respiratory
A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? A) Continuous bubbling in the water-seal chamber B) Fluid-level fluctuations in the water-seal chamber C) Bloody drainage in the collection chamber D) Constant bubbling in the suction-control chamber
a
The nurse is presenting a class on chest tubes. Which of the following statements, if made by a student, indicates the student understands the concept being presented? Question 31 options: A) "A tension pneumothorax allows air into the pleural space but prevents it from escaping from the pleural space." B) "A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures." C) "A tension pneumothorax results from a puncture of the pleura during a central line placement." D) "A tension pneumothorax occurs when the air moves freely between the pleural space and the atmosphere."
a
A patient with no history of respiratory disease has a sudden onset of dyspnea, chest pain, and tachycardia. A pulmonary embolism is suspected. The nurse anticipates which set of therapeutic orders to be prescribed for this patient? Select all that apply. Question 32 options: semi-Fowler's position supplemental oxygen as indicated by ABGs morphine sulfate 2 mg intravenously high-Fowler's position titrate heparin to maintain aPTT between 45-70 seconds meperidine hydrochloride (Demerol) 100 mg intramuscular
a, b, c, e
A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. Which of the following is considered a positive result? A) 5 mm induration B) 25 mm induration C) 10 mm induration D) 8 mm induration
c
A client has a chest tube in place for a hemothorax following after being stabbed in the chest. When repositioning the client, the nurse notices 200 mL of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? Question 8 options: A) Clamp the chest tube. B) Continue to monitor the rate of drainage. C) Prepare for blood transfusion. D) Immediately notify the physician.
b
A client is prescribed Streptomycin for susected tuberculosis infection. Which of the following findings requires the nurse to notify the physician? A) The client reports a persistent dry cough. B) The client reports ringing in the ears. C) The client reports a change in vision. D) The client reports a metallic taste in the mouth.
b
A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time? Question 22 options: A) Call for immediate assistance and replace the infusion system. B) Place the client on his left side in Trendelenburg position. C) Prepare the client for chest tube insertion. D) Obtain the appropriate supplies and remove the catheter.
b
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? Question 20 options: A) Sputum smear B) Sputum culture for acid-fast bacillus C) Chest x-ray D) Mantoux test
b
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? Question 24 options: A) Strip the client's chest tube. B) Reposition the client. C) Clamp the client's chest tube. D) Increase the client's wall suction.
b
A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client? A) Room 216 B) Room 212 C) Room 208 D) Room 214
c
A nurse in a long-term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver? Question 2 options: A) The client has a high-pitched inspiratory stridor. B) The client is able to whisper. C) The client is not making any sounds. D) The client is coughing only.
c
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? Question 34 options: A) Protective B) Contact C) Droplet D) Airborne
d
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? Question 7 options: A) Ensure the chest tube collection chamber is emptied prior to transport. B) Clamp the chest tube prior to transferring the client to a wheelchair. C) Disconnect the chest tube from the drainage system during transport. D) Keep the drainage system below the level of the client's chest at all times.
d
A client's friend asks the nurse, "when can my friend come out of isolation? Which of the following is the most accurate response for the nurse to make? Question 28 options: A) "Your friend's isolation will end once isoniazid drug therapy has been initiated." B) "Your friend's isolation will end following the collection of three consecutive acid-fast bacillus (AFB) smears." C) "Your friend's isolation will end when effective instruction on the use of an N-95 mask occurs." D) "Your friend's isolation will end when two consecutive negative x-ray results are confirmed."
b
A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? Question 25 options: A) Infection of the vocal cords. B) Passage of the ET tube into the esophagus. C) Movement of the ET tube into the right main bronchus. D) Blockage of the ET tube by the client's tongue.
c
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? Question 16 options: A) Start an IV infusion of lactated Ringer's. B) Give morphine IV as ordered. C) Administer oxygen therapy. D) Initiate cardiac monitoring.
c
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? A) Continuous bubbling within the water seal chamber. B) Equal amounts of fluid drainage in each collection chamber. C) Absence of fluid in the drainage tubing. D) Fluctuation of the fluid level within the water seal chamber.
D
A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A) Add more water to the suction control chamber of the drainage system. B) Milk the chest tube and dislodge any clots in the tubing that are occluding it. C) Continue to monitor the client as this is an expected finding. D) Verify that the suction regulator is on and check the tubing for leaks.
D
The physician orders an acid-fast bacilli sputum culture smear on a client with suspected tuberculosis. How should the nurse collect the samples? A) Collect 3 different sputum specimens on 3 different days. B) Collect 3 different sputum specimens on the same day. C) Collect 3 different sputum specimens at least 12 hours apart. D) Collect 3 different sputum specimens only in the morning on 3different days.
a
A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? Select all that apply. Question 27 options: A) Monitor PT, PTT and INR results. B) Assess legs for redness. C) Massage the calves every 2 hours. D) Apply elastic compression stockings. E) Perform passive range of motion exercises.
a, b, d, e
A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? Select all that apply. a. Low grade fever b. Flushed cheeks c. Night sweats d. Weight gain e. Blood in sputum
a, c
The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. a. 50 mL of drainage in the drainage collection chamber. b. Excessive bubbling in the water seal chamber. c. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation. d. Vigorous bubbling in the suction control chamber. e. Occlusive dressing in place over the chest tube insertion site. f. Drainage system maintained below the client's chest.
a, c, e, f
The client has a right-sided chest tube. As the client is getting out of the bed it is acci- dentally pulled out of the pleural space. Which action should the nurse implement first? Question 35 options: A) Instruct the client to take slow shallow breaths until the tube is reinserted. B) Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site. C) Notify the health-care provider to have chest tubes reinserted STAT. D) Take no action and assess the client's respiratory status every 15 minutes.
b
The nurse is performing discharge teaching to a patient diagnosed with TB who has been taking medication for a week and a half. Which of the following statements by the patient signifies understanding of the teaching? Question 29 options: A) "I can't shop at the mall for the next 6 months" B) "I shouldn't be contagious after 2-3 weeks of medication." C) "I need to continue taking my medication for 2 months." D) "I can return to work if a sputum culture is negative"
b
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? Question 14 options: A) Reposition the client toward the left side. B) Immediately notify the provider. C) Continue to monitor the client. D) Clamp the chest tube near the water seal.
c
A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? Question 26 options: A) Complaints of discomfort at the puncture site. B) Reduction in oral temperature from 99.3 degrees to 97.8 degrees. C) Increase in heart rate from 100 beats per minute to 140 beats per minute. D) Serosanguineous drainage from the puncture site.
c
A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following information should the nurse provide? Question 30 options: A) "Treatment with this medication will last for 1 month." B) "This medication can cause insomnia." C) "Urine and other secretions might turn orange." D) "It is best to take the medication with meals."
c
A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take? Question 23 options: A) Use IV tubing specific for heparin sodium when administering the infusion. B) Administer 50,000 units of heparin by IV bolus every 12 hr. C) Ensure vitamin K is available on the nursing unit should it be needed. D) Check the activated partial thromboplastin time (aPTT) every 4 hr.
d
A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching? Question 13 options: A) The client's family will also need to take medications to prevent infection B) Medications will need to be taken for the rest of the client's life, even if the client feels better. C) Until the Mantoux test is negative, medications will be required to be taken. D) A typical course of treatment involves 6 to 9 months of consistent medication use
d
Immediately after assisting the physician with the removal of a chest tube, the client begins to complain of difficulty breathing, Further assessment includes an elevated heart rate, tachypnea, and tracheal deviation to the left side of the throat. Which of the following is accuate? Question 17 options: A) This often indicates aspiration of secretions. B) The client is showing early acute respiratory failure. C) This is a normal finding after chest tube removal. D) The client has developed a pneumothorax.
d
The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement, if made by the client, indicates a need for further teaching? Question 15 options: A) "I should avoid heavy lifting for at least 4 to 6 weeks." B) "If I have any difficulty in breathing, I should call the health care provider." C) "If I note any signs of infection, I should contact the health care provider (HCP)." D) "I should remove the chest tube site dressing as soon as I get home."
d
