Respiratory ATI

A nurse is assisting with trudging clients after a mrs casualty event. Which of the following clients should the nurse attend to first?

a client who has sever respiratory stridor and deviated trachea

A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?

a client who is short of breath

A nurse is assisting with the plan of care for a client who pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?

auscultate lung sounds

A nurse is dining at a restraint when a women calls for help because her partner is choking. Which of the following actions should the nurse take first?

asks the victim if he can speak

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

instruct the client to use a pursed-lip breathing

A nurse is reinforcing teaching with a client who has pleaurisy. Which of the following statements by the client indicates an understanding of the teaching?

I should lie on the affected side

A nurse is reinforcing teaching for a client who has COPD. Which of the following statements by the client indicates a need for further teaching?

I will drink plenty of beverages with my meals

A nurse is preparing to administer diphenhydramine 30 mg IM stat to a client who is having an allergic reaction. Available is diphenhydramine 50mg/mL. How many mL should the nurse administer per dose?

0.6 mL

A nurse is reinforcing teaching about self-management strategies with a client who has emphysema. Which of the following client statements indicates that the client understands the instructions?

I will follow a diet high in calories and protein

A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 Pa02 78 mm Hg Oxygen saturation 80% Biacarbonate 28 mEq/L

Respiratory acidosis

A nurse is assigned a group of postoperative clients. Which of the following client findings should the nurse identify as the priority?

SaO2 88%

A nurse is assisting in the care of a client who is 2 hr postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider?

abdomen is distended

A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of pneumothorax?

absence of breath sounds

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. After administering high- flow oxygen which of the following actions is the nurses highest priority?

administer a short acting adrenergic medication

A nurse is caring for a client who has a femur fracture and 8 hr after the injury reports a sudden onset of dyspnea and a severe headache. Which action should the nurse take first?

administer oxygen

A home health nurse is planning care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

advice the client to keep snacks handy

A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching?

agitation

A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk of the client?

airway obstruction

A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk for to the client?

airway obstruction

A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?

airway protection

A nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the following actions should the nurse take first?

allow the client to keep her hearing aids in

A nurse is caring for a client following an open reduction and internal flexion of a fractured femur. Which of the following findings is the nurses priority?

altered level of consciousness

A nurse is collecting data from a client who has COPD. The nurse should expect the clients Chets to be which of the following shapes?

barrel

A nurse is collecting data from a client who has chronic bronchitis. Which of the following findings should the nurse expect?

barrel chest

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?

begin oxygen therapy

A nurse is caring for a client who is conscious and has an airway obstruction. Which of the following actions should the nurse take next?

begin the heimlich maneuver

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

breathe in through her nose and out through pursed lips

A nurse is caring for a client who has heart failure. The client states she has recently been bothered by a non-productive cough. Which of the following medications should the nurse associate with the non-productive cough?

captopril

A nurse in a clinic is collecting data from a client who reports nausea, headache, weakness, and vertigo after turning on his furnace. The clients oral mucous membranes are cherry red. Then nurse should associate the clients manifestations with which of the following conditions?

carbon monoxide poisoning

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention by the nurse?

check the clients respiratory rate

A nurse is assisting with monitoring a client following a bronchoscopy. Which of the following actions should the nurse identify as the priority?

confirming presence of gag reflex

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with client inspiration?

continue to monitor the client

A nurse is collecting data from a client who has a new chest tube that is attached to closed chest water-seal drainage and suction. The nurse should report which of the following findings to the charge nurse?

continuous bubbling in the water-seal chamber

A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?

cyanosis

A nurse is caring for a client who has an acute respiratory illness. For which of the following manifestations of an airway obstruction should the nurse monitor?

inspiratory stridor, retractions, cyanosis

A nurse is caring for a client who has burns to his face, ears, and eyelids. Which of the following is the priority finding to report to the provider?

difficulty swallowing

A nurse is. collecting data from a client who has emphysema. Which of the following findings should the nurse expect?

dyspnea, barrel chest, clubbing of the fingers, and shallow respirations

A nurse enters a clients room to administer medication and finds the client lying in bed disoriented with labor and fast respirations. Which of the following actions should the nurse take first?

elevate the head of the bed

A nurse is contributing to the care plan of an older adult who has pneumonia. Which of the following interventions should the nurse include in the plan?

encourage fluid intake of 2.5 L per day

A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

encourage the client to drink 8 glasses of water a day

A nurse is assisting with the care of a client who is postoperative following pneumonectomy. Which of the following actions should the nurse take?

encourage the client to splint the incision when coughing

A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following actions is the nurses priority at this time?

evaluate the clients respiratory status

A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the clients chest the nurse should expect to hear which of the following sounds?

expiratory wheeze

A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?

fatigue

A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first?

feel a carotid pulse

A nurse is caring for a client who is to have a chest x-ray. Which of the following teaching should the nurse reinforce with the client prior to the procedure?

front, back, and side views of the chest will be taken during the test

A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations should indicate to the nurse the client is experiencing a complication and the provider should be notified immediately?

increased heart rate

A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect?

increasing dyspnea

A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period?

ineffective airway clearance related to thick copious secretions

A nurse is caring for a client who has been admitted with asthma exacerbation and is experiencing increased wheezing and has an oxygen saturation of 91%. The client is scheduled for his next breathing treatment in 1 hr. Which of the following actions should the nurse take?

instructing respiratory therapy to administer a PRN albuterol aerosol

A nurse is assisting with the care of a client who has newly inserted chest tube. Which of the following actions should the nurse take?

keep the collection device below the clients chest level

A nurse is assisting with the plan of care for a client who has a chest tube connected to a closed chest drainage system. Which of the following interventions should the nurse include in the plan of care?

keep the collection device below the level of the clients chest

A nurse is caring for a client who has a hemothorax following a motor-vehicle crash. The client has a chest tube connected to a closed drainage system. When assisting the client out of bed to a chair which of the following actions should the nurse take?

keep the drainage system below the level of the chest

A nurse is caring for a client who has tuberculosis and Is about to start taking pyrazinamide. The nurse should identify that the client needs which of the following tests while taking this medication therapy?

liver function tests

The nurse is caring for a client who has pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

maintain the drainage container below the level of the clients chest

A nurse is reviewing the laboratory results of a client who was hyperventilating during a panic attack. Which of the following arterial blood gas values should the nurse expect?

pH 7.46 and PaCO2 31 mm Hg

A nurse is collecting data from a school-age child who has asthma. The nurse should identify which of the following findings?

periodic episodes of wheezing

A nurse is assisting with planning interventions for an influenza outbreak in a ling term care facility. Which of the following interventions should the nurse include in the plan?

place restrictions on visitation

A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The clients SiO2 is 89%. ABG results are: pH 7.31, PaO2 93 mm Hg, PcO2 50 mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?

place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing

A nurse is caring for a client who reports shortness of breath. The nurse notices that the client has decreased movement of the chest wall and absent breath sounds on the right side. The nurse should suspect which of the following conditions?

pleaural effusion

A nurse is assisting with the care of a client who has adult respiratory distress syndrome (ARDS). Which of the following actions should the nurse take?

position the client in supine for ventilatory support

A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The clients jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action?

prevent aspiration

A nurse is admitting a client who has an exacerbation of asthma. When reviewing the providers orders the nurse recognized that clarification is needed for which of the following prescribed medications>?

propranolol

A nurse is assisting with the care of a client who is 2 days postoperative following the creation of a tracheostomy. Which of the following actions should the nurse plan to take?

provide humidified air

A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin the clients secretions?

provide humidified oxygen

A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain the nurse should explain that the medication should have which of the following effects?

reducing anxiety

The nurse is assisting with the care of a client who is postoperative following a bowel resection and just a arrived to the unit from PACU. Which of the following actions should the nurse take?

remove the anti embolic stocking for 20 min every 8 hr

A nurse is caring for a client who has a chest tube connected to a water-seal drainage system. Which of the following actions should the nurse take?

replace the water-seal unit when the collection chamber is full

A nurse is assisting in the care of a client who has acute onset pulmonary edema and is experiencing dyspnea with low oxygen saturation rates. The nurse should recognize the client is at risk for which of the following acid-base imbalances?

respiratory acidosis

A nurse is caring for a client whose arterial blood gas results show the following results: pH 7.2 PaCO2 50 mm Hg HCO3 24 mEq/L

respiratory acidosis

A nurse is collecting data from a c client who has shallow respirations and a respiratory rate of 9/min. Which of the following acid base imbalances should the nurse expect?

respiratory acidosis

A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal excretion. Which of the following acid-base imbalances should the nurse suspect?

respiratory acidosis

A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor?

respiratory difficulty

A nurse is reinforcing teaching about use of metered-dose inhaler (MD) with a client who has a new diagnosis of asthma. Identify the sequence the client should follow.

shake the canister 3 to 5 seconds vigorously, place her lips firmly around the mouthpiece, inhale slowly over 3 to 5 seconds while pushing down on the canister, hold her breath for 10 seconds, and exhale slowly through pursed lips

A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

sitting, leaning forward over the bedside table

A nurse is reinforcing teaching with a client who is having difficult using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

start slowly and increase volume over several sessions

A nurse is collecting data from a client following removal of the clients endotracheal tube. Which of the following findings should the nurse report to the provider?

stridor

A nurse is collecting data from a client who has a right hemothorax and a water-seal chest tube drainage system to closed suction. For which of the following findings should the nurse contact the charge nurse?

subcutaneous emphysema is present on the clients right chest wall

A nurse is caring for a client who is postoperative following a colon resection. For which of the following findings should the nurse monitor to identify a pulmonary embolus?

sudden shortness of breath

A nurse is caring for a client who has a chest tube inserted for pneuomothorax. Which of the following actions should the nurse take?

tape the connections on the clients chest tube

A nurse is reinforcing teaching with the parent of school-age client who has asthma about the use of a peak flow meter. Which of the following statements about the yellow zone should the nurse include in the teaching?

the child should increase his routine medications, the child is having an exacerbation of the asthma, the child can participate in tremors physical activity

A nurse is collecting data from a client who has recent closed head injury. The nurse should recognize which of the following findings is a priority to report to the provider?

the client is having difficulty speaking

A nurse is checking the suction control chamber of a clients chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

verify that the suction regulator is on

A nurse is caring for a client who has just had a bronchoscopy. Which of the following actions should the nurse take?

withhold food and liquids until the clients gag reflux returns

A nurse is reinforcing teaching for a client who is scheduled for bronchoscopy. Which of the following statements should the nurse include in the teaching?

your neck will be placed in a hyperextended position during the procedure