Test 2 (Respiratory)

Which action should the nurse take first in caring for a client during an acute asthma attack?

Administer bronchodilator as ordered.

Following a femur fracture surgical repair, the client develops hemoptysis, wheezing, and cyanosis. The nurse suspects a pulmonary embolus that originated from which site?

Bone marrow

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?

Chemical irritation

The nurse is teaching a first aid class for parents of small children. The topic for today is nosebleeds. One of the parents ask a question which indicates the need for further teaching with which of the following statements?

flush the nose with warm water

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.

-Increased respiratory effort -nasal flaring with abdominal retractions -lung sounds of wheezing -Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84

The nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select all that apply.

-Risk for Infection related to operative incision and tracheostomy tube placement -Ineffective Airway Clearance related to increased secretions -Impaired Gas Exchange related to shallow breathing and anxiousness

The nurse is mentoring a new graduate nurse, caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would the nurse respond? Select all that apply.

-aspiration -infection -injury to laryngeal nerve

The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instructions would the nurse include? Select all that apply.

-gargle with warm saline water -apply ice collar to the neck area -avoid carbonated fluids -gradually increase fluids then add soft foods

The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would the nurse be sure to include in the workshop? Select all that apply.

-industrial pollutants -tobacco -alcohol

In the prevention of occupational lung diseases, the nurse would direct preventative teaching to which high-risk occupations? Select all that apply.

-mechanic -rock quarry worker -miner

What are the conditions that make up Virchow's triad? Select all that apply.

-venostasis -disruption of vessel lining -hypercoagulability

A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks through the wall of the trachea with a device. The nurse is correct to provide teaching on which method?

A tracheoesophageal puncture

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

Acute respiratory distress syndrome

The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?

Airway patency

The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated?

Audible stridor without using a stethoscope

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds.

The client has been self-medicating with antitussives. Which assessment finding would alert the nurse to an adverse effect of this medication?

Crackles in the bases

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

Develop an alternate method of communication.

A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?

Direct continuous pressure

What is the reason for chest tubes after thoracic surgery?

Draining secretions, air, and blood from the thoracic cavity is necessary.

Tuberculosis is transmitted most commonly through direct contact of ____________

Droplets

The nurse is caring for a client status after adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?

Edema of the upper airway

The nurse is caring for a client status postnasal polypectomy. What would the nurse instruct this client to report?

Excessive swallowing

Which of the following provides the best example of documentation for a client who is presenting with acute bronchitis?

Expectorating moderate amounts of thick, green mucus.

The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?

Face mask

True or False: Excessive bubbling in the water-seal chamber in an under water-seal chest tube drainage system is normal.

False

True or False: Treatment for rhinitis includes oral antibiotics

False

True or False: Tuberculosis is transmitted most commonly through direct contact of droplets.

False

The occupational nurse is completing routine assessments on the employees. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

A nurse is caring for a client following nasal surgery. Which assessment finding best indicates current bleeding?

Frequent swallowing

He nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?

Hoarseness for 2 weeks

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

I was chewing ice chips all day long.

Which of the following statements made to the nurse by her patient would required further teaching is needed for the diagnosis of sinusitis?

I will put ice packs on my nose three times a day

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?

Iodine allergy

The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

Localized calf tenderness

The nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

Mucopurulent sputum

The nurse is receiving a client in the postanesthesia care unit (PACU) diagnosed with postoperative tonsillectomy and adenoidectomy. The unlicensed assistive personnel is assisting the client from the stretcher to the bed. The client remains drowsy from anesthesia. In which position would the nurse instruct the unlicensed assistive personnel to place the client?

On a side

Which is a primary nursing intervention in caring for a client with the diagnosis of bronchiectasis?

Postural drainage

The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

Radial artery, Femoral artery

Upon assessing a client with emphysema, the nurse notes increased difficulty with inspiration. What is the likely cause of this finding?

Rigid chest cage

The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis?

Salt water gargle

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?

Sudden restlessness

A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?

Tell my wife about it, I do not want to touch it.

The nurse is caring for a client diagnosed with coryza, possibly from the rhinovirus. Vital signs are temperature: 101.2°F, pulse: 72 beats/minute, respirations: 28 breaths/minute, and blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are course in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?

Temperature Rise

The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine whether the clear drainage is cerebrospinal fluid?

Test fluid with a Dextrostix

The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, Elevate the head of the bed 45°. Which nursing goal is met in this assessment?

The client will have decreased edema.

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?

The mucus-secreting glands are abnormal.

The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of pneumonia. The nurse devises the outcome statement to read, The client will have clear lungs by the third postoperative day. On the third postoperative day, the client has left lower lobe crackles and infiltrates on the chest X-ray. What conclusion does the nurse reach for this client?

The outcome is not achieved, and the plan requires critical reevaluation and major revision.

The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical neck dissection. When reinforcing information provided by the physician, which nursing instruction is most correct?

The physician removes lymph nodes, muscles, and tissue.

True or False: A cough productive of mucopurulent or blood-streaked sputum is a cardinal sign of lung cancer.

True

True or False: Emphysema is a common cause of disability and the most common obstructive lung disorder

True

True or False: Persistent and progressive hoarseness is usually the earliest symptom of laryngeal cancer

True

True or False: Strep throat can lead to dangerous cardiac complications and harmful renal complications

True

True or False: a cough productive of mucopurulent or blood-streaked sputum is a cardinal sign of lung cancer.

True

A client, who is at risk for pneumonia, has been ordered influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?

Viruses, like influenza, are the most common cause of pneumonia.

____________is an inherited multisystem disorder that affects infants, children and adults. It obstructs the lungs, pancreas and leads to major lung infections.

cystic fibrosis

The nurse is analyzing a client's blood pH of 7.1. Which symptom would indicate that the client's body is working to stabilize?

increased respirations

A 17 year old patient's mother has been recently diagnosed with pulmonary tuberculosis. The nurse would expect the physician to order which of the following tests initially?

the mantoux test