Respiratory

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate?

A.) "You lack the energy to cook wholesome meals." B.) "Blocked nasal passages impair the sense of smell." C.) "Loss of appetite is triggered by the infectious organism." D.) "Infection blocks sensation in the taste buds of the tongue." B

A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses?

A.) Air flows by gravity. B.) The respiratory muscles relax. C.) The respiratory muscles contract. D.) Air is flowing against a pressure gradient. B

The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The health care provider states that because of fluid in the alveoli, surfactant production is falling. The nurse anticipates that insufficient surfactant will cause which effect?

A.) Atelectasis and viral infection B.) Bronchoconstriction and stridor C.) Collapse of alveoli and decreased compliance D.)Decreased ciliary action and retained secretions C

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation?

A.) Cyanosis B.) Hyperinflated chest C.) Rapid, shallow respirations D.) Coarse crackles auscultated bilaterally C

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit?

A.) Dilate the major bronchi. B.) Increase surfactant production. C.)Maintain inflation of the alveoli. D.) Enhance ciliary action in the tracheobronchial tree. c

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client?

A.) Do not exceed 1 L/min. B.) Do not exceed 2 L/min. C.) Adjust the oxygen depending on SpO2. D.) Adjust the oxygen depending on respiratory rate. C

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

A.) Do nothing, because this is an expected finding. B.) Check for an air leak, because the bubbling should be intermittent. C.) Increase the suction pressure so that the bubbling becomes vigorous. D.) Clamp the chest tube and notify the health care provider immediately. B

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.

A.) Excessive bubbling in the water seal chamber B.) Vigorous bubbling in the suction control chamber C.) Drainage system maintained below the client's chest D.) 50 mL of drainage in the drainage collection chamber E.) Occlusive dressing in place over the chest tube insertion site F.) Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation c,d,e,f

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?

A.) Focus only on the physical examination. B.) Obtain all information from family members. C.)Use the health care provider's medical history. D.)Plan short sessions with the client to obtain data. D

The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action?

A.) Hyperoxygenate the client. B.) Set the suction pressure range at 150 mm Hg. C.) Place the catheter into the tracheostomy tube. D.) Apply suction on the catheter, and insert it into the tracheostomy tube. A

The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?

A.) Inflate the cuff on the tracheostomy tube. B.) Deflate the cuff on the tracheostomy tube. C.) Maintain the head of the bed in low Fowler's position. D.) Place the tray in a comfortable position in front of the client. A

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate?

A.) Initiate and maintain supplemental oxygen as prescribed. B.) Plan activities with rest periods to conserve oxygen needs. C.) Provide nasotracheal suctioning as needed to remove secretions. D.) Monitor oxygenation (the oxygen saturation [SaO2]) during activity. C

The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process?

A.) Osmosis B.) Diffusion C.) Ionization D.)Active transport B

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm?

A.) Shut the alarm off and call for help. B.) Call the respiratory therapy department to fix the problem. C.) Call the health care provider (HCP) for further instructions. D.) Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device. D

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)?

A.) Sitting position B.) Tripod position C.) Supine position D.)High Fowler's position B

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply.

A.) Sitting up and leaning on a table B.)Standing and leaning against a wall C.) Lying supine with the feet elevated D.) Sitting up with the elbows resting on knees E.)Lying on the back in a low Fowler's position A,B,D

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply.

A.) Suctioning the client as needed B.)Encouraging coughing every 2 hours C.)Placing the bed in low Fowler's position D.)Supporting the neck incision when the client coughs E.)Monitoring the respiratory status frequently as prescribed A,B,D,E

The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed?

A.) The ties leave no marks on the neck. B.) The tracheotomy can be pulled slightly away from the neck. C.) The nurse places 1 finger loosely between the tie and the neck. D.)The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures. C

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client?

A.) This is expected and will last for at least 1 year. B.) This is expected, and the client should gradually increase activity as tolerated. C.) this is an unexpected finding with TB, but it should resolve within 1 month or so. D.) This is a short-lived problem that should be gone within 1 week after beginning medication therapy. B

The nurse determines that the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this?

A.) Tidaling is absent. B.) Gentle bubbling is observed in the suction control chamber. C.) Vacillation of water in the water seal chamber occurs during respiration. D.) Continuous bubbling is observed in the water seal chamber during inspiration and expiration. D

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action?

A.)Continue to monitor. B.)Document the findings. C.) Change the chest tube drainage system.. D.) Perform a focused respiratory assessment. C

Which are possible causes of upper airway obstruction? Select all that apply.

A.)Thin secretions B.) laryngeal edema C.)Head and neck cancer D.)Foreign body aspiration E.)Lymph node enlargement B,C,D,E