Respiratory NCLEX

The nurse is caring for a client with fractured ribs. Which statement indicates a need for further teaching? 1."My ribs will be healed in a month." 2."I should only need pain med for a week." 3."I should stay calm and rest after taking pain med." 4."I need to support my ribs when I deep breathe and cough."

1."My ribs will be healed in a month." Rib fractures heal in 6 weeks. Pain typically persists for 5 to 7 days. After medications are given, the client should be provided a calm environment and encouraged to rest. After rib fractures, instruct the client to support the fractured ribs while deep breathing and coughing. Focus on the subject, rib fracture, and note the strategic words, need for further teaching. This indicates a negative event query and asks you to select an option that is an incorrect statement. It takes 6 weeks for rib fractures to heal, not a month, which eliminates option 1 making it the correct choice. The other options are correct.

The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis? Select all that apply. 1.Scant mucus 2.Early onset cough 3.Marked weight loss 4.Purulent mucous production 5.Mild episodes of dyspnea

2.Early onset cough 4.Purulent mucous production 5.Mild episodes of dyspnea Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucous production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucous production, minimal weight loss, and milder episodes of dyspnea. Focus on the subject, chronic bronchitis. Recalling the associated signs/symptoms of this disorder and its pathophysiology will direct you to the correct options.

The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure? 1.Clamp the chest tubes. 2.Empty the drainage system. 3.Disconnect the drainage system. 4.Administer pain medication 15 to 30 minutes before the procedure.

4.Administer pain medication 15 to 30 minutes before the procedure. Removal of chest tubes can be uncomfortable for a client. The nurse should medicate the client 15 to 30 minutes before the chest tube is removed. The remaining options are inappropriate actions and would not be performed by the nurse. Use Maslow's Hierarchy of Needs Theory to answer the question. Administration of pain medication before the procedure is the only client-centered nursing action and addresses physiological integrity and the issue of pain.

The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder? 1.Central cyanosis 2.Arterial Pao2 of 48 3.Arterial Pao2 of 81 4.Respiratory rate of 10 breaths per minute

2.Arterial Pao2 of 48 The most characteristic sign of ARDS is increasing hypoxemia with a Pao2 of less than 60 mm Hg. This occurs despite increasing levels of oxygen that are administered to the client. The client's earliest sign is an increased respiratory rate. Breathing then becomes labored, and the client may exhibit air hunger, retractions, and peripheral cyanosis. Note the strategic word, most, and focus on the subject, ARDS. Recalling that increasing hypoxemia occurs in this disorder will direct you to option 2.

The nurse is assisting a client who underwent radical neck surgery to get out of bed. How does the nurse provide support to this client who is afraid to move the head? 1.The nurse applies a soft cervical collar. 2.The nurse places a hand behind the client's head. 3.The nurse raises the head of the bed 90 degrees. 4.The nurse assists the client to roll to the side of the bed and sit up slowly.

2.The nurse places a hand behind the client's head. The nurse provides the most support to the surgical site by placing a hand behind the client's head. Options 3 and 4 involve little assistance or support by the nurse. Option 1 is unnecessary and could occlude a tracheostomy if one is in place. The subject of the question is the method of assisting the client who is afraid to move the head following neck surgery. Visualizing each of the actions in the options and using knowledge regarding this surgical procedure will direct you to option 2.

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made? 1.Skin color becomes cyanotic. 2.Secretions are becoming bloody. 3.Coughing occurs with suctioning. 4.Heart rate decreases from 78 to 54 beats per minute.

3.Coughing occurs with suctioning. The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, or the sudden development of bloody secretions. If they occur, the nurse stops suctioning and reports these signs to the primary health care provider immediately. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure. Focus on the subject, nasotracheal suctioning. The wording of the question asks you to select an option that would be a normal or expected finding while suctioning a client. Cyanosis (option 1) and bradycardia (option 4) are abnormal findings and are eliminated first. From the remaining options, the use of the word becoming in association with bloody secretions in option 2 tells you that this has not been an ongoing problem, making this an incorrect option also. Because the cough reflex is normally present, and suction triggers coughing, this is the preferable option of those remaining.

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection? 1.An uninsured man who is homeless 2.A woman newly immigrated from Korea 3.A man who is an inspector for the U.S. Postal Service 4.An older woman admitted from a long-term care facility

3.A man who is an inspector for the U.S. Postal Service People at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas such as long-term care facilities, prisons, and mental health facilities; older clients; malnourished individuals, those with an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are IV drug users. Note the subject, the client at least risk for developing a tuberculosis infection. Begin to answer this question by eliminating options 1 and 2 because immigrants and the medically underserved are more frequently affected by this infection. From the remaining options, note that the postal inspector may or may not come in contact with many people depending on job description. The client from the long-term care facility, however, lives in a group setting, where a large number of people share a common environment 24 hours a day.

A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes which sign/symptom? 1.Oxygen saturation of 95% 2.Weak gag and cough reflex 3.Respiratory rate of 22 breaths per minute 4.Breath sounds greater on the right than the left

4.Breath sounds greater on the right than the left Asymmetrical breath sounds could indicate pneumothorax, and this should be reported to the primary health care provider. A weak cough and gag reflex 1 hour postprocedure is an expected finding because of residual effects of intravenous sedation and local anesthesia. A respiratory rate of 22 breaths per minute and an oxygen saturation of 95% are acceptable measurements. Focus on the subject, a complication of a bronchoscopy. Look for the abnormal piece of information. Begin to answer this question by eliminating options 1 and 3, which are acceptable data. From the remaining options, recall that the client is premedicated before this procedure, which would cause a weak gag and cough reflex. Remember that unequal breath sounds are always abnormal.

The nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB? 1.Residents of a long-term care facility 2.Persons admitted to the hospital for day surgery 3.A family who has recently emigrated from Australia 4.Children older than 6 years of age in a summer school program

1.Residents of a long-term care facility Residents of long-term care facilities are considered high-risk candidates for TB. Children younger than 4 years of age also are considered a high-risk group. Persons admitted for day surgery are not high-risk candidates. Foreign immigrants (especially from Mexico, the Philippines, and Vietnam) are considered high risk, but those from Australia are not. Focus on the subject, screening for tuberculosis. Recall that the very young and very old are often susceptible to infection as are persons with chronic or debilitating diseases. Persons residing in a long-term care facility may fall into the category of being older and/or having chronic health problems.

The nurse is preparing to perform chest physiotherapy (CPT) on a client. In performing postural drainage, which statement is incorrect? 1.Breathe in a fast-paced pattern. 2.Perform postural drainage before meals. 3.Perform good mouth care after the procedure. 4.Instruct client not to sit up between position changes.

1.Breathe in a fast-paced pattern. The goal of chest physiotherapy is to mobilize secretions for improved respiratory function. The nurse must determine which areas of the lungs should be targeted for this technique. The client should be instructed to breathe slowly and deeply throughout the procedure. The client should not sit up between position changes. Perform postural drainage before meals or tube feedings. It may be ordered after respiratory treatments with bronchodilators. After postural drainage is completed, good mouth care—including brushing the teeth and using a refreshing mouthwash—should be performed. Focus on the subject, postural drainage. Note the word, incorrect, which indicates a negative event query. This asks for an incorrect answer, and option 1 is incorrect. The client should be instructed to breathe slowly and deeply throughout the procedure.

The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when an alarm sounds. Which action should the nurse do first? 1.Check the client. 2.Check the ventilator. 3.Manually ventilate the client with a resuscitation bag. 4.Call the respiratory therapist or rapid response team.

1.Check the client. For a client receiving mechanical ventilation, always check the client first and then check the ventilator. A resuscitation bag should be available at the bedside for all clients receiving mechanical ventilation. If the cause of the alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is corrected. The nurse needs to determine if the respiratory therapist or rapid response team needs to be called. Note the strategic word, first. Focus on the subject, nursing actions when a mechanical ventilator alarm sounds. For a client receiving mechanical ventilation, always check the client first and then check the ventilator. This will lead you to the correct option 1.

The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention? 1.Suction the client. 2.Check for a disconnection. 3.Notify the respiratory therapist. 4.Evaluate the tube cuff for a leak.

1.Suction the client. When the high-pressure alarm sounds on a ventilator, it is most likely caused by an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucous plugging requiring suctioning. It is also important to check the tubing for the presence of any water and determine whether the client is out of rhythm with breathing with the ventilator. A disconnection or a cuff leak can result in the sounding of the low-pressure alarm. The respiratory therapist should be notified if the nurse could not determine the cause of the alarm. Note the strategic word, priority, in the question. Recalling that the high-pressure alarm indicates a possible obstruction will assist in directing you to the correct option.

The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. Which would be the next immediate nursing action? 1.Call the rapid response team overhead. 2.Ventilate the client with a resuscitation bag. 3.Call the respiratory therapist to the bedside. 4.Call the client's primary health care provider to the bedside.

2.Ventilate the client with a resuscitation bag. Mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. Alarm systems must be activated and functional at all times. The nurse must recognize an emergency and intervene promptly so that complications are prevented. If the cause of an alarm cannot be determined, the nurse ventilates the client manually with a resuscitation bag until the problem is corrected by a second nurse, the respiratory therapist, or primary health care provider. The nurse also notifies the registered nurse (RN) of the occurrence and obtains assistance from the RN. Note the strategic word, immediate. Thinking about the purpose of the ventilator will easily direct you to option 2. Remember that a ventilator provides oxygen to the client. The nurse needs to manually ventilate a client if an emergency such as this occurs. Also note that options 1, 3, and 4 are comparable or alike.

The nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer? 1.Cough 2.Wheezing 3.Pleuritic pain 4.Blood-streaked sputum

1.Cough Cough is the most frequent early sign of lung cancer that begins as nonproductive and hacking and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs. Wheezing and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature. Note the strategic words, most and early. Focusing on the client's diagnosis, lung cancer, will direct you to option 1.

The nurse should plan to fill which chamber of the chest drainage unit to prevent atmospheric air from reentering the pleural space? Refer to figure. 1.A 2.B 3.C 4.D

2.B To prevent atmospheric air from reentering the client's pleural space, the nurse needs to fill the water seal chamber to the level prescribed by the manufacturer, usually 2 cm. This is the minimum amount of fluid needed to prevent atmospheric air from reentering the pleural space. Therefore, options 1, 3, and 4 are incorrect. Option 1 identifies the suction control chamber. Options 3 and 4 identify the collection chamber. Focus on the subject, chest tube drainage systems. Recall the various chambers of the chest drainage unit and their purpose when answering this question. Recalling that calibrated columns are provided for drainage will assist you in eliminating options 3 and 4. Next eliminate option 1 because this is the suction control chamber.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased. The nurse explains that this can be harmful because it could cause which difficulty? 1.It could be drying to nasal passages. 2.It could decrease the client's oxygen-based respiratory drive. 3.It could increase the risk of pneumonia from drier air passages. 4.It could decrease the client's carbon dioxide-based respiratory drive.

2.It could decrease the client's oxygen-based respiratory drive. Normally, respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD this natural center becomes ineffective after exposure to high carbon dioxide levels for prolonged periods. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD usually cannot increase oxygen levels independently because it could deplete the respiratory drive and lead to respiratory failure. Physician prescriptions are always followed. Focus on the subject, COPD, and recall that in clients with COPD, the level of oxygen provides the respiratory stimulus. This will direct you to option 2.

Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply. 1.Repositioning client every 4 hours 2.Position on the side until fully recovered 3.Encouraging coughing and deep breathing 4.Monitoring pulse oximetry readings frequently 5.Encouraging the use of an incentive spirometer

2.Position on the side until fully recovered 3.Encouraging coughing and deep breathing 4.Monitoring pulse oximetry readings frequently 5.Encouraging the use of an incentive spirometer Monitoring and maintaining a patent airway is a nursing responsibility. The nurse should monitor oxygen saturation closely and administer oxygen as prescribed. The use of an incentive spirometer is especially helpful to prevent atelectasis and hypoventilation. Unless contraindicated, the client should be positioned on the side or with the head turned to the side to prevent aspiration until fully recovered, alert, and with the gag reflex intact. The client is encouraged to deep breathe and cough every 2 hours to prevent atelectasis. The client should be repositioned every 2 hours, which changes the distribution of gas and blood flow in the lungs and helps move secretions. Focus on the subject, monitoring and maintaining a patent airway. Eliminate option 1 because of the time frame noted in this option.

The nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention should be included? Select all that apply. 1.Ice 2.Rest 3.Local heat 4.Analgesics 5.Oxygen by nasal cannula

2.Rest 3.Local heat 4.Analgesics Common therapies for fractured ribs include rest, analgesics, and the local application of heat that speeds the resolution of inflammation. Ice is not effective 48 hours after injury, and oxygen may not be necessary. Analgesics that cause respiratory depression are avoided. Focus on the subject, rib fracture, and note the words, 2 days earlier. Recalling that ice is used only in the first 24 hours after an injury and that oxygen is not required in all instances will help direct you to options 2, 3, and 4.

The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax? 1.Bradypnea 2.Shortness of breath 3.A low respiratory rate 4.The presence of a barrel chest

2.Shortness of breath The client has sustained a blunt or a closed chest injury. This type of injury can result in a closed pneumothorax. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. There may also be hyperresonance on the affected side. The presence of a barrel chest is characteristic of chronic obstructive pulmonary disease or emphysema. Barrel chest can be eliminated first because it is a characteristic finding in a client with chronic obstructive pulmonary disease or emphysema. Next, eliminate bradypnea and low respiratory rate because they are comparable or alike.

The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications? 1.Decreasing oral fluid intake 2.Monitoring the vital signs every shift 3.Changing the client's position every 2 hours 4.Instructing the client to bear down every hour and to hold his or her breath

3.Changing the client's position every 2 hours Frequent position changes help mobilize lung secretions and prevent pooling. This is the only intervention identified in the options that will prevent respiratory complications. The nurse should encourage fluid intake to thin secretions and thus enable the client to expectorate more easily. It is important to encourage coughing and deep breathing to mobilize lung secretions. The nurse should assess the client's vital signs every 4 hours to identify an elevated temperature, which may suggest infection. The client should be instructed to avoid the Valsalva maneuver or any activity that involves holding the breath. Focus on the subject, preventing respiratory complications. Changing the position of the immobilized client every 2 hours will help prevent the pooling of lung secretions. The other options do not assist the client with improving ventilatory efforts or preventing respiratory complications.

The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which finding? 1.High fever 2.Flushed skin 3.Complaints of weight gain 4.Complaints of night sweats

4.Complaints of night sweats The client with tuberculosis usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease. Focus on the subject, tuberculosis. Knowledge regarding the signs/symptoms associated with tuberculosis is needed to answer this question. Recall that night sweats are characteristic of tuberculosis.

A client with a respiratory disorder has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if which action is taken? 1.The client selects foods that are very dry. 2.The client increases the use of milk products. 3.The client increases the use of stimulants such as caffeine. 4.The client plans to eat the largest meal of the day at a time when hungry.

4.The client plans to eat the largest meal of the day at a time when hungry. The client is taught to plan the largest meal of the day at a time when the client is most likely to be hungry. It is also beneficial to eat four to six small meals per day if needed. The client avoids dry foods, which are hard to chew and swallow. The client also avoids milk and chocolate, which have a tendency to thicken saliva and secretions. Finally, the client should avoid the use of caffeine, which contributes to dehydration by promoting diuresis. Focus on the subject, respiratory disorder and anorexia, related to dyspnea. Eliminate option 1 first because dry foods are hard to chew and swallow. Options 2 and 3 are eliminated next because they thicken secretions and have a dehydrating effect, respectively.

A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect? 1.Hypercalcemia 2.Peripheral neuritis 3.Small blood vessel spasm 4.Impaired peripheral circulation

2.Peripheral neuritis An adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesia in the extremities. This adverse effect can be minimized with pyridoxine (vitamin B6) intake. Focus on the subject, the adverse effects of isoniazid. Options 3 and 4 would not cause the symptoms presented in the question but instead would be manifested by pallor and coolness. Thus options 3 and 4 can be eliminated first. From the remaining options, it is necessary to know either that peripheral neuritis is an adverse effect of the medication or that the client's symptoms do not correlate with hypercalcemia.

The nurse is collecting respiratory data from an adult client and is auscultating for normal breath sounds. The nurse should expect to hear bronchial breath sounds in which anatomical area? Refer to figure. 1.A 2.B 3.C 4.D

1.A

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination? 1.An air leak is present. 2.The tubing is kinked. 3.The lung has reexpanded. 4.The system is functioning as expected.

4.The system is functioning as expected. Fluctuations in the water seal chamber are normal during inhalation and exhalation until the lung reexpands and the client no longer requires chest drainage. If fluctuations are absent, it could indicate an air leak, kinking, or that the lung has reexpanded. Focus on the subject, fluctuations in the water seal chamber of a closed chest drainage system. Remember that fluctuations in the water seal chamber are normal during inhalation and exhalation until the lung reexpands.

The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client? 1.Abdominal distention 2.Purulent drainage around the tracheotomy site 3.Excessive secretions from the tracheotomy site 4.Inability to pass a suction catheter through the tracheotomy

1.Abdominal distention Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and the esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also can cause aspiration of gastric contents. Option 2 may indicate an infection. Option 3 may indicate the need for more frequent suctioning. Option 4 may indicate an obstruction of some sort or the presence of bronchoconstriction. A fistula is an artificial opening. Review the options remembering that the subject, tracheoesophageal fistula, indicates trachea to esophagus. If you think of air moving from the trachea to the esophagus, you will know that abdominal distention occurs with this condition.

The nurse is discussing signs of severe airway obstruction with a group of nursing students. Which sign should the nurse emphasize as one that indicates severe airway obstruction? 1.Cyanosis 2.A loud cough 3.Pink color to the skin 4.Respiratory rate of 12 to 16 breaths per minute

1.Cyanosis Signs of severe airway obstruction include cyanosis, poor air exchange, increased breathing difficulty, a silent cough, or inability to speak or breathe. Options 2, 3, and 4 are incorrect and may be signs of mild respiratory distress that would not require immediate intervention. Focus on the subject, severe airway obstruction. Remember that cyanosis is a late sign of respiratory distress and if noted would indicate severe airway obstruction requiring immediate intervention.

The nurse is caring for a client with laryngitis. Which interventions should the nurse implement? Select all that apply. 1.Discourage smoking. 2.Use a room humidifier. 3.Speak only in whispers. 4.Use the intercom to contact the nurse. 5.Use lozenges that contain a topical anesthetic agent.

1.Discourage smoking. 2.Use a room humidifier. 5.Use lozenges that contain a topical anesthetic agent. Smoking irritates the throat, so the client is discouraged from smoking. A humidifier will prevent a dry nose and throat. Lozenges with a topical anesthetic agent will decrease throat discomfort. Voice rest means not talking at all, even whispering. There should be a sign on the intercom indicating voice rest and going to the client's room. Focus on the subject, laryngitis, and think about the measures that will relieve the client's discomfort and promote healing. This will direct you to options 1, 2, and 5.

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply. 1.Enables the client to speak 2.Is necessary for mechanical ventilation 3.Must have the cuff deflated when capped 4.Eliminates the need for tracheostomy care 5.Prevents air from being inhaled through the tracheostomy opening

1.Enables the client to speak 3. Must have the cuff deflated when capped A fenestrated tracheostomy tube is used when a client is being weaned from breathing through the tracheostomy to breathing normally through the nose and mouth. A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. The cuff of the tracheostomy tube must always be deflated before the fenestrated tube is capped. When the cuff is inflated, the tracheostomy tube can be used for mechanical ventilation. When the cuff is deflated and the cap is applied, the client can breathe around the tracheostomy tube. The client continues to need cleaning of the tracheostomy site. The client is unable to breathe through the tracheal opening or at all if the cuff is inflated and the opening capped. Focus on the subject, a fenestrated tracheostomy tube. Recall that the term fenestrated means there is an opening in the object like a fenestrated drape in a catheterization kit. Knowledge regarding the design and purpose of a fenestrated tracheostomy tube will direct you to the correct option.

The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse sign/symptom indicating acute pulmonary edema? 1.Frothy sputum 2.Pain with deep breathing 3.Increased chest tube drainage 4.Respiratory rate of 20 breaths per minute

1.Frothy sputum The client developing pulmonary edema after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A respiratory rate of 20 breaths per minute is within normal limits. Pain with deep breathing is expected and managed with analgesics. The client with pneumonectomy usually does not have a chest tube. The subject of the question is postoperative assessment after a pneumonectomy and manifestations of pulmonary edema. Increased chest drainage indicates hemorrhage, not pulmonary edema, and is eliminated first. In addition, the client with pneumonectomy usually does not have a chest tube. A respiratory rate of 20 breaths per minute is normal, and pain with deep breathing is expected in the immediate postoperative period, so these options may be eliminated next. The presence of frothy sputum indicates pulmonary edema and is the correct option.

The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining a proper specimen? 1.Have the client take three deep breaths. 2.Limit fluids before obtaining the specimen. 3.Ask the client to obtain the specimen after eating. 4.Ask the client to spit into the collection container.

1.Have the client take three deep breaths. To obtain a sputum specimen, the client should brush his or her teeth to reduce mouth contamination. The client should then take three deep breaths and cough into a sputum specimen container. The client should be encouraged to cough and not spit so that sputum can be obtained. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning. Focus on the strategic word, essential. Limiting fluids can be eliminated first by recalling that fluids assist in loosening or thinning secretions. Next, eliminate the option that uses the word spit. Spit is very different from sputum. Finally, eliminate the option that asks the client to obtain the specimen after eating.

The nurse is collecting data on a client with chronic sinusitis. Which are signs and symptoms of chronic sinusitis? Select all that apply. 1.Loss of smell 2.Chronic cough 3.Nasal stuffiness 4.Clear nasal discharge 5.Severe evening headache

1.Loss of smell 2.Chronic cough 3.Nasal stuffiness Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough caused by nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. Focus on the subject, chronic sinusitis. Use knowledge of signs and symptoms of upper respiratory problems to answer this question. Remember that chronic sinusitis is characterized by a headache that is worse on arising after sleep and purulent nasal discharge.

A client is admitted to the emergency department with carbon monoxide poisoning. Which signs and symptoms indicate carbon monoxide poisoning? Select all that apply. 1.Mental changes 2.Cardiac irregularities 3.Cherry-red skin color 4.Abnormal arterial blood gas results 5.Negative carboxyhemoglobin levels

1.Mental changes 2.Cardiac irregularities 3.Cherry-red skin color Carbon monoxide poisoning results from a buildup of carboxyhemoglobin. Evaluate for early signs and symptoms of carbon monoxide poisoning, which include headache and shortness of breath with mild exertion. Dizziness, nausea, vomiting, and mental changes appear next. As the amount of carbon monoxide in the bloodstream rises, the victim loses consciousness and develops cardiac and respiratory irregularities. A victim usually dies when the carbon monoxide bound with hemoglobin exceeds 70%. Although a cherry-red skin color is a clear indicator of carbon monoxide poisoning, skin color is often found to be pale or bluish with reddish mucous membranes. In carbon monoxide poisoning, the readings of pulse oximetry and the values of arterial blood gases can appear normal despite significant toxic exposure. Focus on the subject, signs and symptoms of carbon monoxide poisoning. Arterial blood gas results appear normal eliminating option 4. Eliminate option 5 by definition.

The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority? 1.Report the findings. 2.Document the finding in the client's record. 3.Call the employee health service department. 4.Call the radiology department for a chest x-ray.

1.Report the findings. The nurse who interprets a tuberculin skin test as positive notifies the PHCP immediately. The PHCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis or old healed lesions. A sputum culture would be done to confirm the diagnosis of active tuberculosis. The client is placed on tuberculosis precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client. Note the strategic word, priority. Because the nurse may not prescribe diagnostic tests, eliminate option 4 first. Option 3 can be eliminated because calling the employee health service is of no benefit to the client. From the remaining options, notifying the PHCP should have a higher priority than the documentation, even though both may be done in the same narrow time period.

The nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse uses this data to make which interpretation? 1.The behavior is likely the result of hypoxia. 2.The client probably suffers from alcoholism. 3.The client must also have a high blood alcohol level. 4.The carbon monoxide has caused the blood glucose to fall.

1.The behavior is likely the result of hypoxia. The client with carbon monoxide poisoning may appear intoxicated. This is the end result of hypoxia on the central nervous system (CNS). With carbon monoxide poisoning, oxygen cannot easily bind onto the hemoglobin, which is carrying strongly bound carbon monoxide. Because cerebral tissue has a critical need for oxygen, sustained hypoxia may yield this typical finding. For this reason, options 2, 3, and 4 are incorrect interpretations. Eliminate options 2 and 3 first because they are comparable or alike, and both address the subject of alcohol. From the remaining options, recalling that carbon monoxide displaces oxygen on the hemoglobin molecule will direct you to option 1. In addition, option 1 addresses oxygen, the highest priority.

A client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions should be done? Select all that apply. 1.Turn completely on the side. 2.Administer humidified oxygen. 3.Instruct on the use of the incentive spirometer. 4.Monitor vital signs and pulse oximetry frequently. 5.Place in respiratory isolation to prevent infection.

2.Administer humidified oxygen. 3.Instruct on the use of the incentive spirometer. 4.Monitor vital signs and pulse oximetry frequently. A client with a pneumonectomy can be turned slightly and supported with a pillow, but complete lateral positioning is contraindicated because of pressure on the bronchial stump or shifting of mediastinal contents. In addition, the surgeon's prescription for positioning is always checked and followed. The client needs to receive oxygen and use an incentive spirometer to prevent atelectasis in the remaining lung. Vital signs and pulse oximetry need to be monitored frequently. The client should not be placed in respiratory isolation to prevent infection; this is unnecessary. Focus on the subject, pneumonectomy. Note the word completely in option 1; complete lateral option is contraindicated. The client needs to receive oxygen and use an incentive spirometer. Vital signs and pulse oximetry need to be monitored frequently. It is not necessary to place the client in respiratory isolation to prevent infection, which eliminates option 5.

A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage. Which type of drainage is expected? 1.Serous 2.Bloody 3.Serosanguineous 4.Bloody with several clots

2.Bloody In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience significant clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing. Focus on the subject, chest tube drainage during the first few hours postoperatively. Recall that following thoracic surgery there may be considerable capillary oozing for some hours in the postoperative period. This should lead you to choose the bloody drainage over serous or serosanguineous. Knowing that patent chest tubes do not allow blood to collect in the pleural space eliminates the option of blood with clots.

The nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which should the nurse do first? 1.Contact the registered nurse. 2.Check for kinks in the chest drainage system. 3.Check the client's blood pressure and heart rate. 4.Connect a new drainage system to the client's chest tube.

2.Check for kinks in the chest drainage system. If the nurse notes that a chest tube is not draining, the nurse would first check for a kink or possible clot in the chest drainage system. The nurse then notifies the registered nurse and observes the client for respiratory distress or mediastinal shift (if this occurs, the primary health care provider is notified). Checking the heart rate and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new drainage system to the client's chest tube is done when the fluid drainage chamber is full. There is a specific procedure to follow when a new drainage system is connected to a client's chest tube. Note the strategic word, first. Focusing on the subject, that there has been no chest tube drainage, will direct you to option 2.

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement? 1.Continue suctioning to remove the blood. 2.Check the amount of suction pressure being applied. 3.Encourage the client to cough out the bloody secretions. 4.Remove the suction catheter from the nose and begin vigorous suctioning through the mouth.

2.Check the amount of suction pressure being applied. The return of bloody secretions is an unexpected outcome related to suctioning. If this occurs, the nurse should first assess the client and then determine the amount of suction pressure being applied. The amount of suction pressure may need to be decreased. The nurse also needs to be sure that intermittent suction and catheter rotation are being done during suctioning. Continuing with the suctioning or vigorous suctioning through the mouth will cause increased trauma and thus increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. Therefore, it is unlikely that the client will be able to cough out the bloody secretions. Eliminate options 1 and 4 first because they are comparable or alike. Next, eliminate option 3 because it is unlikely that the client will be able to cough out the bloody secretions.

The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions should the nurse anticipate performing during this process? Select all that apply. 1.Reinforce instructions to breathe deeply while the tube is removed. 2.Cover the site with an occlusive dressing after the tube is removed. 3.Clamp the chest tube near the insertion site just before the removal. 4.Raise the drainage system to the level of the chest tube insertion site. 5.Have the client perform the Valsalva maneuver as the chest tube is pulled out.

2.Cover the site with an occlusive dressing after the tube is removed. Have the client perform the Valsalva maneuver as the chest tube is pulled out. A chest tube is removed when the lung has fully reexpanded or there is limited drainage. When the chest tube is removed, the client is asked to perform a Valsalva maneuver (i.e., take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight (occlusive) dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. After the tube is removed, the client should take deep breaths to ensure adequate lung expansion. The tube is not usually clamped before it is removed, and the drainage apparatus must always be lower than the chest tube site. Focus on the subject, removal of a chest tube. Visualize the procedure, client instructions, and the effect of each of the actions in the options to answer correctly.

The nurse is collecting data from a client who is experiencing the typical signs/symptoms of tuberculosis (TB). Which are signs and symptoms of tuberculosis? Select all that apply. 1.Weight gain 2.Night sweats 3.Sporadic coughing 4.Mucopurulent sputum 5.Afternoon low grade fever

2.Night sweats 4.Mucopurulent sputum 5.Afternoon low grade fever The client with tuberculosis may report symptoms that have been present for weeks or even months. The symptoms may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever in the afternoon, and cough with mucoid or blood-streaked sputum. The cough is often persistent. To answer this question, it is necessary to be familiar with the usual signs/symptoms of the subject, tuberculosis. Weight loss is characteristic of tuberculosis eliminating option 1. The cough is persistent, not sporadic, eliminating option 3.

The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse should monitor for which item as the best indicator of an adequate respiratory status? 1.Oxygen saturation of 89% 2.Respiratory rate of 18 breaths per minute 3.Moderate amounts of tracheobronchial secretions 4.Small to moderate amounts of frank blood suctioned from the tube

2.Respiratory rate of 18 breaths per minute An airway problem could occur following tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion caused by immobility, or concurrent respiratory conditions. The respiratory rate of 18 breaths per minute is well within the normal range of 14 to 20 breaths per minute. An oxygen saturation of 89% is less than optimal. Note the strategic word, best. Focus on the subject, the best indicator of an adequate respiratory status. An oxygen saturation of 89% is suboptimal and is eliminated first. Bloody secretions are also abnormal, although secretions may be blood-tinged for a few days after tracheostomy insertion. Although tracheobronchial secretions may be expected, they are not the best indicator of an adequate respiratory status making the respiratory rate of 18 breaths per minute the correct option.

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action? 1.Notify the registered nurse immediately. 2.Stop the procedure and oxygenate the client. 3.Continue to suction the client at a quicker pace. 4.Ensure that the suction is limited to 15 seconds.

2.Stop the procedure and oxygenate the client. During suctioning the nurse should monitor the client closely for complications including hypoxemia, drop in heart rate due to vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If complications develop, especially cardiac irregularities, the nurse should stop the procedure and oxygenate the client. Note the strategic word, next. Recalling that suction can cause cardiac rate or rhythm changes, use the ABCs—airway, breathing, and circulation—to guide you to the correct option. The correct option is the only one that protects the client's airway and breathing.

The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion should the nurse make? 1.There is a leak in the system. 2.The chest tube is functioning as expected. 3.The amount of suction needs to be decreased. 4.The occlusive dressing at the insertion site needs reinforcement.

2.The chest tube is functioning as expected. The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded. The remaining options are incorrect interpretations of the finding. Focus on the subject, fluctuation of the fluid level in the water-seal chamber. Think about the physiology associated with the use of a closed chest tube drainage system. Recalling that this is an expected finding will direct you to the correct option.

The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client? 1.The client inhales slowly. 2.The client is breathing through the nose. 3The client removes the mouthpiece from the mouth to exhale. 4. The client forms a tight seal around the mouthpiece with the lips.

2.The client is breathing through the nose. Incentive spirometry is not effective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 3, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results. Note the strategic word, ineffective. This indicates a negative event query and the need to select the incorrect client action. Visualizing the use of the incentive spirometer will assist in directing you to the correct option.

A client reports the chronic use of nasal sprays. The nurse reinforces instructions to this client about which piece of information related to chronic use of nasal sprays? 1.Nosebleeds are common. 2.The protective mechanism of the nose may be damaged. 3.It is acceptable to double the dose if one dose is ineffective. 4.Fungal infections of the nose may occur because of container contamination.

2.The protective mechanism of the nose may be damaged. The protective mechanisms of the nose may be altered with the chronic use of nasal sprays. Fungal infections occur with oral inhalers but not nasal sprays. Nosebleeds are uncommon. The client should not double-dose medications to increase their effect. Focus on the subject, use of nasal spray, and note the words chronic use. This tells you that the correct option will be an adverse consequence of prolonged use of nasal sprays. Use medication knowledge to direct you to option 2.

A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. Which finding does this indicate? 1.This is normal. 2.The tube may be occluded. 3.The lung has fully reexpanded. 4.The client needs to cough and deep breathe.

2.The tube may be occluded. Chest tube drainage in the first 24 hours following thoracic surgery may total 500 to 1000 mL. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further evaluation. Options 1, 3, and 4 are incorrect interpretations. Focus on the subject, chest tube drainage. Noting that the chest tube drainage has dropped from 75 to 5 mL will direct you to option 2.

The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the nurse take? 1.Administer oxygen. 2.Ventilate the client manually. 3.Check the client's vital signs. 4.Start cardiopulmonary resuscitation (CPR).

2.Ventilate the client manually. If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR. Use the concept of ABCs—airway, breathing, and circulation—and note the strategic word, initial. Read the question carefully to note that the subject relates to adequate ventilation of the client. Focusing on this subject will direct you to the correct option.

A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure? 1.Sims' position with the head of the bed flat 2.Prone with the head turned to the side supported by a pillow 3.Left side-lying with the head of the bed elevated at 45 degrees 4.Right side-lying with the head of the bed elevated at 45 degrees

3.Left side-lying with the head of the bed elevated at 45 degrees To facilitate removal of fluid from the chest wall, two positions may be used. The client may be positioned sitting on the edge of the bed, leaning over the bedside table with his or her feet supported on a stool. The other position is lying in bed on the unaffected side with the head of the bed elevated 45 degrees (Fowler's position). The other options are incorrect because they do not facilitate drainage of fluid to an area where it can be easily removed with thoracentesis. Focus on the subject, positioning for a thoracentesis. Option 4 can be eliminated because if the client was lying on the affected side, the site would not be accessible. Option 1 can be eliminated because Sims' position is used primarily for rectal enemas or irrigations. In the prone position, the client is lying on his or her abdomen, which is not an appropriate position for this procedure.

A client who has just suffered a flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action? 1.Reposition the client. 2.Document the findings. 3.Notify the registered nurse. 4.Medicate the client for pain.

3.Notify the registered nurse. The nurse would notify the registered nurse who would then contact the primary health care provider. The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This will lead to severe pain and dyspnea and can affect circulatory hemodynamics. Focus on the subject, flail chest, and note the words severe pain and dyspnea, which will assist in directing you to option 3.

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which results that are consistent with this disorder? 1.Pao2 58 mm Hg, Paco2 32 mm Hg 2.Pao2 60 mm Hg, Paco2 45 mm Hg 3.Pao2 49 mm Hg, Paco2 52 mm Hg 4.Pao2 73 mm Hg, Paco2 62 mm Hg

3.Pao2 49 mm Hg, Paco2 52 mm Hg Respiratory failure is described as a Pao2 of 50 mm Hg or less, and a Paco2 of 50 mm Hg or greater in a client with no history of respiratory disease. In a client with a history of respiratory disorder with hypercapnia, Paco2 elevations of 5 mm Hg or more from the client's baseline are considered diagnostic. Focus on the subject, blood gas results in a client with respiratory distress. Knowing that the carbon dioxide level in respiratory failure is greater than 50 mm Hg helps you eliminate options 1 and 2 first. You would choose option 3 over option 4 because the arterial oxygen level in respiratory failure is less than 50 mm Hg.

The nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure? 1.Asks the client to sit upright 2.Uses the diaphragm of the stethoscope 3.Places the stethoscope on the client's gown 4.Asks the client to breathe slowly and deeply through the mouth

3.Places the stethoscope on the client's gown To listen to breath sounds, the stethoscope always is placed directly on the client's skin, and not over a gown or clothing. The nurse asks the client to sit up and breathe slowly and deeply through the mouth. Breath sounds are auscultated using the diaphragm of the stethoscope, which is warmed before use. Focus on the subject, listening to breath sounds. Note the words incorrect procedure. These words indicate a negative event query and the need to select the incorrect option as the answer. Thinking about this data collection procedure and noting the words on the client's gown in option 3 will direct you to this option.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which? 1.This is normal on the second postoperative day. 2.The client has a large amount of fluid that is being evacuated by the system. 3.There is a leak in the system that requires immediate investigation and correction. 4.This is due to the suction applied to the system, which is set at 20 cm of suction pressure.

3.There is a leak in the system that requires immediate investigation and correction. Continuous bubbling in the water seal chamber of a chest tube indicates that a leak exists somewhere in the system and air is being sucked into the apparatus. The nurse needs to assess the system and initiate corrective action that may include notifying the primary health care provider. Bubbling may occur intermittently with the evacuation of a pneumothorax, but it should not be continuous, especially with a client who had surgery 2 days earlier. Hemothorax results in accumulation of drainage in the collection chamber but does not cause bubbling in the water seal chamber. Application of suction to the system causes bubbling in the suction control chamber but not the water seal chamber. Focus on the subject, closed chest tube system. Use knowledge of the function and normal findings for each of the chambers of the closed chest drainage system. Remember that continuous bubbling in the water seal chamber indicates leakage of air into the system.

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation? 1.Expected and indicates the result of massive hemolysis 2.Unexpected and indicates a concurrent history of renal insufficiency 3.Unexpected and indicates a deficit of hydrogen ions in the bloodstream 4.Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out

4.Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out With severe respiratory acidosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell forcing intracellular potassium out. This is an expected finding in this situation. Options 1, 2, and 3 are incorrect interpretations. Note the strategic word, best. Use knowledge regarding the effects of the subject, acidosis on the body. Note the relation between acidosis in the question and in the correct option. Also note that the potassium level is elevated and the relation between this elevated level and the issue of forcing potassium out of the cells in option 4.

A client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. In addition to respiratory failure, the nurse plans to monitor the client for which complication of this disorder? 1.Paralytic ileus 2.Hypernatremia 3.Hyperglycemia 4.Increased intracranial pressure

4.Increased intracranial pressure Carbon dioxide acts as a vasodilator to cerebral blood vessels. With a sufficient rise in carbon dioxide, the client may suffer increased intracranial pressure, which is reflected initially as papilledema and dilated conjunctival blood vessels. Options 1, 2, and 3 are not complications. Focus on the subject, carbon dioxide narcosis. Knowing that carbon dioxide vasodilates the cerebral blood vessels guides you to choose option 4 as the correct option because the cerebral circulation is one of the components that contributes to intracranial pressure.

The nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a Pao2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client? 1.Fatigue 2.Aspiration 3.Airway obstruction 4.Ineffective gas exchange

4.Ineffective gas exchange Restlessness and low Pao2 are hallmark signs of ineffective oxygen exchange. Airway obstruction and aspiration are not problems that are specifically associated with existing pneumonia. Although many clients with pneumonia experience fatigue, this is not the priority problem. Note the strategic word, priority. Avoid options that present problems that are generalized and not necessarily life threatening (fatigue). Eliminate options that are unrelated to the subject (airway obstruction and aspiration).

The nurse is assisting a primary health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan which as a final measure to determine correct tube placement? 1.Hyperoxygenate the client. 2.Tape the tube securely in place. 3.Listen for bilateral breath sounds. 4.Verify placement by a chest x-ray.

4.Verify placement by a chest x-ray. The final measure to determine ETT placement is to verify it by a chest x-ray. The chest x-ray shows the exact placement of the tube in the trachea, which should be above the bifurcation of the right and left mainstream bronchi. The other options are incorrect because they are completed initially after tube placement. Focus on the subject, correct tube placement, and note the words, final measure. These words tell you that you are looking for a correct item and also imply a time sequence. Knowing that the client is hyperoxygenated before and immediately after insertion, you would eliminate option 1. Option 3 is eliminated next because it is the initial means used to verify placement, not the final one. Option 2 is done before option 4 to avoid tube displacement before or during the x-ray.

The nurse is checking the chest tube drainage system of a postoperative client who had a right upper lobectomy. The closed drainage system has 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water-seal chamber. One hour following the initial data collection, the nurse notes that the bubbling in the water-seal chamber is now constant, and the client appears dyspneic. Based on these findings, which action should the nurse do first? 1.Check the client's vital signs. 2.Note the amount of drainage. 3.Check the client's lung sounds. 4.Inspect chest tube connections.

4.Inspect chest tube connections. The client's dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear in the pulmonary pleura, which requires primary health care provider intervention. Although the other options are correct, they should be performed after initial attempts to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client's symptoms should resolve. The nurse would also notify the registered nurse. Note the strategic word, first, and focus on the data in the question. Recalling that a constant bubbling in the water-seal chamber could indicate a leak in the system will direct you to the correct option.

While assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder? 1.Early morning fatigue 2.Dyspnea that is relieved by lying flat 3.Pain that worsens when the breath is held 4.Knifelike pain that worsens on inspiration

4.Knifelike pain that worsens on inspiration A typical symptom with pleurisy is a knifelike pain that worsens on inspiration. This is a result of the friction caused by the rubbing together of inflamed pleural surfaces. This pain usually disappears when the breath is held because these surfaces stop moving. The client does not experience early morning fatigue or dyspnea relieved by lying flat. Focus on the subject, pleurisy. Option 2 is eliminated first because dyspnea is not relieved by lying flat. Option 1 is eliminated next because fatigue, if it were to occur, would not be present in the morning when the client is most well rested. From the remaining options, keep in mind that pleurisy results from inflammation of the pleura. Because the visceral and parietal lung pleura glide over one another with respiration, it is expected that chest movement precipitates or intensifies the pain. With this in mind, eliminate option 3.

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position because it will aggravate breathing? 1.Sitting up and leaning on a table 2.Standing and leaning against a wall 3.Sitting up with elbows resting on knees 4.Lying on his or her back in low-Fowler's position

4.Lying on his or her back in low-Fowler's position The client should use the positions outlined in options 1, 2, and 3. These positions allow for maximal chest expansion and decreased use of accessory muscles of respiration. The client should not lie on his or her back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing whenever possible. If no chair is available, then leaning against a wall while standing allows accessory muscles to be used for breathing rather than posture control. Note the word avoid in the question. This is a negative event inquiry and asks you to select an option that is an incorrect statement. Note that options 1, 2, and 3 are comparable or alike in that they are all upright positions.

A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit? 1.Epistaxis 2.Headache 3.Runny nose 4.Nasal obstruction

4.Nasal obstruction Nasal obstruction is the most common symptom associated with a nasal tumor because the tumor occupies space in the nasal area. Bleeding (epistaxis) may occur but is not a primary sign. Headache and a runny nose are not compatible with the clinical picture of a client with a nasal tumor. Focus on the subject, a nasal tumor, and note the strategic word, primary. Eliminate options 2 and 3 first because they are not typical signs and symptoms with a nasal tumor. Choose correctly between the remaining options, recalling that a tumor is likely to exert pressure causing obstruction.

The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing is which? 1.Promote oxygen intake 2.Strengthen the diaphragm 3.Strengthen the intercostal muscles 4.Promote carbon dioxide elimination

4.Promote carbon dioxide elimination Pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing. Focus on the subject, pursed lip breathing, and note the strategic word, primary. Visualize the use of this breathing technique to assist with answering correctly. Recalling the respiratory conditions in which this type of breathing is helpful will also assist in directing you to the correct option.

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely? 1.The family does not need therapy, and the client will not be contagious after 1 month of medication therapy. 2.The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy. 3.The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy. 4.The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

4.The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis. Focus on the subject, treatment of those exposed to tuberculosis and reassuring the client. Recalling that the family requires prophylactic therapy allows you to eliminate options 1 and 2. From the remaining options, it is necessary to know that the client is not contagious after 2 to 3 weeks of therapy.