Exam 2: Lower Respiratory Problems NCLEX Questions
b c d e
A nurse in the ED is assessing a client who has sustained multiple rib fractures and has a flail chest. Which of the following findings should the nurse expect? Select all that apply a. bradycardia b. cyanosis c. hypotension d. dyspnea e. paradoxical chest movement
a
2 days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety. What is the first action that the nurse should take? a. raise the head of bed b. notify the healthcare provider c. take the patient's pulse and blood pressure d. determine the patient's SpO2 with an oximeter
a
A client has been in an automobile accident, and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for a. sudden, sharp chest pain b. wheezing breath sounds over the affected side c. hemoptysis d. cyanosis
c
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? a. hot, flushed feeling b. sudden chills and fever c. chest pain that occurs suddenly d. dyspnea when deep breaths are taken
c
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? a. cyanosis b. hypotension c. paradoxical chest movement d. dyspnea, especially on exhalation
c
A UAP is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP a. looping the drainage tubing on the bed b. securing the drainage container in an upright position c. stripping or milking the chest tube to promote drainage d. reminding the patient to cough and deep breathe every 2 hours
a
A client has a chest tube attached to a water seal drainage system, and the nurse notes that the fluid in the chest tube and in the water seal column has stopped fluctuating. The nurse should determine that a. the lung has fully expanded b. the lung has collapsed c. the chest tube is in the pleural space d. the mediastinal space has decreased
a
A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the upper lobe of the lung. The nurse immediately assesses for other signs of which condition? a. right pneumothorax b. pulmonary embolism c. displaced endotracheal tube d. acute respiratory distress syndrome
a b e
A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? Select all that apply a. tachypnea b. deviation of the trachea c. bradycardia d. decreased use of accessory muscles e. pleuritic pain
b c
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? Select all that apply a. continuous bubbling in the water seal chamber b. gentle constant bubbling in the suction control chamber c. rise and fall in level of water in water seal chamber with inspiration and expiration d. exposed sutures without dressing e. drainage system upright at chest level
b d e
A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? Select all that apply a. bradypnea b. pleural friction rub c. hypertension d. petechiae e. tachycardia
d
A nurse is assessing a provider with the removal of a chest tube. Which of the following actions should the nurse take? a. instruct the client to lie prone with arms by the sides b. complete a surgical checklist on the client c. remind the client that there is minimal discomfort during the removal process d. place an occlusive dressing over the site once the tube is removed
b
A nurse is assisting the provider to care for a client who has developed a spontaneous pneumothorax. Which of the following actions should the nurse perform first? a. assess the client's pain b. obtain a large-bore IV needle for decompression c. administer lorazepam d. prepare for chest tube insertion
b
A nurse is caring for a client who has a chest tube and a drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? a. obtain a chest x-ray b. apply sterile gauze to the insertion site c. place tape around the insertion site d. assess respiratory status
b
A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? a. "I am allergic to morphine" b. "I take antacids several times a day for my ulcer" c. "I had a blood clot in my leg several years ago" d. "It hurts to take a deep breath"
a b e
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? Select all that apply a. encourage the client to cough and deep breathe b. check for continuous bubbling in the suction chamber c. strip the drainage tubing every 4 hours d. clamp the tube once a day e. obtain a chest x-ray
a b c e
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply) a. oxygen b. sterile water c. enclosed hemostat clamps d. indwelling urinary catheter e. occlusive dressing
c
A nurse is receiving prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air". Vital signs are: HR: 117, RR: 38, Temp: 101.2, and BP: 100/54. Which of the following actions is the priority? a. notify the provider b. administer heparin via IV infusion c. administer oxygen therapy d. obtain a CT scan
c
A nurse should interpret which finding as an early sign of a tension penumothorax in a client with chest trauma? a. diminished bilateral breath sounds b. muffled heart sounds c. respiratory distress d. tracheal deviation
a
A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. paradoxic chest movement. b. the complaint of chest wall pain. c. a heart rate of 110 beats/minute. d. a large bruised area on the chest.
c
A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? a. Position the patient so that the right chest is dependent. b. Keep the head of the patients bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.
d
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the surgeon of a possible pneumothorax. d. take no further action with the collection device.
a
A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? a. Cover the chest wound with a nonporous dressing taped on three sides. b. Pack the chest wound with sterile saline soaked gauze and tape securely. c. Stabilize the chest wall with tape and initiate positive pressure ventilation. d. Apply a pressure dressing over the wound to prevent excessive loss of blood.
b
A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to a. start a peripheral intravenous line to administer the necessary sedative drugs. b. position the patient sitting upright on the edge of the bed and leaning forward. c. remove the water pitcher and remind the patient not to eat or drink anything for 6 hours. d. instruct the patient about the importance of incentive spirometer use after the procedure.
a
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurses first action should be to a. elevate the head of the bed to 45 to 60 degrees. b. administer the ordered pain medication. c. notify the patients health care provider. d. offer emotional support and reassurance.
a
A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is a. administering ordered analgesia b. monitoring chest tube drainage c. sending pleural fluid for laboratory analysis d. monitoring the patient's level of consciousness
c
A pulmonary embolus is suspected in a patient with a DVT who develops dyspnea, tachycardia, and chest pain. Diagnostic testing is scheduled. Which test should the nurse plan to teach the patient about? a. D-dimer b. chest x-ray c. spiral (helical) CT scan d. ventilation-perfusion lung scan
a
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Administer the prescribed PRN morphine. b. Assist the patient to deep breathe and cough. c. Milk the chest tube gently to remove any clots. d. Tape the area around the insertion site of the chest tube.
d
How should the nurse explain to the patient and family what the purpose of video-assisted thoracic surgery (VATS) is? a. removal of a lung b. removal of one or more lungs segments c. removal of lung tissue by multiple wedge sections d. inspection, diagnosis, and management of intrathoracic injuries
c
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? a. Water-seal chamber has 5 cm of water. b. No new drainage in collection chamber c. Chest tube with a loose-fitting dressing d. Small pneumothorax at CT insertion site
d
The HCP has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube a. for administration of oxygen b. to promote formation of lung scar tissue c. to insert antibiotics into the pleural space d. to remove air and fluid
b d e
The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. a. Assess puncture site and dressing for leakage. b. Check vital signs every 15 minutes for 1 hour. c. Auscultate for absent or reduced lung sounds. d. Remind the patient to take deep breaths. e. Take the specimens to the laboratory. f. Teach the patient symptoms of pneumothorax.
b
The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 mL of blood in the collection chamber. c. complaint of pain with each deep inspiration. d. subcutaneous emphysema at the insertion site.
c
The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the health care provider (HCP)? a. The patient starts crying and says she can't go on with treatment much longer. b. The patient reports sharp, stabbing chest pain with every deep breath. c. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. d. The dressing at the thoracentesis site has 1 cm of bloody drainage.
c
The nurse identifies a flail chest in a trauma patient when a. multiple rib fractures are determined by x-ray b. a tracheal deviation to the unaffected side is present c. paradoxical chest movement occurs during respiration d. there is decreased movement of the involved chest wall
b
The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? a. "I need to take this medicine with meals." b. "The medicine will be prescribed for 10 days." c. "I will inject this medicine into my upper arm." d. "The medicine will dissolve the clot in my lung."
a
The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? a. The patient was recently in a motor vehicle crash. b. The patient participated in an aerobic exercise program for 6 months. c. The patient gave birth to her youngest child 1 year ago. d. The patient was on bed rest for 6 hours after a diagnostic procedure.
a c d e
The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess? Select all that apply a. Obesity b. Pneumonia c. Malignancy d. Cigarette smoking e. Prolonged air travel
d
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? a. slow, deep respirations b. rapid, deep respirations c. paradoxical respirations d. pain, especially with inspiration
b
The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Instructing the patient to alternate rest and activity periods b. Encouraging, monitoring, and recording nutritional intake c. Monitoring cardiorespiratory response to activity d. Planning activities for periods when the patient has the most energy
b
The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? a. Chest tube drainage of 10 to 15 mL/hr b. Continuous bubbling in the water-seal chamber c. Reports of pain at the chest tube site d. Chest tube dressing dated yesterday
c
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit up at the bedside. b. Splint the patients chest during coughing. c. Medicate the patient with the prescribed morphine. d. Have the patient use the prescribed incentive spirometer.
a
The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with a closed chest tube drainage. The nurse should a. continue to monitor the patient b. check all connections for a leak in the system c. lower the drainage collector further from the chest d. clamp the tubing at progressively distal points away from the patient until the tidaling stops
b
The nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system. The nurse should a. continue monitoring as usual; this is expected b. check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system c. decrease the suction and continue observing the system for changes in bubbling during the next several hours d. notify the healthcare provider
d
The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? a. The patient has lung cancer. b. The incision will be medial sternal or lateral. c. Chest tubes will not be needed postoperatively. d. Less discomfort and faster return to normal activity
b
To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient? a. dull percussion sounds on the injured side b. severe respiratory distress and tracheal deviation c. muffled and distant heart sounds with decreasing blood pressure d. decreased movement and diminished breath sounds on the affected side
d
When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for a. emergency pericardiocentesis. b. stabilization of the chest wall with tape. c. administration of an inhaled bronchodilator. d. insertion of a chest tube with a chest drainage system.
d
When caring for a client with a chest tube and water seal drainage system, the nurse should a. verify that the air vent on the water seal drainage system is capped when the suction is off b. strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs c. ensure that the chest tube is clamped when moving the client out of the bed d. make sure that the drainage apparatus is always below the client's chest level
b
When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on bed rest b. using sequential compression devices c. encouraging the patient to cough and deep breathe d. teaching the patient how to use the incentive spirometer
a
When should the nurse check for leaks in the chest tube and pleural drainage system? a. there is continuous bubbling in the water-seal chamber b. there is constant bubbling of water in the suction control chamber c. fluid in the water seal chamber fluctuates with the patient's breathing d. the water levels in the water seal and suction control chambers are decreased
b
Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90 mm Hg. b. Oxygen saturation is 89%. c. Pain level is 5/10 with a deep breath. d. Respiratory rate is 24 when lying flat.
d
Which finding would suggest pneumothorax in a trauma victim? a. pronounced crackles b. inspiratory wheezing c. dullness on percussion d. absent breath sounds
d
Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? a. Evaluating the patient's reports of chest pain b. Monitoring laboratory values for changes in oxygenation c. Assessing for symptoms of respiratory failure d. Auscultating the lungs for crackles
c
While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. What should the nurse do next? a. lower the head of bed, and call the HCP b. prepare an aspiration tray c. mark the area with a skin pencil at the outer periphery of the crackling d. turn off the suction of the chest drainage