Exam 1
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 mg
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 mL
A nurse is caring for a client diagnosed with pneumonia, a urinary tract infection, dehydration, and temperature of 101.4°F (38.6°C). The physician orders 1,000 mL of D5W to infuse over 8 hours. The available drop factor is 20 gtt/mL. The nurse should regulate the I.V. flow rate to deliver how many drops per minute? Round your answer to the nearest whole number.
42 gtts/ml
A client with pneumonia has just finished dinner. The nurse must calculate the client's fluid intake before taking the tray from the room. The client had 6 oz of soup, 4 oz of milk, and 8 oz of juice. How many milliliters of fluid should the nurse record on the client's intake record? Record your answer using a whole number.
540 mL
Theophylline is ordered for a 1-year-old infant with bronchopulmonary dysplasia. The recommended dosage is 24 mg/kg/day. The child weighs 10 kg. How many milligrams should be given per dose when administered 4 times per day? Record your answer using a whole number.
60 mg
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 mL
Why must the nurse always be aware of exactly what type of oxygen delivery system is being utilized?
A healthcare facility may stock only one type of multipurpose mask, which is adapted according to specific needs of the client. A three-in-one mask setup can be established to become a simple mask, a partial-rebreathing mask, or a non-rebreathing mask. Therefore, it is important that the nurse be aware of exactly what type of oxygen delivery system is being utilized so the mask can be configured correctly.
During paracentesis or thoracentesis, why must the nurse take the client's blood pressure and pulse immediately after the procedure and every 15 minutes until readings are stable.
A large amount of fluid withdrawn (>1,000 mL) during paracentesis or thoracentesis can result in vasodilation and hypovolemia (decreased circulating fluid volume). These situations can cause syncope (temporary loss of consciousness, fainting) and shock.The nurse should take the client's blood pressure and pulse immediately after paracentesis or thoracentesis and every 15 minutes until readings are stable and within acceptable levels.
A child is diagnosed with tuberculosis (TB). When reinforcing education for the parents about care of the child, which statement made by the parent would indicate a need for further instruction? A. "As long as I keep a surgical mask on I will not get TB." B. "I understand that tuberculosis is highly contagious." C. "I am willing to follow the rigid medication regimen." D. "Increasing calories will be important at this time."
A. "As long as I keep a surgical mask on I will not get TB."
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? A. "At least one complication I don't have to worry about is blood clots." B. "I will be sure to drink plenty of fluids so my milk will come in." C. "I will cough and take deep breaths so I do not develop pneumonia." D. "I will need to be active as soon as possible, so I do not get muscle atrophy."
A. "At least one complication I don't have to worry about is blood clots."
A nurse is reinforcing education about proper nutrition with the parents of a child with cystic fibrosis. Which instructions should the nurse include? Select all that apply A. "Encourage a high-calorie, high-protein diet." B. "Administer digestive enzymes with all food consumed." C. "Restrict fluids to 1,500 mL per day." D. "Limit salt intake to 2 g per day." E. "Encourage foods high in vitamin B."
A. "Encourage a high-calorie, high-protein diet." B. "Administer digestive enzymes with all food consumed."
An infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission-based precautions. The nurse determines that the program was successful based on which statement by the staff? A. "The client needs to be placed in a private, negative air pressure room." B. "If the client needs to be transported, transport personnel need to wear a mask." C. "When wearing a respirator, it needs to be removed before leaving the client's room." D. "It is okay to leave the client's room door open to allow for interaction with the staff."
A. "The client needs to be placed in a private, negative air pressure room."
A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is likely to include which nursing diagnosis? A. Anxiety B. Imbalanced nutrition: More than body requirements C. Impaired swallowing D. Unilateral neglect
A. Anxiety
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? A. Arterial blood gas (ABG) values are normal. B. The bronchoscopy results are negative. C. The client's blood pressure has stabilized. D. The sputum and sensitivity culture shows no growth in bacteria.
A. Arterial blood gas (ABG) values are normal.
A child with thoracic water-seal drainage is on the elevator. The transport aide has placed the drainage system on the stretcher. What action should the nurse on the elevator take first? A. Assist the aide in placing the drainage system lower than the child's chest. B. Report the incident to the registered nurse when she returns to the unit. C. Clamp the drainage tubing with a hemostat. D. Immediately take the child's respiratory and pulse rates.
A. Assist the aide in placing the drainage system lower than the child's chest.
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom? A. Bleeding B. Difficulty swallowing C. Throat pain D. Difficulty talking
A. Bleeding
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? A. Cheyne-Stokes B. Biot's respirations C. Kussmaul breathing D. tachypneic rate
A. Cheyne-Stokes
The nurse is caring for a client with left lower lobe pneumonia. Which nursing action would assist in improving oxygen delivery to the lungs and tissues? A. Encourage frequent coughing and deep breathing. B. Position the client with the head of the bed slightly elevated. C. Provide deep endotracheal suctioning. D. Use a bag valve mask to ventilate the client.
A. Encourage frequent coughing and deep breathing.
The rescue squad brings into the emergency department a client who has a blocked airway after choking on a piece of steak. The client is unresponsive, and resuscitation efforts are continued with a bag valve mask. Which action by the nurse is a priority? A. Gather equipment for an emergency tracheotomy. B. Intubate the client. C. Start an intravenous infusion. D. Perform a blind finger sweep.
A. Gather equipment for an emergency tracheotomy.
A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client? A. Impaired gas exchange B. Impaired skin integrity C. Activity intolerance D. Imbalanced nutrition: Less than body requirements
A. Impaired gas exchange
he nurse is caring for a client with chest trauma. Which nursing diagnosis takes highest priority? A. Impaired gas exchange B. Anxiety C. Decreased cardiac output D. Ineffective tissue perfusion: cardiopulmonary
A. Impaired gas exchange
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? A. Measuring and documenting the drainage in the collection chamber B. Maintaining continuous bubbling in the water-seal chamber C. Keeping the collection chamber at chest level D. Stripping the chest tube every hour
A. Measuring and documenting the drainage in the collection chamber
A client is admitted to the acute care unit due to a chronic cough with copious, foul-smelling secretions. The nurse identifies dyspnea, hemoptysis, and recent weight loss. What should be the priority independent action by the nurse for this client? A. Monitor respiratory status and pulse oximetry values. B. Provide supportive care. C. Administer antibiotics . D. Administer a bronchodilator.
A. Monitor respiratory status and pulse oximetry values.
The nurse is caring for a client who is intubated and mechanically ventilated. Which is a priority nursing intervention? A. Provide oral care every 2 hr. B. Suction the client every hour. C. Apply petroleum jelly to the lips to prevent dryness. D. Deflate the cuff and reposition the tube.
A. Provide oral care every 2 hr.
The nurse is assisting a client with chest tubes to the bedside commode when the tube becomes disconnected and falls on the floor. Which is the priority action by the nurse? A. Reconnect the tubing. B. Double-clamp tube close to the chest wall. C. Allow the client to ambulate to the bathroom. D. Place the client in the supine position.
A. Reconnect the tubing.
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? A. absence of breath sounds over the left lung field B. crackles one-third up the posterior lung fields C. wheezing on expiration throughout the lung fields D. clear breath sounds bilaterally
A. absence of breath sounds over the left lung field
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? A. chest x-ray B. electrocardiogram C. laboratory tests D. sedation
A. chest x-ray
A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should: A. collaborate with the social worker to investigate possible availability of funds. B. contact the community's free clinic for medications. C. call the public health nurse to research free medications. D. coordinate with the pharmaceutical company for free samples.
A. collaborate with the social worker to investigate possible availability of funds.
When auscultating the chest of a client with pneumonia, the nurse hears bronchial sounds. What does this sound indicate to the nurse? A. consolidation B. friction rub C. normal lung sound D. pus in lung
A. consolidation
The nurse is caring for a child with an upper respiratory tract infection experiencing difficulty breathing. The health care provider has prescribed a mist tent with a nebulizer for the child. What does the nurse identify is the purpose of the mist tent and nebulizer? A. creates a cool, moist environment that decreases respiratory tract edema B. lowers anxiety by creating a tent play environment C. dries secretions and decreases nasal stuffiness D. increases fluid intake and helps prevent dehydration
A. creates a cool, moist environment that decreases respiratory tract edema
A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: A. instruct the client to drink 2 L of fluid daily. B. maintain the client on bed rest. C. administer anxiolytics, as prescribed, to control anxiety. D. administer pain medication as prescribed.
A. instruct the client to drink 2 L of fluid daily.
A nurse is gathering data from a client with primary pulmonary hypertension for a heart-lung transplant. Which medication treatment would the nurse anticipate to be included? Select all that apply. A. oxygen therapy B. aminoglycosides C. diuretics D. vasodilators E. antihistamines F. Sulfonamides
A. oxygen therapy C. diuretics D. vasodilators
A ventilation-perfusion scan is frequently performed to help diagnose a pulmonary embolism. What other uses does the nurse correctly identify for this test? Select all that apply. A. to detect poor blood flow in the lungs, blood vessels B. to examine the lungs before different types of surgeries C. to detect air trapping in the lungs D. location and size of the pulmonary embolism E. location of all the peripheral arteries
A. to detect poor blood flow in the lungs, blood vessels B. to examine the lungs before different types of surgeries C. to detect air trapping in the lungs
A client with a diagnosis of tuberculosis (TB) is informed he will have to take medication for the treatment of the disease. How long does the nurse inform the client he will have to be compliant with treatment? A. 2 to 4 months B. 9 to 12 months C. 18 to 24 months D. more than 2 years
B. 9 to 12 months
The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which statement concerning PPD testing is true? A. A positive reaction indicates that the client has active tuberculosis (TB). B. A positive reaction indicates that the client has been exposed to the disease. C. A negative reaction always excludes the diagnosis of TB. D. The PPD can be read within 12 hours after the injection.
B. A positive reaction indicates that the client has been exposed to the disease.
A client has a sucking stab wound to the chest. Which action should the nurse take first? A. Draw blood for a hematocrit and hemoglobin level. B. Apply a dressing over the wound and tape it on three sides. C. Prepare a chest tube insertion tray. D. Prepare to start an I.V. line.
B. Apply a dressing over the wound and tape it on three sides.
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? A. Wipe off the chest tube and reinsert it. B. Apply an occlusive dressing such as Vaseline gauze. C. As long as the client is not dyspneic, no intervention is required. D. Apply an Ace bandage around the chest.
B. Apply an occlusive dressing such as Vaseline gauze.
The nurse applies oxygen at 2 L/min via nasal cannula as prescribed for a client with dyspnea and an oxygen saturation of 90%. Which is a priority nursing action after oxygen administration for this client? A. Adjust the amount of oxygen flow every 4 hr. B. Continually monitor the client's respiratory status. C. Remove the oxygen cannula when ambulating in the room. D. Maintain the client in the supine position.
B. Continually monitor the client's respiratory status.
After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately? A. Assist the client back to bed, assess his respiratory status, and remain with him. B. Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client. C. Cover the insertion site with a sterile gauze dressing, assist the client back to bed, and monitor his vital signs. D. Assist the client back to bed, assess his vital signs, and notify a physician.
B. Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.
The nurse is applying an oxygen cannula to a client with pneumonia. Which information would the nurse be sure to include when reinforcing education about oxygen administration? Select all that apply. A. Use an electric razor instead of a straight razor around oxygen. B. Do not use oils around the oxygen, especially on hands. C. Avoid smoking around oxygen. D. Do not adjust the cannula after it is applied. E. Discontinue the oxygen if there is nasal dryness.
B. Do not use oils around the oxygen, especially on hands. C. Avoid smoking around oxygen. D. Do not adjust the cannula after it is applied.
The nurse is caring for a client in the clinic who is diagnosed with the common cold. Which education would the nurse reinforce to help alleviate symptoms? A. Take antibiotics as prescribed. B. Drink plenty of fluids. C. Increase activity level. D. Avoid contact with others for 2 weeks.
B. Drink plenty of fluids.
An unconscious, intoxicated client who took an overdose of an opioid receives naloxone to reverse the effect of the opioid. After the client awakens, what is the priority action by the nurse? A. Feed the client. B. Educate the client on the effects of taking pills and alcohol together. C. Discharge the client from the hospital. D. Admit the client to a psychiatric facility.
B. Educate the client on the effects of taking pills and alcohol together.
A client has a defective cranial nerve I. Which data would the nurse gather in order to determine function? A. Use a tuning fork to determine bone conduction. B. Instruct the client to smell and identify a variety of scents. C. Ask the client to open and close the eyes. D. Request the client to stick the tongue out and say "ah."
B. Instruct the client to smell and identify a variety of scents.
A client comes to the emergency department with an acute asthma attack. The client is anxious, restless, and diaphoretic, and his respirations are labored. A nurse administers a high-flow nebulizer treatment as prescribed. Which finding suggests that this treatment has been effective? A. Oxygen saturation and respiratory effort decrease. B. Oxygen saturation increases and respiratory effort decreases. C. Oxygen saturation increases and respiratory effort increases. D. Oxygen saturation decreases and respiratory effort increases.
B. Oxygen saturation increases and respiratory effort decreases.
Which intervention provided by the nurse would assist the client with early chronic obstructive lung disease to improve efficiency of lung function? A. Administer breathing treatment with a bronchodilator. B. Provide smoking cessation information. C. Perform chest physiotherapy. D. Encourage coughing and deep breathing.
B. Provide smoking cessation information.
The nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds are not audible. The nurse understands this change occurred for which reason? A. The attack is over B. The airways are so swollen that no air can get through C. The swelling has decreased D. Crackles have replaced wheezes
B. The airways are so swollen that no air can get through
A client admitted to the health care facility with acute bronchitis is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the likely cause of this sound? A. The water level in the humidifier reservoir is too low. B. The oxygen tubing is pinched. C. The client has a nasal obstruction. D. The oxygen concentration is above 40%.
B. The oxygen tubing is pinched.
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? A. The tubing from the client to the chamber is blocked. B. There is a leak somewhere in the tubing system. C. The client's affected lung has re-expanded. D. The tubing needs to be cleared of fluid.
B. There is a leak somewhere in the tubing system.
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? A. constipation B. generalized rash C. increased appetite D. low-grade temperature
B. generalized rash
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? A. decreased heart and respiratory rates and a high peak flow rate B. increased heart and respiratory rates, retractions, and restlessness C. decreased blood pressure D. increased temperature
B. increased heart and respiratory rates, retractions, and restlessness
Which strategy would be best to include when assisting with planning care for a child with acute epiglottitis? A. Encourage oral fluids for hydration. B. Maintain the child in semi-Fowler's position. C. Administer IV antibiotic therapy. D. Maintain respiratory isolation for 48 hours.
C. Administer IV antibiotic therapy.
Which statement best describes what happens to the alveoli in acute respiratory distress syndrome (ARDS)? A. Alveoli are overexpanded. B. Alveoli increase perfusion. C. Alveolar spaces are filled with fluid. D. Alveoli improve gaseous exchange.
C. Alveolar spaces are filled with fluid.
A hospitalized client needs a central venous access device inserted. The health care provider places the device in the subclavian vein. Shortly afterward, the client develops shortness of breath and appears restless. Which action should the nurse take first? A. Administer a sedative. B. Advise the client to calm down. C. Auscultate breath sounds. D. Check to see if the client can have medication.
C. Auscultate breath sounds.
A client is admitted with superficial skin wounds and a back injury following an intense fire. Twenty-four hours after admission, the client reports dyspnea, a harsh cough, and hoarseness. Which nursing interventions are a priority? Select all that apply. A. Monitor for fever. B. Make sure the client's oxygen saturation level remains below 98%. C. Auscultate the lungs for adventitious breath sounds. D. Assess for increased pulse rate. E. Monitor for increased anxiety levels.
C. Auscultate the lungs for adventitious breath sounds. D. Assess for increased pulse rate. E. Monitor for increased anxiety levels.
A nurse observes constant bubbling in the water-seal chamber of a closed-chest drainage system of a client with a pneumothorax. Which action should the nurse take first? A. Document the finding. B. Auscultate the lung sounds. C. Check the system for air leaks. D. Notify the healthcare provider.
C. Check the system for air leaks.
A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? A. Impaired color discrimination B. Increased urinary frequency C. Decreased hearing acuity D. Increased appetite
C. Decreased hearing acuity
The oxygen saturation level of a 48-year-old client admitted to the hospital with bronchial pneumonia decreases, and his breathing is shallow. He refuses to perform coughing and deep-breathing exercises, or use an incentive spirometer. Which measures can the nurse take to help improve the client's respiratory status? A. Place the client in semi-Fowler's position and turn him every 2 hours. B. Reeducate the client about splinting his chest for turning, coughing, and deep breathing. C. Elevate the head of the bed, and demonstrate and reinforce the importance of incentive spirometry, turning, coughing, and deep breathing. D. Notify a physician of the assessment findings, and obtain orders to prevent further complications.
C. Elevate the head of the bed, and demonstrate and reinforce the importance of incentive spirometry, turning, coughing, and deep breathing.
The nurse is preparing a client for a bronchoscopy. Which nursing actions are essential prior to the procedure? Select all that apply. A. Administer an enema. B. Detail the complications that can occur. C. Give mouth care. D. Observe for any loose teeth. E. Explain the procedure.
C. Give mouth care. D. Observe for any loose teeth. E. Explain the procedure.
A client who has a pulmonary embolism has the potential to develop chest pain. What would be the nurse's best explanation for this when reinforcing education for the client? A. It is the same as costochondritis. B. It is a result of a myocardial infarction. C. It is pleuritic pain due to inflammation. D. It is caused by referred pain from the pelvis.
C. It is pleuritic pain due to inflammation.
A nurse is preparing to bathe a client hospitalized for emphysema. Which nursing intervention is correct? A. Remove the oxygen, and proceed with the bath. B. Increase the flow of oxygen to 6 L/ minute by nasal cannula. C. Keep the head of the bed slightly elevated during the procedure. D. Lower the head of the bed and roll the client to his left side to increase oxygenation.
C. Keep the head of the bed slightly elevated during the procedure.
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? A. Change the gauze dressing every 4 hours. B. Monitor subcutaneous emphysema every 8 hours. C. Listen to lung sounds at least every 4 hours. D. Monitor blood gasses every 2 hours.
C. Listen to lung sounds at least every 4 hours.
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? A. Discuss all of the latest treatment options with the client. B. Provide emotional support and explain that his course of treatment will most likely include chemotherapy. C. Offer emotional support and reassure the client that an oncologist is being consulted to devise a treatment plan. D. Explain to the client that he really needs to relax.
C. Offer emotional support and reassure the client that an oncologist is being consulted to devise a treatment plan.
A client has a positive tuberculin skin test. Which action by the nurse is appropriate? A. Administer another tuberculin skin test. B. Administer a tine test. C. Prepare the client for a chest x-ray. D. Prepare the client for a bronchoscopy.
C. Prepare the client for a chest x-ray.
The nurse is reinforcing education for parents whose child is experiencing an episode of "midnight croup," or acute spasmodic laryngitis. What should the nurse be sure to include when reinforcing education? A. Give warm liquids. B. Raise the heat on the thermostat. C. Provide humidified air with cool mist. D. Take the child into the bathroom with a cold, running shower.
C. Provide humidified air with cool mist.
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? A. Encourage the client to accept the prescribed treatment regimen. B. Inform the client that his health will improve if he chooses endotracheal intubation. C. Support the client's treatment decision and provide care as prescribed. D. Explain to the client that care interventions won't be effective without endotracheal intubation.
C. Support the client's treatment decision and provide care as prescribed.
For a client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? A. Restricting fluid intake to 1,000 ml/day B. Enforcing absolute bed rest C. Teaching the client how to perform controlled coughing D. Administering prescribed sedatives regularly and in large amounts
C. Teaching the client how to perform controlled coughing
Which phrase would the nursing student expect to describe the volume of air inspired and expired with a normal breath? A. Total lung capacity B. Forced vital capacity C. Tidal volume D. Residual volume
C. Tidal volume
A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation of the disease and requires a low-level consistent oxygen concentration. Which method of oxygen delivery will the nurse apply? A. Partial-rebreathing mask B. Nonrebreather mask C. Venturi mask D. Nasal cannula
C. Venturi mask
A nurse working in a walk-in clinic has been alerted that there's an outbreak of tuberculosis (TB). Which client does the nurse identify as having the highest risk for developing TB? A. a 16-year-old female high school student B. a 33-year-old day care worker C. a 43-year-old homeless man with a history of alcoholism D. a 54-year-old businessman
C. a 43-year-old homeless man with a history of alcoholism
The nurse on the pediatric unit is caring for a child with asthma. When assisting the health care team to develop a plan of care, which problem should the team be sure to address? A. imbalanced nutrition B. excess fluid volume C. activity intolerance D. constipation
C. activity intolerance
The client who was diagnosed with pneumonia 2 days prior comes to the emergency department with a sudden onset of severe shortness of breath. The chest x-ray shows fluid in the alveolar spaces. Which disease should the nurse suspect this client to have? A. asthma B. bronchitis C. acute respiratory distress syndrome (ARDS) D. TB
C. acute respiratory distress syndrome (ARDS)
A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: A. chronic obstructive pulmonary disease (COPD). B. bronchial asthma. C. adult respiratory distress syndrome (ARDS). D. renal failure.
C. adult respiratory distress syndrome (ARDS).
The nurse is observing a client's breathing. Which finding should the nurse prioritize for follow up? A. respiratory rate of 12 breaths/minute B. expiratory phase twice as long as inspiratory phase C. an audible high-pitched sound upon inspiration D. bilaterally symmetrical and even chest expansion
C. an audible high-pitched sound upon inspiration
An infant is diagnosed with bronchopulmonary dysplasia. What is a priority problem that the nurse expects to see in the plan of care? A. failure to thrive B. effective breast-feeding C. decreased oxygen saturation D. fluid volume overload
C. decreased oxygen saturation
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? A. client teaching about the cause of TB B. reviewing the risk factors for TB C. developing a list of people with whom the client has had contact D. client teaching about the importance of TB testing
C. developing a list of people with whom the client has had contact
A child is exhibiting signs of asthma. Which finding by the nurse would assist with confirmation of this diagnosis? A. circumoral cyanosis B. increased forced expiratory volume C. inspiratory and expiratory wheezing D. normal breath sounds
C. inspiratory and expiratory wheezing
A client admitted with a diagnosis of pneumonia is known to be a "blue bloater." What would be the nurse's best explanation to the client for using this term? A. exhaling more carbon dioxide B. producing more sputum C. retaining more carbon dioxide D. coughing more frequently
C. retaining more carbon dioxide
A client is brought to the emergency department by a friend because the client "won't wake up." The friend reports that the client "took some pills and had a few beers." What reaction would the nurse most likely find when assessing the client? A. hyperreflexive reflexes B. muscle spasms C. shallow respirations D. tachypnea
C. shallow respirations
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: A. inform the family of the client's wishes. B. assure the family that everything possible will be done. C. support the client's decision. D. assure the client that everything possible will be done.
C. support the client's decision.
A 2-month-old infant is given a preliminary diagnosis of bronchiolitis. Which symptom would the nurse expect to find? A. bradycardia B. increased appetite C. wheezing on auscultation D. no signs of an upper respiratory infection
C. wheezing on auscultation
A client has been diagnosed with a pulmonary embolism. When the nurse informs the family members, they become very upset and say they do not understand what that means. Which statement by the nurse to the family would be most effective? A. "It's a blood clot that originates in the lung." B. "It's a blood clot that has occluded an alveolus." C. "It's a blood clot that has occluded a bronchiole." D. "It's a blood clot that has occluded a pulmonary blood vessel."
D. "It's a blood clot that has occluded a pulmonary blood vessel."
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid as prophylaxis against tuberculosis. The client's teenage daughter asks the nurse how long the drug must be taken. What appropriate timeline does the nurse provide for the duration of prophylactic isoniazid therapy? A. 3 to 5 days B. 1 to 3 weeks C. 2 to 4 months D. 6 to 12 months
D. 6 to 12 months
The nurse is gathering data for several clients. When obtaining pulse oximetry readings, the nurse determines that this method is ineffective for which client? A. A client on oxygen via nonrebreather mask B. A client with pneumonia C. A client with chronic obstructive pulmonary disease (COPD) D. A client with severe anemia
D. A client with severe anemia
The parent of a 2-year-old child with epiglottitis states she has to leave to pick up another child from school. The 2-year-old child begins to cry with stridor. Which intervention by the nurse is best? A. Ask the parent how long she may be gone. B. Tell the 2-year-old everything will be all right. C. Tell the 2-year-old that the nurse will stay. D. Ask the parent if someone else can pick up the older child.
D. Ask the parent if someone else can pick up the older child.
A client is eating supper and begins coughing. Which action should the nurse take first? A. Insert fingers into the mouth to do a blind sweep and remove object. B. Lay the client flat and perform chest thrusts. C. Pat the client on the back to assist with dislodging the foreign body. D. Do nothing. Coughing will usually dislodge the foreign body.
D. Do nothing. Coughing will usually dislodge the foreign body.
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? A. Nonproductive cough and normal temperature B. Sore throat and abdominal pain C. Hemoptysis and dysuria D. Dyspnea and wheezing
D. Dyspnea and wheezing
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be A. Risk for falls. B. Ineffective breathing pattern. C. Impaired tissue integrity. D. Ineffective airway clearance.
D. Ineffective airway clearance.
The nurse is preparing a client for abdominal surgery. Which action by the nurse can prevent postoperative atelectasis? A. Suction the client every 2 hr. B. Administer supplemental oxygen. C. Administer an inhaled bronchodilator. D. Instruct the client about the use of incentive spirometry.
D. Instruct the client about the use of incentive spirometry.
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? A. Incentive spirometry B. Arterial blood gas (ABG) studies C. Peak flow measurement D. Pulse oximetry
D. Pulse oximetry
A 68-year-old client with end-stage chronic obstructive pulmonary disease (COPD) has discharge orders that include home oxygen therapy. The client exhibits anxiety about becoming dependent on supplemental oxygen. How can a nurse help allay the client's anxiety? A. Send the client to the respiratory therapy department for instruction about home oxygen use. B. Arrange for the client to meet the respiratory therapists who provide assistance with home oxygen therapy. C. Notify the physician of the client's concerns about home oxygen use. D. Remain with the client during an education session taught by the respiratory therapist, and reinforce teaching after the session.
D. Remain with the client during an education session taught by the respiratory therapist, and reinforce teaching after the session.
A client with a nursing diagnosis of Impaired spontaneous ventilation undergoes a tracheostomy after many failed attempts at weaning from a mechanical ventilator. The nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? A. Call the physician. B. Remove the malfunctioning cuff. C. Add more air to the cuff. D. Withdraw residual air from the cuff and then reinflate it.
D. Withdraw residual air from the cuff and then reinflate it.
The nurse is caring for a group of clients. Which client should be most closely monitored for the development of respiratory failure? A. a client with breast cancer B. a client with cervical sprains C. a client with a fractured hip D. a client with Guillain-Barré syndrome
D. a client with Guillain-Barré syndrome
A client has been diagnosed with primary pulmonary tuberculosis (TB). Which condition should the nurse monitor the patient for? A. active TB within 2 weeks B. active TB within 1 month C. a fever requiring hospitalization D. a positive skin test
D. a positive skin test
At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone by I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer: A. alprazolam. B. propranolol. C. morphine. D. albuterol.
D. albuterol.
A nurse is caring for a client with pneumonia. When gathering data, which finding does the nurse anticipate? A. increased oxygen saturation B. decreased respiratory effort C. pleural rub D. crackles
D. crackles
A client who has just delivered a full-term baby tells the nurse that sudden infant death syndrome (SIDS) is a big fear. When reinforcing education the mother about SIDS, which factor does the nurse identify as being associated with SIDS? A. breast-feeding the infant B. gestational age of 42 weeks C. immunizations D. low birth weight
D. low birth weight
A client diagnosed with active tuberculosis is started on triple antibiotic therapy. Which signs and symptoms would indicate that the therapy is inadequate? A. decreased shortness of breath B. improved chest x-ray C. nonproductive cough D. positive acid-fast bacilli in a sputum sample after 2 months of treatment
D. positive acid-fast bacilli in a sputum sample after 2 months of treatment
Which factor does the nurse inform the parents will place a child at increased risk for an asthma-related death? A. use of an inhaler at home B. one admission for asthma last year C. prior admission to the general pediatric floor D. prior admission to an intensive care unit for asthma
D. prior admission to an intensive care unit for asthma
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? A. acute asthma B. chronic bronchitis C. pneumonia D. spontaneous pneumothorax
D. 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? A. arterial blood gas (ABG) analysis B. chest x-ray C. blood cultures D. sputum culture and sensitivity
D. sputum culture and sensitivity
The nurse is caring for a child with bronchopulmonary dysplasia that is preparing for discharge. Which parental care outcome should be anticipated? A. reports increased levels of stress B. only makes safe decisions with professional assistance C. participates in routine, but not complex, caretaking activities D. verbalizes the causes, risks, therapy options, and nursing care
D. verbalizes the causes, risks, therapy options, and nursing care
Should you use a humidifier with a Venturi mask and ensure that the windows of the mask are not exposed to room air? Why or why not?
No,A humidifier must not be used with a Venturi mask, as significant back-pressure may activate the safety pressure valve on the humidifier, causing it to burst. The large amount of room air that a Venturi mask uses will humidify the gas adequately.The nurse must also ensure that the windows of the Venturi mask remain exposed to room air. Sheets or blankets must not cover the windows or the end of the adapter to prevent occlusion of the oxygen flow, which would alter the desired oxygen concentration.
What is the CPAP machine used for?
The continuous positive airway pressure (CPAP) apparatus is commonly used to assist persons with sleep apnea. This machine looks like an oxygen-delivery system and is used at night so the person can sleep. It delivers air, and sometimes oxygen, to the person at a continuous positive pressure that holds the alveoli open. This positive pressure prevents respiratory obstruction, increases oxygenation, and reduces breathing effort.
Is the following statement true or false? A nurse should provide the client on a ventilator with communication aids.
True Clients on ventilators are often sedated, which will decrease their responsiveness and ability to communicate. Sedation may also depress respiratory effort. In addition, artificial airways prevent clients from speaking.The nurse should be sensitive to the needs of these clients. For clients on long-term ventilation, use various communication aids (e.g., chalkboard, letter-pointing board, Magic Slate) and continue to talk to the clients, explaining everything that is being done.
