Saunders Respiratory NCLEX questions
The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse should check to see that the oxygen flow rate is prescribed at which rate? A. 2 to 3 liters per minute B. 4 to 5 liters per minute C. 6 to 8 liters per minute D. 8 to 10 liters per minute
A In carbon dioxide narcosis, the central chemoreceptors lose their sensitivity to increased levels of carbon dioxide and no longer respond by increasing the rate and depth of respiration. For these clients, the stimulus to breathe is a decreased arterial oxygen concentration. In the client with COPD, a low arterial oxygen level is the client's primary drive for breathing. If high levels of oxygen are administered, the client may lose the respiratory drive, and respiratory failure results. Thus, the nurse checks the flow of oxygen to see that it does not exceed 2 to 3 liters per minute, unless a specific health care provider prescription indicates a different flow of the oxygen.
The home health care nurse is instructing a client diagnosed with chronic obstructive pulmonary disease (COPD) on how to perform breathing techniques that will assist in exhaling carbon dioxide and open the airways. Which statement by the client indicates that teaching has been effective? A. "Pursed-lip breathing helps keep the airways open." B. "Abdominal breathing is the best way to ease COPD." C. "Chest physical therapy helps increase expiratory volume." D. "Intercostal chest expansion can increase inspiratory volume."
A Pursed-lip breathing allows the client to slowly exhale carbon dioxide while keeping the airways open. Abdominal breathing is recommended for clients with dyspnea. Chest physical therapy and intercostal chest expansion are not breathing techniques.
A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client? A. Noting whether the client has visitors B. Instructing all staff members to not touch the client C. Giving the client a roommate with TB who persistently tries to talk D. Removing the calendar and clock in the room so that the client will not obsess about time
A The nurse should note whether the client has visitors and social contacts because the presence of others can offer positive stimulation. Touch may be important to help the client feel socially acceptable. A roommate who insists on talking could create sensory overload. In addition, the client on respiratory isolation should be in a private room. The calendar and clock are needed to promote orientation to time.
The nurse assesses a client with a diagnosis of rib fractures to identify the risk for potential complications. The nurse notes that the client has a history of emphysema. After the assessment, the nurse ensures that which interventions are documented in the plan of care? Select all that apply. A. Maintain the client in a position of comfort. B. Collect sputum specimens at the hour of sleep. C. Offer medication to suppress the cough as needed. D. Administer small, frequent meals with plenty of fluids. E. Have the client cough and breathe deeply 20 minutes after pain medication is given. F. Administer 4 to 6 liters of oxygen when the client's pulse oximetry drops below 90%.
A, D, E Clients with a diagnosis of rib fractures need interventions focused on their ability to maintain an effective breathing pattern and support the body in the healing process. Breathing effort is supported when the client is maintained in a comfortable position. Giving the client small frequent meals with plenty of fluids prevents the client from doing too much eating activity at one time and provides hydration to keep sputum liquefied for easier expectoration. Giving the client prescribed pain medication first and then having the client cough and deep breath will encourage the client to complete these actions while limiting the amount of pain from doing them. If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client's awakening. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen could halt the hypoxic drive and cause apnea. A prescription is needed for changes in the oxygen flow
The nurse determines that a tuberculin skin test is positive. Which diagnostic test should the nurse anticipate will be prescribed to confirm a diagnosis tuberculosis (TB)? A. Chest x-ray B. Sputum culture C. Complete blood cell count D. Computed tomography scan of the chest
B Although the findings of the chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on the basis of this examination because other diseases can mimic the appearance of TB. The demonstration of tubercle bacilli bacteriologically is essential for establishing a diagnosis. The microscopic examination of sputum for acid-fast bacilli is usually the first bacteriological evidence of the presence of tubercle bacilli. Options 3 and 4 will not diagnose TB
The nurse is caring for a client with a tentative diagnosis of emphysema. The nurse monitors the client for which sign that distinguishes emphysema from chronic bronchitis? A. Minimal weight loss B. Pronounced dyspnea C. Copious sputum production D. Cough that began before the dyspnea
B Key features of pulmonary emphysema include dyspnea that is often pronounced, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and a milder severity of dyspnea.
A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation. Which factor contributed most to the change in client status A. Decreased fat intake B. Decreased fluid intake C. Sleeping soundly during the night D. Anxiety about the upcoming pulmonologist visit
B The client with exacerbation of COPD has ineffective coughing and excess sputum in the airways. The nurse assesses the client for contributing factors such as dehydration and a lack of knowledge of proper coughing techniques. The reduction of these factors helps limit exacerbations of the disease. Decreased fat intake, sleeping soundly, and anxiety related to scheduled pulmonologist visit are not directly associated with this change in condition.
The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply. A. "All used dishes should be sterilized." B. "My close contacts should be tested for TB." C. "Soiled tissues should be disposed of properly." D. "House isolation is required for at least 8 months." E. "The mouth should always be covered when coughing."
B, C, E Tuberculosis is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.
When the home care nurse arrives, the client with a diagnosis of emphysema is smoking. Which statement by the nurse would be most therapeutic? A. "Well, I can see you never got to the stop smoking clinic." B. "Now that your secret is out, may we decide what you are going to do?" C. "Did you explore the stop smoking program at the senior citizens center?" D. "I wonder if you realize that by smoking you are slowly killing yourself."
C Clients with emphysema must avoid smoking and all airborne irritants. The nurse who observes a maladaptive behavior in a client should not make judgmental comments and should instead explore an adaptive strategy with the client without being overly controlling. This will place the decision making in the client's hands and provide an avenue for the client to share what may be expressions of frustration about an inability to stop what is essentially a physiological addiction. Option 1 is an intrusive use of sarcastic humor that is degrading to the client. Option 2 is a disciplinary remark and places a barrier between the nurse and the client within the therapeutic relationship. In option 4, the nurse preaches and is judgmental.
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding? A. Loud wheezing B. Wheezing on expiration C. Noticeably diminished breath sounds D. Increased displays of emotional apprehension
C Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress being experienced
The nurse is planning care for a client newly diagnosed with active tuberculosis (TB). In addressing the psychosocial needs of the client, what would be a primary goal? A. The client will list all medications and explain when to use each. B. The client will verbalize ways to lessen the risk of transmitting the infection. C. The client will share with the nurse or other support person fears concerning the disease. D. The client will ask questions and actively seek information about the disease and its care.
C Providing psychosocial support means helping the client deal with her or his feelings. Goals for the client will focus on open expression of feelings and fears and the development of coping skills in dealing with the client's illness and care. Options 1, 2, and 4 identify important components of care but are unrelated to providing psychosocial support.
The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, which priority activity should the nurse plan time for after the arterial blood is drawn? A. Holding a warm compress over the puncture site for 5 minutes B. Encouraging the client to open and close the hand rapidly for 2 minutes C. Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes D. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes
C. Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take? A. Determine the need to increase the oxygen. B. Reassure the client that there is no need to worry. C. Conduct further assessment of the client's respiratory status. D. Call emergency services to take the client to the emergency department.
C. With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is "no need to worry" is inappropriate. Calling emergency services is a premature action
A client diagnosed with chronic obstructive pulmonary disease has been prescribed theophylline intravenously. When the client's theophylline blood serum level is shown to be 18 mcg/mL which action should the nurse take? A. Asks about increasing the dose B. Asks that the client be prescribed a different medication C. Continues to monitor the client and administers the medication D. Stops the medication immediately and notifies the primary health care provider
D -PER KIRKWOOD LAB VALUES OF THEOPHYLLINE THERAPEUTIC LEVEL (5-15) (saunders correct answer was C, saying therapeutic levels were 10-20)
The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which is the appropriate client concern? A. Lack of knowledge about COPD B. Difficulty coping related with a situational crisis C. Negative self-image because of neurological deficit D. Restricted verbal communication because of a physical barrier
D A client with COPD may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support the remaining options. (Focus on the subject, that the client is experiencing extreme dyspnea during an interview. Based on this, option 4 is the only option that addresses this subject.)
The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? A. Cyanosis B. Hyperinflated chest C. Coarse crackles bilaterally D. Rapid, shallow respirations
D COPD is also known as chronic obstructive lung disease and chronic airflow limitation. It is a disease state characterized by airflow obstruction. An increase in the rate of respirations and a decrease in the depth of respirations indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present with some, but not all, clients. A hyperinflated chest (barrel-chest) and hypertrophy of the accessory muscles of the upper chest and neck may normally be found in clients with severe COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.
A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home care nurse should most importantly plan teaching strategies that are designed to do what? A. Promote membership in support groups. B. Encourage the client to become a more active person. C. Identify irritants in the home that interfere with breathing. D. Improve oxygenation and minimize carbon dioxide retention
D Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow obstruction. Improving oxygenation and minimizing carbon dioxide retention are the primary goals. The other options are interventions that will help with the achievement of this primary goal.
The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position? A. Sit bolt upright in bed with the arms crossed over the chest. B. Lie on the side with the head of the bed at a 45-degree angle. C. Sit in a reclining chair tilted slightly back with the feet elevated. D. Sit on the edge of the bed with the arms leaning on an overbed table.
D Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Sitting bolt upright with arms folded across the chest restricts the movement of the anterior and posterior walls of the lung, and side-lying with the head of bed raised to a 45 degree position restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.
A client is suspected of having a diagnosis of pulmonary tuberculosis. The nurse should assess the client for which signs/symptoms of tuberculosis? A. High fever and chest pain B. Increased appetite, dyspnea, and chills C. Weight gain, insomnia, and night sweats D. Low-grade fever, fatigue, and productive cough
D The client with pulmonary tuberculosis generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles.
The nurse has been preparing a client diagnosed with chronic obstructive pulmonary disease for discharge. Which statement by the client indicates the need for further teaching about nutrition? A. "I will rest a few minutes before I eat." B. "I will not eat as much cabbage as I once did." C."I will certainly try to drink 3 L of fluid every day." D. "It's best to eat three large meals a day, so that I will get all my nutrients."
D. Large meals distend the abdomen and elevate the diaphragm, which may interfere with breathing for the client diagnosed with chronic obstructive pulmonary disease. Resting before eating may decrease the fatigue that is often associated with chronic obstructive pulmonary disease. Gas-forming foods may cause bloating, which interferes with normal diaphragmatic breathing. Adequate fluid intake helps liquefy pulmonary secretions.
The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action? A. Breathes in and then holds the breath for 30 seconds B. Loosens the abdominal muscles while breathing out C. Inhales with puckered lips and exhales with the mouth open wide D. Breathes so that expiration is two to three times as long as inspiration
D. COPD is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing.
