ATI Respiratory Med-Surg

A nurse is collecting data from a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider? A. Elevated temperature B. Swollen cervical lymph nodes C. Inspiratory stridor D. Purulent nasal discharge

c

A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? A. pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mmHg B. pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mmHg C. pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mmHg D. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg

d

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

a

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

a

A nurse is collecting data from a client who has a positive tuberculin skin test. Which of the following findings should the nurse identify as an indication that the client has active tuberculosis? A. Rhinitis B. Air hunger C. Night sweats D. Weight gain

c

A nurse is assisting with the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat high-calorie foods first B. Increase intake of water at mealtimes C. Perform active range-of-motion exercises before meals D. Keep saltine crackers nearby for snacking

a

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. Which of the following actions should the nurse take to assist the client with smoking cessation? A. Discuss ways the client can reduce the number of cigarettes smoked per day B. Suggest the client switch from smoking cigarettes to smoking a pipe C. Inform the client that treatment will be ineffective if smoking continues D. Discourage the use of nicotine gum

a

A nurse is reinforcing discharge instructions with a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? A. Aspiration of water B. Infection of the stoma C. Bleeding around the stoma D. Skin breakdown around the stoma

a

A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. Which of the following pieces of information should the nurse include in the teaching? A. Use pursed-lip breathing during periods of dyspnea B. Limit fluid intake to 1,500 mL per day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94%

a

A nurse is reinforcing teaching with 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

A nurse on a medical unit is assisting with the care of a client who has a possible closed 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 hear which of the following findings when auscultating the client's lung sounds? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

a

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax B. A client who has an acute exacerbation of Crohn's disease C. A client who is postoperative following a laparoscopic appendectomy D. A client who is recovering from a thyroid storm

a

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

a

A nurse on a medical-surgical unit is collecting data from a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the charge nurse? A. Increased coughing B. Diaphragmatic breathing C. Hemoptysis D. Kussmaul respirations

a

A nurse is assisting with preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.) A. Explain that the client will receive sedation and will not remember the procedure B. Verify that the client understands the purpose and nature of the procedure C. Offer the client sips of clear liquids until 1 hour before the test D. Obtain a pre-procedural sputum specimen E. Instruct the client to keep his neck in a neutral position

a,b

a nurse is reinforcing preoperative teaching with a client who has lung cancer and will undergo a pneumonectomy. Which of the following pieces of information should the nurse include? (Select all that apply.) A. "You will have a chest tube in place after surgery." B. "We'll help you turn, cough, and breathe deeply frequently after surgery." C. "You will have to remain in bed for about 2 days after the surgery." D. "We'll give you oxygen to support your breathing if you need it." E. "You should expect pain for the first few days after surgery."

a,b,d

A nurse is assisting with planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should suggest including which of the following topics? (Select all that apply.) A. NPO status B. Alternative methods of communication C. Endotracheal intubation D. Changes in body image E. Swallowing exercises

a,b,d,e

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) A. Assign the client to a private room with negative-pressure airflow B. Add contact precautions to the client's plan of care C. Wear an N95 respirator when entering the client's room D. Ensure the client's environment provides 4 exchanges of fresh air per minute E. Institute protective environment precautions as soon as the client arrives on the unit

a,c

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings indicate a tension pneumothorax? (Select all that apply.) A. Tracheal deviation to the left B. Temperature of 38.8°C (102°F) C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea

a,c,d

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing B. Provide pain medication immediately after removal C. Auscultate the lungs after removal D. Delegate removal of the chest tube to an assistive personnel (AP)

c

A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique helps evaluate which of the following structures? A. Lymph nodes B. Maxillary sinuses C. Intercostal spaces D. Salivary glands

b

A nurse is assisting with the development of a teaching plan about how to prevent an acute asthma attack for a young adult client. Which of the following points should the nurse plan to discuss first? A. Explain how to eliminate environmental triggers that precipitate attack B. Determine the client's perception of the disease process and what might have triggered the current attack C. Discuss the client's medication regimen D. Review the manifestations of respiratory infections

b

A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? A. Insert a large-bore IV catheter B. Ensure an adequate airway C. Obtain an accurate medication history D. Prepare to administer an antagonist

b

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) and 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

A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following recommendations should the nurse make? A. Turn off ventilator alarms when performing endotracheal suctioning B. Maintain the head of the bed at 30 degrees C. Provide oral care at least every 12 hours D. Initiate enteral feeding with a low-calorie formula

b

A nurse is reinforcing discharge teaching with a client who has emphysema. Which of the following instructions should the nurse include? A. "Be sure to take cough medicine to help avoid coughing." B. "Try to drink at least 2 to 3 liters of fluid per day." C. "Try to reduce your smoking to 2 cigarettes per day." D. "Be sure to eat 3 full meals each day."

b

A nurse is reinforcing teaching about pursed-lip breathing with a client who has chronic obstructive pulmonary disease (COPD) and emphysema. The nurse should explain that this breathing technique does which of the following? A. Increases oxygen intake B. Keeps the airways open on exhalation C. Uses the intercostal muscles D. Strengthens the diaphragm

b

A nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. The nurse should instruct the client that which of the following is the purpose of these treatments? A. To encourage deep breaths B. To mobilize secretions in the airways C. To dilate the bronchioles D. To stimulate the cough reflex

b

A nurse is collecting data about the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of the early onset of respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis

c

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

b

A nurse in a clinic is reinforcing teaching with a client who is scheduled to have a tuberculin skin test. Which of the following pieces of information should the nurse include? A. "If the test is positive, it means you have an active case of tuberculosis." B. "If the test is positive, you should have another tuberculin skin test in 3 weeks." C. "You must return to the clinic to have the test read in 2 or 3 days." D. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."

c

A nurse in a provider's office is collecting data from a client who reports recent exposure to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips

c

A nurse is assisting with the care of a client who had a chest tube inserted 12 hours ago. The nurse notes a crackling sensation upon palpation of the skin on the right side of the client's chest. The nurse should notify the charge nurse that the client is demonstrating a clinical manifestation of which of the following complications? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

c

A nurse is assisting with the plan of care for a client following placement of a chest tube 1 hour 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 seal 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

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in semi- to high-Fowler's position

c

A nurse is caring for a client who had a le lower lobectomy to treat lung cancer. Which of the following factors has a significant impact on the plan of care for this client? A. The client will need intensive smoking-cessation education. B. After surgery, the prognosis for clients with lung cancer is usually good. C. Lung cancer usually has metastasized before the client has symptoms. D. Oxygen therapy is ineffective following a lobectomy.

c

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min B. Prepare the client for the possibility of endotracheal intubation and mechanical ventilation C. Increase the oxygen flow and request an arterial blood gas determination D. Position the client supine and administer an antianxiety medication

c

A nurse is caring for a client who has pneumonia and is experiencing thick oral secretions. Which of the following actions should the nurse take first? A. Provide chest physiotherapy for the client B. Perform oropharyngeal suction C. Encourage deep-breathing and coughing D. Assist the client to ambulate

c

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

c

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place, 1 in the lower portion of the thorax and the other higher up on the chest wall. When the family asks the nurse why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "The tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will take over if blood clots block the first."

c

A nurse is preparing to assist a provider in withdrawing arterial blood from a client's radial artery for ABG measurement. 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. Check the circulation in the client's ulnar artery prior to obtaining the specimen D. Release the pressure applied to the puncture site 1 minute after the needle is withdrawn

c

A nurse is reinforcing discharge teaching with a client who had a pulmonary embolism. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "I'll expect a little leg swelling since I won't be that active for a while." B. "I'll see the doctor every week to change my vena cava filter." C. "I'll call the doctor if I see any blood in my urine or stool." D. "I'll have to take the blood thinner for a few more days."

c

A nurse is reinforcing teaching with a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? A. "I can keep in my dentures during the procedure." B. "I am allowed to have only clear liquids prior to the procedure." C. "A tissue sample might be obtained during the procedure." D. "A signed consent form is not required for this procedure."

c

A nurse is reinforcing teaching about breathing techniques with a client who has emphysema. Which of the following statements should the nurse identify as an indication that the client understands the mechanics behind pursed-lip breathing? A. "I'll inhale slowly through pursed lips to help me breathe better." B. "When I do my pursed-lip breathing, I'll lie down first." C. "When I breathe out through pursed lips, my airways don't collapse between breaths." D. "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises."

d

A nurse in the PACU is collecting data from a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify that these findings are manifestations of which of the following complications? A. Pulmonary edema B. Tension pneumothorax C. Flail chest D. Respiratory obstruction

d

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

d

A nurse is assisting with the care of a client who has a chest tube in place following a thoracotomy. Which of the following actions should the nurse take? A. Empty the drainage container every 4 hours B. Change the client's insertion-site dressing each shift C. Clamp the chest tube when the client is ambulating D. Place the drainage unit below the client's chest level

d

A nurse is assisting with the plan of care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse recommend to use for this client? A. A simple face mask B. A nonrebreather mask C. A bag-valve-mask device D. A nasal cannula

d

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? A. So blowing B. Loud bubbling C. Dry grating D. Noisy wheezing

d

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? A. Place the drainage system at the head of the client's bed B. Increase the suction to the chest drainage system C. Place the client on low-flow oxygen via nasal cannula D. Immerse the end of the chest tube in a bottle of sterile water

d

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 suctioned 2 hours ago. C. The client coughs and expectorates a large mucous plug. D. The client has coarse crackles in the lung fields

d

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse take first? A. Monitor the client's arterial blood gas results B. Reinforce how to perform controlled coughing C. Reinforce how to perform pursed-lip breathing D. Place the client in an upright position

d

A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon? A. Nasal edema B. Mouth breathing C. Periorbital ecchymosis D. Frequent swallowing

d

A nurse is collecting data from a client who has a prescription for cisplatin IV to treat lung cancer. Which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome D. Tinnitus

d

A nurse is helping the provider prepare a client for a thoracentesis. The nurse should instruct the client that which of the following positions will be used for this procedure? 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

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? A. Measuring heart rate B. Palpating peripheral pulses C. Observing sputum for blood D. Confirming the gag reflex

d

A nurse is reinforcing preoperative teaching with a client who is scheduled to undergo a pneumonectomy. The client states, "I am afraid that coughing will hurt after the surgery." Which of the following responses should the nurse make? 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

A nurse is reinforcing preoperative teaching with a client who will undergo a total laryngectomy. Which of the following statements should the nurse identify as an indication that the client understands the impact of the surgery? A. "I'm not going to be able to cough for a while after the surgery." B. "After I recover from the anesthesia, I'll be able to eat regular food again." C. "After the surgery, my voice will gradually return but might be weak." D. "I understand that I will have a permanent tracheostomy after the surgery."

d