accessory muscles 4 Early unexplained restlessness

4 Early unexplained restlessness

The nurse finds that a client has an increased temperature. What other sign can be noticed on further assessment? 1 Increased appetite 2 Decreased pulse rate 3 Decreased perspiration 4 Increased respiratory rate

4 Increased respiratory rate

A nurse is assisting a health-care provider in providing palliative care to a client with lung cancer who has just undergone surgery. The provider instructs the nurse to assist the client with frequent position changes. Which complication is this intervention intended to prevent? 1 Fever and nausea 2 Fear related to prognosis 3 Fear related to treatment 4 Ineffective airway clearance

4 Ineffective airway clearance

After a discussion with the health care provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond? 1 The diameter of the aorta is enlarged. 2 The wall between the right and left ventricles is open. 3 It is a narrowing of the entrance to the pulmonary artery. 4 It is a connection between the pulmonary artery and the aorta.

4 It is a connection between the pulmonary artery and the aorta.

Which nursing action would be appropriate to decrease carbon dioxide for a client with respiratory acidosis? 1 Administering sodium bicarbonate 2 Sedating the client to slow the breathing 3 Helping the client breathe into a paper bag 4 Using continuous positive airway pressure (CPAP)

4 Using continuous positive airway pressure (CPAP) The aim of treating respiratory acidosis is to improve ventilation and to decrease carbon dioxide levels in the body. Continuous positive airway pressure (CPAP) helps achieve these goals. Sodium bicarbonate is for metabolic acidosis FYI.

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? Select all that apply. 1 Diplopia 2 Dysphagia 3 Tachypnea 4 Bradycardia 5 Hypotension

5 Hypotension 3 Tachypnea

If suffering from shock what is the first thing the nurse should do: Call physician Elevate to 30 degrees Administer 2L of oxygen Blood transfusion

Call physician

When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? 1 Slide slowly to the floor to prevent a fall and injury. 2 Sit on the edge of the bed while they hold the client upright. 3 Bend forward because this will increase blood flow to the brain. 4 Lie down quickly so the legs can be raised above the heart level.

Correct2 Sit on the edge of the bed while they hold the client upright.

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? Select all that apply. 1 Diplopia 2 Dysphagia 3 Tachypnea 4 Bradycardia 5 Hypotension

Tachypnea Hypotension

Which acid base imbalance results in excretion of carbon dioxide by the lungs in compensatory attempt to raised pH levels? metabolic acidosis metabolic alkalosis respiratory acidosis respiratory alkalosis

metabolic acidosis

Tetralogy of Fallot palliative procedure explained by LVN

creates an artificial connection from the pulmonary artery to the aorta

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black tarry stools. The client recently joined Alcoholics Anonymous. The nurse should give priority to which patient history item? 1 Pain that increases after meals 2 Frequent nausea 3 Black tarry stools 4 Joining Alcoholics Anonymous

3 Black tarry stools

The nurse observes a client collapse while walking down the hallway. The nurse rushes to the client and determines that the client is in cardiopulmonary arrest. What will the nurse do first? 1 Do a blind finger sweep 2 Begin chest compressions 3 Check for a carotid pulse 4 Perform the abdominal thrust maneuver

3 Check for a carotid pulse

A client with a history of recurrent cholecystitis is scheduled for an abdominal cholecystectomy. What should the nurse specifically emphasize when planning preoperative teaching for this client? 1 Possible complications 2 Food and fluid restrictions 3 Coughing and deep breathing 4 Isometric exercises of the extremities

3 Coughing and deep breathing

As a result of pulmonary tuberculosis, a client has a decreased surface area for gas exchange in the lungs. Which physiologic process does the nurse consider will be affected as a result? 1 Osmosis 2 Filtration 3 Active transport 4 Molecular diffusion

4 Molecular diffusion Decreased surface area affects diffusion. The respiratory membrane, consisting of alveolar and capillary walls, is extremely thin. Thinness facilitates exchange of respiratory gases by diffusion without the need for additional energy; molecules move from an area of higher concentration to an area with lower concentration.

A nurse teaches a client with varicose veins about prevention of a thromboembolus. Which statement regarding preventive measures indicates the client requires further teaching? 1 "I must increase my fluid intake." 2 "I will massage my legs twice a day." 3 "Elastic stockings should be worn every day." 4 "Involving my upper and lower extremities in all exercises is important."

2 "I will massage my legs twice a day."

A nurse determines that a newborn is in respiratory distress. Which signs confirm respiratory distress in the newborn? Select all that apply. 1 Crackles 2 Cyanosis 3 Wheezing 4 Tachypnea 5 Retractions

2 Cyanosis 4 Tachypnea 5 Retractions

A complete blood count is ordered for a 5-month-old infant with Tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results? 1 Anemia 2 Polycythemia 3 Agranulocytosis 4 Thrombocytopenia

2 Polycythemia

The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding? 1 Productive coughing 2 Return of breath sounds 3 Increased pleural drainage in the chamber 4 Constant bubbling in the water-seal chamber

2 Return of breath sounds The return of breath sounds indicates that the lung has reinflated. A cough that raises sputum (productive cough) may indicate a complication, such as infection. The drainage should decrease, not increase.

The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that which characteristic is common to both crises? 1 Diarrhea 2 Salivation 3 Difficulty breathing 4 Abdominal cramping

3 Difficulty breathing

A client reports having a bad cold and chest pain that worsens when the client takes deep breaths. Where should the nurse place the stethoscope to determine the presence of a pleural friction rub?

D. lowest right corner of back (lower lateral chest)

Arrange the events that occur in respiratory acidosis. 1. The level of carbonic acid in the blood is increased. 2. The blood pH falls and ratio of bicarbonate-to-carbonic acid ratio is upset. 3. The partial pressure of carbon dioxide increases. 4. Respiration must increase to eliminate carbon dioxide.

The level of carbonic acid in the blood is increased. 2. The blood pH falls and ratio of bicarbonate-to-carbonic acid ratio is upset. 3. The partial pressure of carbon dioxide increases. 4. Respiration must increase to eliminate carbon dioxide.

A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective? 1 Pain subsides as a result of arteriole and venous dilation 2 Pulse rate increases because the cardiac output has been stimulated 3 Sublingual area tingles because sensory nerves are being triggered 4 Capacity for activity improves as a response to increased collateral circulation

1 Pain subsides as a result of arteriole and venous dilation

A nurse is caring for an infant born with a myelomeningocele who is scheduled for surgery. What is the appropriate preoperative goal for this infant? 1 Keeping the infant sedated 2 Keeping the infant infection free 3 Ensuring maintenance of leg movement 4 Ensuring development of a strong sucking reflex

2 Keeping the infant infection free

A 3-year-old child with severe iron-deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? 1 Cold, clammy skin 2 Increased pulse rate 3 Increased blood pressure 4 Cyanosis of the nail beds

2 Increased pulse rate

A toddler is placed in a bilateral hip spica cast for the treatment of developmental dysplasia of the hip. The nurse should teach the parents to monitor their child and report to the practitioner the occurrence of what? 1 Warm toes 2 Leg numbness 3 Skin desquamation 4 Generalized discomfort

2 Leg numbness

A nurse tells a 71-year-old client with dyspnea, orthopnea, pulmonary crackles, wheezing, and frothy, pink sputum upon coughing to avoid isometric exercise. What is the rationale behind this suggestion? 1 To reduce pain 2 To prevent fatigue 3 To improve coping 4 To strengthen the body

2 To prevent fatigue

Which is a clinical manifestation of respiratory acidosis? 1 Tetany 2 Tremors 3 Bradycardia 4 Hypertension

2 Tremors Tremors are a clinical manifestation of respiratory acidosis. Tetany is a clinical manifestation of respiratory alkalosis. Tachycardia, not bradycardia, is a clinical manifestation of respiratory acidosis. Hypotension, not hypertension, may manifest in respiratory acidosis.

Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals what? 1 A pH of 7.35 2 A potassium level of 4.6 mEq/L 3 An increased Paco2 of 55 mm Hg 4 An arterial O2 pressure of 80 mm Hg

3 An increased Paco2 of 55 mm Hg (more CO2 = acidosis)