Respiratory Quiz
A client requires a chest tube to be inserted in the right upper chest. Which action is part of the nurse's role?
preparing the chest tube drainage system
A nurse is caring for a client who underwent a total hip replacement. Which intervention should the nurse implement in this client's care to prevent dislocation of the new prosthesis? You Selected:
Avoid moving the extremity into positions that cause internal rotation.
A nurse reinforces education for a pregnant woman who is scheduled for a cesarean birth regarding prevention of complications that can develop after the birth. Which statement by the client indicates a need for further education?
"At least one complication I don't have to worry about is blood clots."
A nurse reinforce teaches a group of police officers about the spread of TB. Which statement by an officer indicates that teaching has been effective?
"I could get TB if I inhale infected droplets when an infected individual coughs."
A client was infected with tuberculosis (TB) bacillus 10 years ago but never developed the disease. The client is now being treated for cancer and begins to develop signs of TB. Which statement by the nurse is most accurate?
"Some people carry dormant TB infections that may develop into active disease."
A young adult was told that he had a significant reaction to the Mantoux test. The client asks the nurse what is the meaning of this significant reaction. How does the nurse appropriately respond?
"You have been exposed to tuberculosis."
The nurse cares for a client who has experienced a stroke. During morning round, the nurse observes that the client has deeper breaths followed by shallower breaths with apneic periods. Which breathing pattern should the nurse document?
Cheyne-Stokes
A child admitted with pneumonia has a history of cystic fibrosis (CF). Which statement made by the parents best demonstrates an understanding of cystic fibrosis?
Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells.
The nurse is collecting data on a client who comes to the clinic for care. Which findings, collected by the nurse during an assessment, in this client suggest bacterial pneumonia?
Dyspnea and wheezing
The nurse is caring for a child with a respiratory infection. Which precaution should the nurse take to adhere to infection control measures?
Enforce handwashing.
For a client with impaired gas exchange, which position is best?
High Fowler's
The nurse is caring for a group of clients. Which client should be most closely monitored for the development of respiratory failure?
a client with Guillain-Barré syndrome
A client is receiving emergency care following a motor vehicle collision. The health care provider has diagnosed a left pneumothorax. Which sign would typically be present upon auscultation of the client's lungs?
absence of breath sounds over the left lung field
The nurse is caring for a client with asthma and impending anaphylaxis from hypersensitivity to a drug. What is the priority action by the nurse?
administer bronchodilators
Pleural membranes
are serous membranes that surround the lungs
The alveoli
are the primary site of respiratory gas exchange.
A client arrives in the emergency department displaying apnea, altered mental status, and dyspnea and central cyanosis. The client was found inside a car by neighbors while the motor was still running. Which sign or symptom would the nurse expect to observe and is indicative of late-stage carbon monoxide poisoning?
cherry-red mucous membranes
The diaphragm
is the chief muscle of inhalation.
The nurse is assisting the health care provider with removing a client's chest tube. Which intervention is essential to prevent complications following chest tube removal?
Listen to lung sounds at least every 4 hours.
A client presents with shortness of breath and absent breath sounds on the right side, from the apex to the base. Which condition best explains these symptoms?
spontaneous pneumothorax
A client is admitted with symptoms of fever, cough with copious secretions, and chest pain. Which test should the nurse ensure is performed prior to giving an antibiotic?
sputum culture and sensitivity
A client is admitted to the hospital with a diagnosis of respiratory failure. The client is intubated, placed on 100% FiO2, and is coughing up copious secretions. Which intervention has priority?
suctioning the client
A client with severe acute respiratory syndrome privately informs a nurse that he doesn't want to be placed on a ventilator if his condition worsens. The client's wife and children have repeatedly expressed their desire that everything be done for the client. The most appropriate action by the nurse would be to:
support the client's decision.
When the muscles of respiration relax,
thoracic volume decreases and air moves out of the lungs.
Which phrase would the nursing student expect to describe the volume of air inspired and expired with a normal breath?
tidal volume
The nurse is caring for a child with bronchopulmonary dysplasia that is preparing for discharge. Which parental care outcome should be anticipated?
verbalizes the causes, risks, therapy options, and nursing care
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides.
A 10-year-old child is admitted with asthma. The health care provider orders an aminophylline infusion. A loading dose of 6 mg/kg is ordered. The client weighs 30 kg. How many milligrams of aminophylline is contained in the loading dose? Record your answer using a whole number.
180
A child comes to the emergency department (ER) with symptoms of asthma and the health care provider begins treatment. The nurse is requested to obtain a sputum culture. What is the best explanation for the test in this situation?
It will rule out a respiratory infection.
A nurse is caring for a client with pneumonia who was prescribed ceftriaxone oral suspension 600 mg once daily. The medication label indicates that the strength is 125 mg/5 mL. How many milliliters of medication should the nurse pour to administer the correct dose? Record your answer as a whole number.
24
A client with bronchitis is ordered 300 mg of liquid guaifenesin every 4 hours. The container indicates that there is 200 mg/5 mL. How many milliliters should the nurse administer per dose? Record your answer using one decimal place.
7.5
A child is to receive furosemide 4 mg/kg/day in one daily dose. The child weighs 20 kg. How many milligrams should the nurse administer in each dose? Record your answer using a whole number.
80
The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which statement concerning PPD testing is true?
A positive reaction indicates that the client has been exposed to the disease.
A client is suspected of impending anaphylaxis secondary to hypersensitivity to a medication. What is the priority action by the nurse?
Administer oxygen.
A client has a chest tube inserted for the treatment of a pneumothorax. While ambulating, the client dislodges the tube, and it falls on the floor. What is the first action by the nurse?
Apply an occlusive dressing such as Vaseline gauze.
A nurse is monitoring the progress of a client with acute respiratory distress syndrome (ARDS). Which data best indicate that the client's condition is improving?
Arterial blood gas (ABG) values are normal.
A nurse monitoring a client with a chest tube connected to a water seal drainage device notices constant bubbling in the water seal chamber. What is the appropriate action by the nurse?
Assess the chest tube connections and drainage device for an air leak.
A nurse monitoring a client with a chest tube connected to a water seal drainage device notices constant bubbling in the water seal chamber. What is the appropriate action by the nurse? You Selected:
Assess the chest tube connections and drainage device for an air leak.
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care?
Measuring and documenting the drainage in the collection chamber
Which of the following structures prevents entrance of food and water into the respiratory passages?
Epiglottis
When reinforcing discharge education for a parent and newborn, which statement made by the parent indicates a need for further instruction?
I will place my baby in a prone position when napping.
A recent immigrant from Vietnam is diagnosed with pulmonary tuberculosis (TB). Which intervention is most important for the nurse to implement with this client?
Identify other people with whom the client had contact.
A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician prescribes codeine, 10 mg by mouth every 4 hours. When discussing this medication with a nursing colleague, which statement that accurately describes codeine will the nurse include?
It is a centrally acting antitussive and can cause dependence.
A 52-year-old client admitted with a 3-month history of hemoptysis, shortness of breath, weight loss, and chronic productive cough undergoes testing, which reveals bronchial cancer. After being informed of his diagnosis, the client is tearful and nervous. He tells the nurse he has questions about the type of treatment plan an oncologist might offer. Which action should the nurse take?
Offer emotional support and reassure the client that an oncologist is being consulted to devise a treatment plan.
What will happen under the following conditions: the pO2 is 95 mm Hg (arterial blood) and 40 mm Hg (tissue)?
Oxygen diffuses from the blood to the tissues.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2)
Which nursing intervention is most appropriate for a child with cystic fibrosis who is having difficulty clearing secretions?
Perform chest physiotherapy four times per day.
A 69-year-old client comes to the emergency department with a history of productive cough, night sweats, and a 30-lb weight loss over the past 8 months. A diagnosis of tuberculosis is suspected. Which intervention is necessary for this client?
Place the client in a private room with negative air pressure, and implement airborne precautions.
When caring for an infant with bronchopulmonary dysplasia, which is the best intervention to avoid fatigue and to decrease respiratory effort?
Place the infant on a set schedule.
The nurse is monitoring a child with a diagnosis of pertussis. The development of which sign or symptom would be indicative of this disease?
whooping cough
An infant is diagnosed with bronchopulmonary dysplasia. Which nursing action is a priority in the care of this child?
Provide chest physiotherapy.
A client with pneumonia is admitted to the medical-surgical unit. Which painless, noninvasive procedure used to measure SaO2 will the nurse perform on this client?
Pulse oximetry
An older adult client who has chronic respiratory disease comes to the clinic for a 6- month check. The nurse informs the client that it's time for the pneumococcal and flu vaccines. What would be the nurse's best explanation to the client for these injections?
Respiratory infections can cause severe hypoxia and possibly death in clients with chronic respiratory diseases.
The nurse administers albuterol, as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?
Respiratory rate of 22 breaths/minute
A 72-year-old client with end-stage chronic obstructive pulmonary disease (COPD) is admitted to the hospital in acute respiratory distress. He refuses endotracheal intubation but requests less invasive treatment interventions. A nurse notes that the client's oxygen saturation is 82%, his pulse is rapid and thready, and his respirations are shallow. How should the nurse intervene?
Support the client's treatment decision and provide care as prescribed.
After a motor vehicle crash, a client has a chest tube inserted that begins to drain a large amount of dark red fluid. Which explanation best describes what caused this type of drainage from the chest tube insertion?
The client has experienced a hemothorax instead of a pneumothorax.
A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac is bubbling continuously. Which nursing assumptions would be valid?
There is a leak somewhere in the tubing system.
Which intervention would be prescribed first for a client who recently had a central venous access device inserted and now appears short of breath and anxious?
chest x-ray
Ventilation
contains C-shaped cartilaginous rings.
A nurse cares for a client who has undergone a left hemicolectomy for gastrointestinal cancer. Which interventions should the nurse implement to help prevent the occurrence of postoperative pneumonia in this client?
coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
An infant is diagnosed with bronchopulmonary dysplasia. What is a priority problem that the nurse expects to see in the plan of care?
decreased oxygen saturation
The nurse is caring for a child with asthma. Which symptom would cause the most concern if observed in the child?
diminished breath sounds bilaterally
A client is suspected of having developed an acute pulmonary embolism. Which symptom would a nurse most likely observe first?
dyspnea
The primary drive for respiration is
elevated pCO2.
While caring for a client with chronic obstructive pulmonary disease (COPD), a licensed practical nurse observes and reports that the client is short of breath, restless, irritable, and disoriented. After nursing interventions fail to reverse the client's escalating respiratory distress, what medical intervention should the nurse be prepared to assist with?
endotracheal intubation
A client with emphysema will be discharged from the hospital in a few days. While reinforcing education, what should the nurse instruct the client to avoid to prevent possible exacerbation of the disorder?
fumes
A 3-year-old child is receiving ampicillin for acute epiglottitis. Which sign would lead the nurse to suspect that the child is experiencing a common adverse effect of this drug?
generalized rash
Which of the following structures prevents entrance of food and water into the respiratory passages?
has two phases: inhalation and exhalation.
The nurse is caring for a child with increased laryngotracheal edema and early signs of impending airways obstruction. The nurse should observe for which warning sign?
increased heart and respiratory rates, retractions, and restlessness
A nurse is caring for a child diagnosed with bronchiolitis. Which symptom would cause the nurse the most concern?
severe sternal retractions
The nurse is gathereing data to determine the status of a client with a respiratory rate of 4 breaths/minute. What additional data should the nurse obtain?
level of consciousness (LOC) and a pulse oximetry value
A nurse is working in a community health center during the flu season. There is a shortage of flu shots. Which group of clients should have priority in getting the available vaccines?
older clients in a nursing home
A client diagnosed with active tuberculosis is started on triple antibiotic therapy. Which signs and symptoms would indicate that the therapy is inadequate?
positive acid-fast bacilli in a sputum sample after 2 months of treatment
While teaching a class to new parents, which child does the nurse correctly identify as having an increased risk of sudden infant death syndrome (SIDS)?
premature infant with low birth weight
The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client?
providing pain control