Respiratory questions

A client beginning therapy with theophylline. The nurse plans to teach the client to limit the intake of which items while taking this medication? A. Coffee, cola, and chocolate B. Oysters, lobster, and shrimps C. Melons, oranges, and pineapple D. Cottage cheese, cream cheese, and diary creamers

A

A client who is human immunodeficiency virus (HIV)- positive has had a tuberculin skin test. The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? A. Positive B. Negative C. Inconclusive D. Need for repeat testing

A

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? A. Dyspnea B. Headache C. Weight gain D. Hypothermia

A

The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the client should the nurse note as an expected side effect of this combination of medication? A. "I feel like my heart is racing." B. "I feel more bloated than usual" C. "My eyes have been watering lately" D. "I haven't had a bowel movement in 4 days"

A

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? A. Mask B. Gown C. Gloves D. Eye protection

A

The nurse is teaching a client who is beginning antiviral therapy for influenza. Which statement by the client indicates an understanding of the instructions? A. "I must take the medication exactly as prescribed?" B. "Once I start the medication, I will no longer be contagious." C. "I will not get any colds or infections while taking this medication." "This medication has minimal side effects and I can return to

A

The nurse teaches a client about the effects of diphenhydramine, which has been prescribed as a cough suppressant. The nurse determines that the client needs further instructions if the client makes which statement? A. "I will take the medication on an empty stomach." B. "I won't drink alcohol while taking this medication." C. "I won't do activities that require mental alertness while taking this medication" D. "I will use sugarless gym, candy, or oral rinses to decrease dryness in my mouth."

A

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse should monitor for which side and adverse effects of rifabutin? SATA A. Signs of hepatitis B. Flu-like symptoms C. Low neutrophil count D. Vitamin B6 deficiency E. Ocular pain or blurred vision F. Tingling and numbness of the fingers

A B C E

A nurse is assisting a provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should the nurse take? (SATA) a. Wear goggles and a mask during the procedure b. Cleanse the procedure area with an antiseptic solution c. Instruct the client to take deep breaths during the procedure d. Position the client laterally on the affected side before the procedure e. Apply pressure to the site after the procedure

A B E Rationale: The nurse and the provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid; The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure; The application of pressure decreases the risk for bleeding at the procedure site

The community health nurse is conducting an educational session with community members regarding he signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered a diagnosis if which signs and symptoms are present? SATA A. Dyspnea B. Headache C. Night sweats D. A blood, productive cough E. A cough with the expectoration of mucoid sputum

A C D E

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? SATA A. Activities should be resumed gradually B. Avoid contact with other individuals, except family members, for at least 6 months C. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated D. Respiratory isolation is not necessary, because family members already have been exposed E. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags F. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment

A C D E

A nurse in the emergency department is assessing a client for a close pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of a pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

A Rationale: A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side

A nurse in an urgent care clinical is collecting data from a client who reports exposure to anthrax. Which of the following finding is an indication of the prodromal stage of inhalation anthrax? A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes

A Rationale: A dry cough is a clinical manifestation found in the prodromal stage of having inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis.

A nurse is providing discharge teaching to a client that has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching? A. Shake the inhaler for 3 to 5 seconds B. Rinse the mouth with mouthwash after inhaling the medication C. Wait 2 min between inhalations D. Press down twice on the MDI canister

A Rationale: After fully inserting the canister into the inhaler, the client should shake it vigorously for 3 to 5 seconds to make sure he mixes the medication thoroughly

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breathe deeply and cough B. Instruct the client to limit fluid intake to less than 2000 mL/day C. Prepare to administer antibiotics D. Place the client on bed rest in semi-Fowler's position

A Rationale: Although crackles often indicated fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or cough.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

A Rationale: Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? A. Attach a humidifier bottle to the base of the flow meter B. Remove the nasal cannula while the client eats C. Secure the oxygen tubing to the bed near the client's head D. Apply petroleum jelly to the nares as needed to soothe mucus membranes

A Rationale: Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula

A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

A Rationale: Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should identify that which of the following assessments is the priority? a. Presence of gag reflex b. Pain level rating using a 0 to 10 scale c. Hydration status d. Appearance of the IV insertion site

A Rationale: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription? a. A client who has epistaxis b. A client who has amyotrophic lateral sclerosis c. A client who has pneumonia d. A client who has emphysema

A Rationale: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding

A nurse is assessing a client who has lung cancer. Which of the following manifestations should the nurse expect? a. Blood-tinged sputum b. Decreased tactile fremitus c. Resonance with percussion Peripheral edema

A Rationale: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism? a. A client who is 48 hours postoperative following a total hip arthroplasty. b. A client who is 8 hours postoperative following an open surgical appendectomy c. A client who is 2 hour postoperative following an open reduction external fixation of the right radius d. A client who is 4 hours postoperative following a laparoscopic cholecystectomy

A Rationale: The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of thigh following hip surgery. Deep vein thromboses are most likely to occur 48 to 72 hours following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression device or antiembolic stockings and by administering anticoagulant medications.

A nurse is developing a plan of care for a client who has active tuberculosis. Which of the following isolation precautions should the nurse include in the plan? a. Airborne b. Neutropenic c. Contact d. Droplet

A Rationale: The nurse should initiate airborne precautions for a client who has tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? A. Auscultate breath sounds at least every 2 hr. B. Perform range-of-motion (ROM) exercises at least two to three times daily C. Make sure the client has an intake of 2000 to 3000 mL of fluid per day Apply antiembolic stockings.

A Rationale: The priority action the nurse should contribute to the plan of care when using the airway, breathing, circulation approach to client care is auscultating breath sounds to determine the client's need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea.

A nurse in an emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? a. Apply supplemental oxygen b. Increase the rate of IV fluids c. Administer pain medication d. Initiate cardiac monitoring

A Rationale: When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesia's, and tingling in the extremities. The nurse interprets that the client is experiencing which problem? A. Hypercalcemia B. Peripheral neuritis C. Small blood vessel spasm D. Impaired peripheral circulation

B

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action? A. Use alcohol in small amounts only B. Report yellow eyes or skin immediately C. Increase intake of swiss or aged cheese D. Avoid vitamin supplements during therapy

B

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? A. A low respiratory rate B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injury

B

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure? A. Beclomethasone first and then the salmeterol B. Salmeterol first and then the beclomethasone C. Alternating a single puff of each, beginning with the salmeterol D. Alternating a single puff of each, beginning with the beclomethasone

B

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? A. Surgical mask and gloves B. Particulate respirator, gown, and gloves C. Particulate respirator and protective eyewear D. Surgical mask, gown, and protective eyewear

B

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? SATA A. Low arterial PCo2 level B. A hyperinflated chest noted on the chest x-ray C. Decreased oxygen saturation with mild exercise D. A widened diaphragm noted on the chest x-ray E. Pulmonary function tests that demonstrate increased vital capacity

B C

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (SATA) A. Verify the oxygen flow rate every other day B. Check the cannula position on a regular basis C. Check the tops of the ears for skin breakdown D. Post "no smoking" signs in a prominent location in the home Apply petroleum ointment to nares if they become dry and irritated

B C D Rationale: The position of the nasal cannula should be verified every 8 hours or more often if needed; The tops of the ear, the nares, and the nasal mucus membranes should be assessed regularly for skin breakdown; The family is instructed to post "no smoking" signs in a prominent location in the home because oxygen increases the risk of fire injuries.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? SATA A. A client who has lactose intolerance B. A client who has had a cerebrovascular accident C. A client who is 4 hr postoperative following a leg amputation with general anesthesia D. A client who has had prolonged diarrhea E. A client who has had radiation therapy for head and neck cancer

B C E Rationale: Clients who have had a cerebrovascular accident are at risk for aspiration due to the impairment of the muscles, nerves, and reflexes that coordinate the swallowing process; Pain medications, intubation, and general anesthesia increase the risk of aspiration due to the impairment of the muscles, nerves, and reflexes that coordinate the swallowing process; Radiation therapy to the head and neck to treat cancer increases the risk for aspiration because it can impair the muscles, nerves, and reflexes that coordinate the swallowing process.

A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in place following thoracic surgery with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? a. "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration" b. "I will notify the provider if there is continuous bubbling in the water seal chamber." c. "I will notify the provider if there is drainage of 60 mm in the first hour after surgery" d. "I will notify the provider if there are several small, dark-red blood clots in the tubing"

B Rationale: Continuous bubbling in the water seal chamber suggest an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

B Rationale: Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale dioxide due to a loss of elastic recoil in the lungs

A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching? A. "The spacer increases the amount of medication delivered to the oropharynx." B. "The space increases the amount of medication delivered to the lungs." C. "Inhale rapidly using the spacer with the MDI." D. "Cover exhalation slots of the spacer with the lips when inhaling."

B Rationale: The client uses a spacer to increase the amount of medication that reaches the lungs

A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease with emphysema. The nurse should explain that this breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B Rationale: The client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100%oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. Tympanic temperature of 38 C (100.4 F) B. PaO2 50 mmHg C. Rhonchi D. Hypopnea

B Rationale: The client who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations? A. Finger B. Earlobe C. Toe D. Skin fold

B Rationale: The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. How to eliminate environmental triggers that precipitate attacks B. The client's perception of the disease process and what might have triggered past attacks C. The client's medication regimen D. Manifestations of respiratory infections

B Rationale: The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client's current knowledge.

A nurse is caring for a newly admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? a. Lateral position a pillow at the back and over the chest to support the arm b. High-Fowler's position with the arms supported on the overbed table. c. Semi-Fowler's position with pillows supporting both arms d. Supine position with the head of the bed elevated to 15 degrees

B Rationale: The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? a. Rhonchi on inspiration b. Elevated temperature c. Barrel-shaped chest d. Diminished breath sounds

B Rationale: The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections

A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. Which of the following statements by a staff nurse indicates an understanding of the teaching? a. "I will use clean technique when suctioning a client's endotracheal tube" b. "I will use a rotating motion when removing the suction catheter." c. "I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube." d. "I will suction a client's endotracheal tube every 2 hours."

B Rationale: The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen? a. Nasal cannula b. Nonrebreather mask c. Simple face mask d. Partial rebreather mask

B Rationale: The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2

A nurse is assessing a client who is 4 hours postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? a. Bleeding at the surgical site b. Decreased oxygen saturation c. Urinary retention d. Increased pain level

B Rationale: when using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia because of airway obstruction.

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? a. Increased anterior posterior chest diameter b. Productive cough with green sputum c. Clubbing of the fingers d. Pursed-lip breathing with exertion

B Rationale: when using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection

A client has a prescription to take guaifenesin. The nurse determines that the client understand the proper administration of this medication if the client states that he or she will perform which action? A. Take an extra dose if fever develops B. Take the mediation with meals only C. Take the tablet with a full glass of water D. Decrease the amount of daily fluid intake

C

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication? A. Should always be taken with food or antacids B. Should be double-dosed if 1 dose is forgotten C. Causes orange discoloration of sweat, tears, urine, and feces D. May be discontinued independently if symptoms are gone in 3 months

C

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? A. Hot, flushed feeling B. Sudden chills and fever C. Chest pain that occurs suddenly D. Dyspnea when deep breaths are taken

C

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? A. Cyanosis B. Hypotension C. Paradoxical chest movement D. Dyspnea, especially on exhalation

C

A client with tuberculosis is starting antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed? A. Electrolyte levels B. Coagulation times C. Liver enzyme levels D. Serum creatinine level

C

Terbutaline is prescribed for a client with bronchitis. Which disorder in the client's medical history requires caution by the nurse? A. Osteoarthritis B. Hypothyroidism C. Diabetes mellitus D. Polycystic disease

C

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the primary health care provider? A. Dry cough B. Hematuria C. Bronchospasm D. Blood-streaked sputum

C

The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside? A. Nasogastric tube B. Paracentesis tray C. Resuscitation equipment D. Central line insertion tray

C

The nurse performs an admission assessment of a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? A. Chest x-ray B. Bronchoscopy C. Sputum culture D. Tuberculin skin test

C

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? A. Platelet count B. Neutrophil count C. Liver function test D. Complete blood count

C

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? A. Delivers a constant rate of specific concentration of oxygen B. Delivers a high concentration of oxygen C. Delivers a low concentration of oxygen D. Restricts the client's ability to eat, speak, or drink

C Rationale: A nasal cannula delivers a relatively low concentration of oxygen (24% to 44%)

A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? a. Excessive secretions b. Kinks in the tubing c. Artificial airway cuff leak d. Biting on the endotracheal tube

C Rationale: An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound

A nurse is assessing a client who has bacterial pneumonia. Which of the following manifestations should the nurse expect? a. Decreased fremitus b. SaO2 95% on room air c. Temperature 38.8 degrees C (101.8 degrees F) d. Bradypnea

C Rationale: An elevated temperature is an expected finding for a client who has bacterial pneumonia

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates and understanding of the teaching? a. "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma" b. I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage" c. "I should remove the old twill ties after the new ties are in place."

C Rationale: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tractile fremitus

C Rationale: Crepitus, also called subcutaneous emphysema, is a course crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? A. Use a stiff toothbrush to clean the client's teeth B. Use the thumb and index finger to keep the client's mouth open C. Turn the client on his side before starting oral care D. Apply petroleum jelly to the client's lips after oral care

C Rationale: Placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking

A nurse is preparing to assist a provider to withdraw arterial blood from a client's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen B. Apply ice to the site after obtaining the specimen C. Perform an Allen's test prior to obtaining the specimen D. Release pressure applied to the puncture site 1 min after the needle is withdrawn

C Rationale: The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? a. Extra drainage system b. Suture removal set c. Container of sterile water d. Nonadherent pads

C Rationale: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include? a. "Ringing in the ears is an adverse effect of this medication" b. "Have your skin test repeated in 4 months to show a positive result." c. "Expect your urine and other secretions to be orange while taking this medication." d. "Remember to take this medication with a sip of water just before your first bite of each meal."

C Rationale: The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? a. Schedule respiratory treatments following meals b. Have the client sit up in a chair for 2-hr periods three times per day c. Provide a diet that is high in calories and protein d. Combine activities to allow for longer rest periods between activities

C Rationale: The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates

A nurse working in an emergency department is caring for a client following an acute chest trauma. Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? a. Collapsed neck veins on the affected side b. Collapsed neck veins on the unaffected side c. Tracheal deviation to the unaffected side d. Tracheal deviation to the affected side

C Rationale: The nurse should recognize that deviate of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to the unaffected side.

A nurse is planning care for a client following placement of a chest tube 1 hours ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8 hours

C Rationale: The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting.

A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? A. Ask the provider about advancing a client's diet B. Reinsert an intravenous catheter that was removed due to infiltration C. Suction the tracheostomy of a client who has copious secretions D. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift

C Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to suction the tracheostomy of a client who has copious secretions to clear the airway

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnae of the ears B. Dorsal surface of the hand C. Conjunctivae D. Dorsal surface of the foot

C Rationale: To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes.

A nurse is caring for a client who is 1 hour postoperative following a thoracentesis. Which of the following is the priority assessment finding? a. Pallor b. Insertion site plan c. Persistent cough d. Temperature 37.3 C (99.1 F)

C Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency

A nurse is caring for a client who is in acute respiratory failure and is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? a. Blood pressure b. Capillary refill c. Arterial blood gases d. Heart rate

C Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk for aspiration? A. A client who has a chest tube following a fall from a ladder B. A client who had a hemi-colectomy and placement of a colostomy C. A client receiving continuous enteral feeding through NG tube D. A client who Crohn's Disease and has an ileostomy

C Rationale: a client who is receiving continuous enteral feedings through an NG tube is at greatest risk for aspiration because if the tube slips into the lungs the feeing can enter the lungs. The RN should confirm placement of the NG tube after inserting and before initiating enteral feedings. The RN should confirm initial placement with an x-ray and subsequently, check by aspirating stomach contents and measuring the pH of the fluids. The aspirate should have a pH of 1 to 4, or as high as 6 if receiving medication that controls gastric acid.

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? a. Hyperkalemia b. Dyspnea c. Tachycardia d. Candidiasis

C Rationale: the nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if they client uses albuterol on a regular basis

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication? A. Insomnia B. Constipation C. Hypotension

D

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that they client has understood the information if the client makes which statement? A. "I need to continue medication therapy for 1 month." B. "I can't shop at the mall for the next 6 months" C. "I can return to work if a sputum culture comes back negative." D. "I should not be contagious after 2 to 3 weeks of medication therapy."

D

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understand the instructions if the client states that they will immediately report which finding? A. Impaired sense of hearing B. Gastrointestinal side effects C. Orange-red discoloration of body secretions D. Difficulty in discriminating the color red from green

D

The nurse has just administered the first dose of omalizumab to a client. Which statement by the client alerts the nurse of a life-threatening effect? A. "I have a severe headache." B. "My feet are quite swollen." C. "I am nauseated and may vomit." D. "My lips and tongue are swollen."

D

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? A. Bilateral wheezing B. Inspiratory crackles C. Intercostal retractions Increased respiratory rate

D

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which of the follow? A. Slow, deep respirations B. Rapid, deep respirations C. Paradoxical respirations D. Pain, especially with inspiration

D

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? A. Sitting up in bed B. Side lying in bed C. Sitting in a recliner chair D. Sitting up and leaning on an overbed table

D

The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation? A. Fever B. Fatigue C. Weight loss D. Shortness of breath

D

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? A. A client who has scabies B. A client who has pertussis C. A client who has streptococcal pharyngitis D. A client who has measles

D Rationale: A client who has measles requires airborne precautions as well as a negative pressure room

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome D. Tinnitus

D Rationale: An adverse effect of cisplatin is ototoxicity, which can cause tinnitus

A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following client statements indicates an understanding of the teaching? a. "I will monitor my heart rate every day while taking this medication." b. "I will make sure I have this medication with me at all times." c. "I will need to carefully rinse my mouth after I take this medication." d. "I will take this medication every night even if I don't have symptoms."

D Rationale: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening

A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery." Which of the following statements by the nurse is appropriate? A. "After the surgeon removes the lung, you will not need to cough." B. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." C. "Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain." D. "I will show you how to splint your incision while coughing."

D Rationale: The client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint her incision to reduce pain when coughing.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? a. Cromolyn sodium b. Prednisone c. Fluticasone/salmeterol d. Albuterol

D Rationale: The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? A. The client is unable to speak B. The client's airway secretions were last sectionized 2 hours ago C. The client coughs and expectorates a large mucus plug D. The nurse auscultates coarse crackles in the lung fields

D Rationale: The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia

D Rationale: The nurse should expect the client who has hypoxia to manifest tachycardia

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation? A. Restlessness B. Retractions C. Dependent edema D. Clubbing of the fingers

D Rationale: The nurse should expect the clients who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen and the ends of the fingers and toes can increase in size.

A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? A. "Apply warm compressed to the face" B. "Take aspirin 650 mg by mouth for mild pain" C. "Close your mouth when sneezing" D. "Lie on your back with your head elevated 30 degrees when resting"

D Rationale: The nurse should instruct the client to rest in the semi-Fowlers position to prevent aspiration of nasal secretions

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? a. Decreased bowel sounds b. Oxygen saturation 92% c. CO2 24 d. Intercostal retractions

D Rationale: The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS

A nurse is caring for a client who is postoperative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis? a. pH 7.50, PO2 95, PaCO2 25, HCO3 22 b. pH 7.50, PO2 87, PaCO2 35, HCO3 20 c. pH 7.30 PO2 90, PaCO2 35, HCO3 20 d. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L

D Rationale: These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45, which indicates respiratory acidosis

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse heas continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? A. Crackles B. Rhonchi C. Stridor D. Wheezes

D Rationale: Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope

A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client? A. Lying flat on the affected side B. Prone with the arms raised over the head C. Supine with the head of the bed elevated D. Sitting while leaning forward over the bedside table

D Rationale: When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the client's ribs and allows for aspiration of accumulated fluid and air.

A nurse in a long-term care facility is assisting a client with eating during mealtime and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver? A. The client has a high-pitched inspiratory stridor B. The client is able to whisper C. The client is coughing only D. The client is not making any sounds

D Rationale: When the airway is totally blocked, the client is not able to make any sounds. This finding, along with the client grasping his neck, comprise the universal sign of distress. This requires immediate action, and the nurse should perform the Heimlich maneuver at this time.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the nurse's priority? a. Provide a quiet environment b. Encourage use of incentive spirometry every 1 to 2 hours c. Obtain a blood sample for electrolyte study d. Administer heparin via continuous IV infusion

D Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

A nurse in an emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? a. Arterial pH 7.50 b. PaCO2 25 mm Hg c. SaO2 92% d. PaO2 58 mm Hg

D Rationale: the nurse should expect the client to have a lower partial pressures of oxygenation

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. "I will be able to tell how much oxygen I'm getting by looking at the flowmeter." B. "I should call my doctor if I find it harder to concentrate." C. "I will make sure my visitors smoke outside." D. "I will wear synthetic clothing and woolen socks when using my oxygen."

D Rationale: woolen and synthetic materials can generate static electricity. Because oxygen is a flammable gas, the client should wear cotton clothing and use cotton bedding and blankets.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promotor thinning of respiratory secretions? A. Encourage the client to ambulate frequently B. Encourage coughing and deep breathing C. Encourage the client to increase fluid intake D. Encourage regular use of the incentive spirometer

c Rationale: increase fluid intake to 1500 to 2000 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.