Respiratory

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung trans-plant. Which initial assessment data would the nurse anticipate? Select all that apply. 1. decreased respiratory rate 2. dyspnea on exertion 3. barrel chest 4. shortened expiratory phase 5. unintended weight loss 6. fever

2,3,5

The nurse is caring for a client following a segmental resection of the lung because of the presence of a malignant mass. The nurse explains to the family the difference between various types of lung excisions. Which picture best documents a segmental resection?

2

A nurse is preparing a staff education program on innovative devices in pulmonary circulation. Beginning with basic concepts, place the following structures in chronological order to trace the pathway of normal pulmonary circulation. All options must be used. 1. pulmonary vein 2. right ventricle 3. pulmonary artery 4. arterioles 5. alveoli 6. left atrium

2,3,4,5,1,6

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply. 1. a client who is on complete bed rest following extensive spinal surgery 2. a client who has a large venous stasis ulcer on the right ankle area 3. a client who has recently been admitted with a broken femur and is awaiting. 4. a client who has a pleural effusion secondary to infection. 5. a client who is receiving supplemental oxygen following shoulder surgery. 6. a client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy.

1,2,3,6

A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagno. ses are admission priorities? Select all that apply. 1. activity intolerance related to inadequate oxygenation 2. anxiety related to breathlessness 3. disturbed sleep pattern related to restlessness in the night 4. ineffective breathing pattern related to hypoxia 5. risk for decreased cardiac output related to failure of the left ventricle 6. impaired nutrition: less than body requirements related to anorexia

1,2,4,5

A client with a suspected pulmonary embolus is brought to the emergency department stating shortness of breath and chest pain. Which additional signs and symptoms are anticipated? Select all that apply. 1. anxiety 2. irregular heartbeat 3. bradycardia 4. frothy sputum 5. tachycardia 6. blood-tinged sputum

1,2,5,6

A nurse is evaluating a client with primary pulmonary hypertension for a heart-lung trans-plant. Which medication treatment would the nurse anticipate to be included in the plan of care? Select all that apply. 1. oxygen therapy 2. aminoglycosides 3. diuretics 4. vasodilators 5. antihistamines 6. sulfonamides

1,3,4

A nurse is caring for a client with a traumatic injury and developing tension pneumothorax. Which assessment data would be of concern? Select all that apply. 1. decreased cardiac output 2. flattened neck veins 3. tracheal deviation to the affected side 4. hypotension 5. tracheal deviation to the unaffected side 6. bradypnea

1,4,5

A client comes to the emergency department with status asthmaticus. Based on the documentation noted below, the nurse suspects that the client has what abnormality? 1. respiratory acidosis 2. respiratory alkalosis 3. metabolic acidosis 4. metabolic alkalosis

2

The nurse is caring for several clients on the respiratory unit who are receiving the ß-adrenergic agonist bronchodilator albuterol in the prescribed nebulizer treatments. Which side effects would the nurse expect to assess following administration? Select all that apply. 1. increased tachypnea 2. irritability and nervousness 3. tachycardia 4. increased somnolence 5. insomnia 6. anxiety

2,3,5,6

The nurse is caring for a senior citizen who lives alone. When evaluating the effectiveness of adding fluticasone propionate salmeterol to the chronic obstructive airway disease (COPD) client's medication regimen , when chent sidements would support symptom improvement? Select all that apply: 1. "I have noted an increase in sputum 2. "I have begun walking upstairs to use the bathroom." 3. "I can rely on the medication when I have an exacerbation of symptoms." 4. "I seem to feel nervous and shaky making me more productive." 5. "I can now push my granddaughter on the swings when she visits." 6. "The nurse aide no longer comes to the house to help me bathe."

2,5,6

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 would the nurse pour to administer the correct dose? Record your answer as a whole number.

24

A nurse is caring for a client with pulmonary edema whose respiratory status is declining. Chronologically arrange the nursing interventions to prioritize care. All options must be used. 1. Initiate oxygen via nasal cannula at 2 L/ minute: 2. Call the health care provider. 3. Position the client upright at a 45° angle. 4. Prepare suctioning equipment at the bedside. 5. Administer furosemide 40 mg intravenously STAT. 6. Insert an indwelling urinary catheter.

3,1,4,2,5,6

A fireman is admitted with superficial skin wounds and a sprained back following an intense fire. No respiratory concerns are verbalized. Nearly 24 hours after admission, the fireman reports dyspnea, a harsh cough, and hoarseness. Which nursing interventions would the nurse add to the plan of care? Select all that apply. 1. Monitor for fever. 2. Prepare the chest for chest tube insertion. 3. Auscultate the lungs for adventitious breath sounds. 4. Assess for increased pulse rate. 5. Monitor for increased anxiety levels.

3,4,5

The registered nurse (RN) is assisting the licensed practical nurse (LPN) in performing a purified protein derivative (PPD) test on a nursing home resident. Which statements about this test are correct? Select all that apply. 1. A PPD test is done to test for allergies. 2. Always aspirate before injecting the PPD solution. 3. The PPD test is an intradermal test. 4. Hold the syringe at a 45° angle to the 5. The preferred injection site is the ventral surface of the forearm. 6. No wheal should appear at the site following injection.

3,5

A nurse is caring for a client with a wound infection who develops septic shock. The nurse notes the following arterial blood gas results: pH of 7.25, PaCO2 of 43 mm Hg (43 mmol/L), partial pressure of arterial oxygen (PaOz) of 70 mm Hg (9.31 kPa), and bicarbonate (HCO3) of 18 mEa/L (18 mmol/L). According to the oxyhemoglobin dissociation curve, the nurse would be most correct to highlight which finding on shift report? 1. The client's profile reflects alkalosis. 2. The client's hemoglobin saturation is close to 100%. 3. The client's oxyhemoglobin curve is shifted to the left. 4. The client's hemoglobin saturation is close to 85%.

4

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 health care provider orders 1,000 ml of D,W to infuse over 8 hours. The available drop factor is 20 gtt/ ml. The nurse would regulate the intravenous flow rate to deliver how many drops per minute? Round your answer to the nearest whole number.

42