Chapter 19
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? a. "You need to start using the incentive spirometer 2 days after surgery." b. "Before you do the exercise, I'll give you pain medication if you need it." c. "Breathe in and out quickly." d. "Don't use the incentive spirometer more than 5 times every hour."
"Before you do the exercise, I'll give you pain medication if you need it."
A nurse recognizes that a client with tuberculosis needs further teaching when the client states: a. "The people I have contact with at work should be checked regularly." b. "I'll have to take these medications for 9 to 12 months." c. "It won't be necessary for the people I work with to take medication." d. "I'll need to have scheduled laboratory tests while I'm on the medication."
"The people I have contact with at work should be checked regularly."
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? a. "The tube will drain secretions from the lung." b. "The tube will allow air to be restored to the lung." c. "The tube will drain air from the space around the lung." d. "The tube will provide a route for medication instillation to the lung."
"The tube will drain air from the space around the lung."
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? a. "Influenza vaccine will prevent typical pneumonias." b. "Viruses like influenza are the most common cause of pneumonia." c. "Getting the flu can complicate pneumonia." d. "Influenza is the major cause of death in the United States."
"Viruses like influenza are the most common cause of pneumonia."
The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient? a. 3 months b. 6 to 12 months c. 13 to 18 months d. 3 to 5 months
6 to 12 months
A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? a. The ET tube must be advanced. b. A disease process is present. c. The ET tube must be pulled back. d. The X-ray is inconclusive.
A disease process is present.
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a. Atelectasis b. Acute respiratory distress syndrome c. Metabolic alkalosis d. Respiratory acidosis
Acute respiratory distress syndrome
For a client with an endotracheal (ET) tube, which nursing action is the most important? a. Turning the client from side to side every 2 hours b. Providing frequent oral hygiene c. Monitoring serial blood gas values every 4 hours d. Auscultating the lungs for bilateral breath sounds
Auscultating the lungs for bilateral breath sounds
Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated? a. Blood pressure increase of 20 mm Hg b. PaO2 60 mmHg with an FiO2 <40% c. Heart rate <100 bpm d. Vital capacity of 12 mL/kg
Blood pressure increase of 20 mm Hg
The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? a. Drug ingestion b. Direct lung damage c. Chemical irritation d. Aspiration
Chemical irritation
The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? a. Heart rate, 112 bpm b. Moderate amounts of colorless sputum c. Chest tube drainage, 190 mL/hr d. Pain of 5 on a 1-to-10 scale
Chest tube drainage, 190 mL/hr
A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? a. Wheezes b. Rhonchi c. Crackles d. Decreased breath sounds
Decreased breath sounds
The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? a. Encourage the client to do deep breathing and coughing exercises. b. Document that the chest drainage system is operating as it is intended. c. Inform the physician promptly that there is in imminent leak in the drainage
Document that the chest drainage system is operating as it is intended.
What is the reason for chest tubes after thoracic surgery? a. Draining secretions, air, and blood from the thoracic cavity is necessary. b. Chest tubes allow air into the pleural space. c. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. d. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
Draining secretions, air, and blood from the thoracic cavity is necessary.
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? a. Dyspnea b. Hypertension c. Ascites d. Syncope
Dyspnea
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a. Nonproductive cough and normal temperature b. Hemoptysis and dysuria c. Sore throat and abdominal pain d. Dyspnea and wheezing
Dyspnea and wheezing
A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? a. Encourage coughing to mobilize secretions. b. Make sure that a thoracotomy tube is linked to open chest drainage. c. Restrict intravenous fluids for at least 24 hours. d. Assist with positioning the client on the right side.
Encourage coughing to mobilize secretions.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a. Incentive spirometry b. Endotracheal suctioning c. Use of a cooling blanket d. Encouragement of coughing
Endotracheal suctioning
A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to: a. Expect coughing when using the spirometer properly. b. Maintain a supine position to use the spirometer. c. Use the spirometer twice every hour. d. Inhale and exhale rapidly with the spirometer.
Expect coughing when using the spirometer properly.
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? a. Increased blood pressure b. Decreased level of consciousness (LOC) c. Increased restlessness d. Decreased heart rate
Increased restlessness
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? a. An ET cuff leak b. A disconnected ventilator circuit c. Kinking of the ventilator tubing d. A change in the oxygen concentration without resetting the oxygen level alarm
Kinking of the ventilator tubing
---The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? a. Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide b. Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting c. Dries and reinserts the inner cannula or replaces it with a new di
Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting
A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? a. Placing the client in respiratory isolation b. Monitoring the client's fluid intake and output c. Assessing the client's temperature every 8 hours d. Wearing gloves during all client contact
Placing the client in respiratory isolation
A client has been brought to the ED by the paramedics. The client is suspected of having acute respiratory distress syndrome (ARDS). What intervention should the nurse first anticipate? a. Performing deep suctioning b. Setting up oxygen at 5 L/minute by nasal cannula c. Setting up a nebulizer to administer corticosteroids d. Preparing to assist with intubating the client
Preparing to assist with intubating the client
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? a. Deflating the cuff before removing the tube b. Ensuring that humidified oxygen is always introduced through the tube c. Checking the cuff pressure every 6 to 8 hours d. Routinely deflating the cuff
Routinely deflating the cuff
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? a. See if the chest tube is clogged. b. See if the wall suction unit has malfunctioned. c. See if a kink has developed in the tubing. d. See if there are leaks in the system.
See if there are leaks in the system.
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? a. See if there are leaks in the system. b. See if the wall suction unit has malfunctioned. c. See if a kink has developed in the tubing. d. See if the chest tube is clogged.
See if there are leaks in the system.
The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? a. Fever and chills b. Dyspnea and coughing c. Stabbing pain during respiratory movement d. Dullness or flatness on percussion over areas of collected fluid
Stabbing pain during respiratory movement
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? a. The patient is having a stress reaction. b. The patient is in a hypermetabolic state. c. The patient is hypoxic from suctioning. d. The patient is having a myocardial infarction.
The patient is hypoxic from suctioning.
A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? a. Notify the respiratory therapist. b. Troubleshoot to identify the malfunction. c. Manually ventilate the client. d. Reposition the endotracheal tube.
Troubleshoot to identify the malfunction.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a. Water-seal chamber b. Suction control chamber c. Air-leak chamber d. Collection chamber
Water-seal chamber
On auscultation, which finding suggests a right pneumothorax? a. Bilateral inspiratory and expiratory crackles b. Bilateral pleural friction rub c. Inspiratory wheezes in the right thorax d. Absence of breath sounds in the right thorax
Absence of breath sounds in the right thorax
The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS? a. Elevated myoglobin levels b. Elevated white blood count c. Elevated B-type natriuretic peptide (BNP) levels d. Elevated troponin levels
Elevated B-type natriuretic peptide (BNP) levels
A client who is post-thoracotomy is retaining secretions. What is the nurse's initial intervention? a. Encourage the client to cough b. Perform postural drainage c. Perform nasotracheal suctioning d. Perform chest physiotherapy
Encourage the client to cough
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? a. Promote more efficient and controlled ventilation and to decrease the work of breathing b. Promote the strengthening of the client's diaphragm c. Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing d. Promote the client's ability to take in oxygen
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? a. Monitor the pressure in the cuff at least every 8 hours b. Deflate the cuff overnight to prevent tracheal tissue trauma. c. Keep the tracheostomy tube plugged at all times. d. Inflate the cuff to the highest possible pressure in order to prevent aspiration.
Monitor the pressure in the cuff at least every 8 hours
A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen? a. Simple mask b. Face tent c. Nonrebreather mask d. Nasal cannula
Nonrebreather mask
The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation? a. Shortness of breath b. Fever c. Weight loss d. Headache
Shortness of breath
A mediastinal shift occurs in which type of chest disorder? a. Traumatic pneumothorax b. Simple pneumothorax c. Cardiac tamponade d. Tension pneumothorax
Tension pneumothorax
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? a. "Because I had a previous reaction to the test, this time I need to get a chest X-ray." b. "I will avoid contact with my family until I am done with the test." c. "If the test area turns red that means I have tuberculosis." d. "I will come back in 1 week to have the test read."
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? a. "It is fine if I eat sushi with a little bit of soy sauce." b. "I am going to have a tuna fish sandwich for lunch." c. "It is all right if I have a grilled cheese sandwich with American cheese." d. "It is all right if I drink a glass of red wine with my dinner."
"It is all right if I have a grilled cheese sandwich with American cheese."
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient? a. "Only wear your contact lenses during the day and take them out in the evening before bed." b. "You should switch to wearing your glasses while taking this medication." c. "The physician can give you eye drops to prevent any problems." d. "There are no significant problems with wearing contact lenses."
"You should switch to wearing your glasses while taking this medication."
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? a. 58 mm Hg b. 45 mm Hg c. 120 mm Hg d. 84 mm Hg
84 mm Hg
A client has a sucking stab wound to the chest. Which action should the nurse take first? a. Prepare a chest tube insertion tray. b. Apply a dressing over the wound and tape it on three sides. c. Draw blood for a hematocrit and hemoglobin level. d. Prepare to start an I.V. line.
Apply a dressing over the wound and tape it on three sides.
Which of the following is a potential complication of a low pressure in the endotracheal cuff? a. Aspiration pneumonia b. Tracheal bleeding c. Pressure necrosis d. Tracheal ischemia
Aspiration pneumonia
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? a. Low-pitched rhonchi during expiration b. Sibilant wheezes c. Crackles in the lung bases d. Pleural friction rub
Crackles in the lung bases
What assessment method would the nurse use to determine the areas of the lungs that need draining? a. Chest X-ray b. Arterial blood gas (ABG) levels c. Auscultation d. Inspection
Auscultation
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? a. Surgery to remove the tonsils and adenoids b. Medications to assist the patient with sleep at night c. Continuous positive airway pressure (CPAP) d. Bi-level positive airway pressure (BiPAP)
Continuous positive airway pressure (CPAP)
A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? a. Correct use of a mini-nebulizer b. Correct use of incentive spirometry c. Correct technique for rhythmic breathing d. Correct use of a ventilator
Correct use of incentive spirometry
The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session? a. Dyspnea b. Severe pain c. Coughing d. Copious sputum production
Coughing
A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? a. Cardiac tamponade b. Simple pneumothorax c. Pulmonary contusion d. Flail chest
Flail chest
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a. Hypercapnia, hypoventilation, and hypoxemia b. Hyperventilation, hypertension, and hypocapnia c. Hyperoxemia, hypocapnia, and hyperventilation d. Hypotension, hyperoxemia, and hypercapnia
Hypercapnia, hypoventilation, and hypoxemia
The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique? a. It will prevent the alveoli from overexpanding. b. It increases the respiratory rate to improve oxygenation. c. It prolongs exhalation. d. It will assist with widening the airway.
It prolongs exhalation.
A nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? a. Percuss the client's lungs and thorax. b. Have the client perform incentive spirometry. c. Determine whether the client can now perform forced expiratory technique (FET). d. Measure the client's oxygen saturation.
Measure the client's oxygen saturation.
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? a. Progressive loss of lung function associated with chronic disease b. Sudden loss of lung function associated with chronic disease c. Progressive loss of lung function with history of normal lung function d. Sudden loss of lung function with history of normal lung function
Progressive loss of lung function associated with chronic disease
The home care nurse is monitoring a client discharged home after resolution of a pulmonary embolus. For what potential complication should the home care nurse be most closely monitoring this client? a. Activity level and role performance b. Swallowing ability and signs of aspiration c. Signs and symptoms of pulmonary infection d. Residual effects of compromised oxygenation
Residual effects of compromised oxygenation
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: a. Symmetry of the client's chest expansion b. A scheduled time for deflation of the tracheal cuff c. Tracheal cuff pressure set at 30 mm Hg d. Cool air humidified through the tube
Symmetry of the client's chest expansion
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? a. Cough b. Syncope c. Hemoptysis d. Tachypnea
Tachypnea
A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: a. Lay in bed with the head on a pillow. b. Take prescribed albuterol (Ventolin) before performing postural drainage. c. Hold each position for 5 minutes. d. Perform drainage 1 hour after meals.
Take prescribed albuterol (Ventolin) before performing postural drainage.
The nurse has explained to the client that after his thoracotomy, it will be important to adhere to a coughing schedule. The client is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client? a. Teach him how to use a metered dose inhaler. b. Teach him to use a mini-nebulizer. c. Teach him postural drainage. d. Teach him how to perform huffing.
Teach him how to perform huffing.
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. b. The client exhibits restlessness and confusion. c. The client exhibits bronchial breath sounds over the affected area. d. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? a. To drain copious sputum secretions b. To remove air from the pleural space c. To assist with mechanical ventilation d. To monitor bleeding around the lungs
To remove air from the pleural space
Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall? a. Turn onto the affected side. b. Avoid using a pillow while splinting. c. Use a prescribed analgesic. d. Use a heat or cold application.
Turn onto the affected side.
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? a. Turning the client every 4 hours to prevent fatigue b. Using strict hand hygiene c. Keeping the head of the bed at 15 degrees or less d. Providing oral hygiene daily
Using strict hand hygiene
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a. Vitamin C b. Vitamin B6 c. Vitamin E d. Vitamin D
Vitamin B6
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a. Vitamin C b. Vitamin E c. Vitamin D d. Vitamin B6
Vitamin B6
Which type of ventilator has a preset volume of air to be delivered with each inspiration? a. Time cycled b. Pressure cycled c. Negative pressure d. Volume cycled
Volume cycled
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: a. hyperthermia. b. a compromised skin graft. c. a malignant tumor. d. pneumonia.
a compromised skin graft.
A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. a. To reduce stress on the myocardium b. To provide visual feedback to encourage the client to inhale slowly and deeply c. To decrease the work of breathing d. To clear respiratory secretions e. To provide adequate transport of oxygen in the blood
a. To reduce stress on the myocardium c. To decrease the work of breathing e. To provide adequate transport of oxygen in the blood
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: a. turn and reposition himself every 2 hours. b. continue to take antibiotics for the entire 10 days. c. maintain fluid intake of 40 oz (1,200 ml) per day. d. follow up with the physician in 2 weeks.
continue to take antibiotics for the entire 10 days.
A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. a. hand antisepsis b. incentive spirometry c. vaccinations d. prescribed opioids
hand antisepsis vaccinations
A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a. preventing him from developing an infection. b. keeping his airway patent. c. helping him communicate. d. encouraging him to perform activities of daily living (ADLs).
keeping his airway patent.
Arterial blood gas analysis would reveal which value related to acute respiratory failure? a. pH 7.35 b. PaO2 80 mm Hg c. pH 7.28 d. PaCO2 32 mm Hg
pH 7.28
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? a. pH 7.28, PaO2 50 mm Hg b. pH 7.35, PaCO2 48 mm Hg c. pH 7.46, PaO2 80 mm Hg d. pH 7.36, PaCO2 32 mm Hg
pH 7.28, PaO2 50 mm Hg
A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to: a. remove air from the pleural space. b. remove fluid from the lungs. b. ventilate the client. c. administer IV medication.
remove air from the pleural space.
