Med Success - Respiratory

35. The nurse is caring for a client on a ventilator and the alarm goes off. Which action should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Check the ventilator to determine the cause. 3. Elevate the head of the client's bed. 4. Assess the client's oxygen saturation.

2. Check the ventilator to determine the cause.

112. The client diagnosed with COPD is admitted to the medical unit. The client has thin extremities, truncal obesity, and multiple ecchymotic areas on the arms. Based on the assessment data, which question should the nurse ask the client? 1. "Do you take prednisone?" 2. "Can you tell me who hurts you?" 3. "May I check your coccyx for pressure areas?" 4. "Do you sleep with the head of the bed elevated?"

1. "Do you take prednisone?" 1. The symptoms described indicate Cushing's syndrome, developed as a result of long-term steroid use. The steroid of choice for home administration is prednisone. The client must continue to receive a form of glucocorticoid medication, or the client may develop symptoms of cortisol insufficiency. 2. The symptoms indicate steroid-induced Cushing's syndrome, not a potential abuse situation. 3. Nothing indicates the client is immobile or has an issue with the coccyx. 4. Whether or not the client sleeps with the HOB elevated does not address the described symptoms.

35. Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD? 1. "I need to get an influenza vaccine each year, even when there is a shortage." 2. "I need to get a vaccine for pneumonia each year with my influenza shot." 3. "If I reduce my cigarettes to six a day, I won't have difficulty breathing." 4. "I need to restrict my drinking liquids to keep from having so much phlegm."

1. "I need to get an influenza vaccine each year, even when there is a shortage."

117. The nurse is applying oxygen via nasal cannula to a client diagnosed with COPD. The client reports extreme shortness of breath. At which rate should the nurse set the flowmeter? 1. 2 LPM. 2. 4 LPM. 3. 6 LPM. 4. 10 LPM.

1. 2 LPM.

19. The client in the intensive care unit diagnosed with end-stage COPD has a Swan-Ganz mean pulmonary artery pressure of 35 mmHg. Which HCP order would the nurse question? 1. Administer intravenous fluids of normal saline at 125 mL/hr. 2. Provide supplemental oxygen per nasal cannula at 2 L/min. 3. Continuous telemetry monitoring with strips every 4 hours. 4. Administer a loop diuretic intravenously every 6 hours.

1. Administer intravenous fluids of normal saline at 125 mL/hr. 1. Normal mean pulmonary artery pressure is about 15 mmHg, and an elevation indicates right ventricular heart failure or cor pulmonale, which is a comorbid condition of COPD. The nurse should question this order because the rate is too high. 2. Supplemental oxygen should be administered at the lowest amount; therefore, this order should not be questioned. 3. Clients diagnosed with hypoxia and cor pulmonale are at risk for dysrhythmias, so monitoring the electrocardiogram (ECG) is an appropriate intervention. 4. Loop diuretics are administered to decrease the fluid and decrease the circulatory load on the right side of the heart; therefore, this order would not be questioned.

97. The UAP is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the RN implement? 1. Demonstrate the correct technique for giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help witerm-42th the bath. 4. Provide praise for performing the bath safely for the client and the UAP.

1. Demonstrate the correct technique for giving a bed bath. 1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is the priority, and the nurse should demonstrate the proper way to bathe a client in the bed. 2. The bed should be at a comfortable height for the UAP to bathe the client, not in the lowest position. 3. The UAP can bathe a client without assistance if the client's safety can be ensured. 4. The UAP is not ensuring the client's safety because the opposite side rail is not elevated to prevent the client from falling out of the bed.

50. Which nursing interventions should the nurse implement for the client diagnosed with a respiratory disorder? Select all that apply. 1. Administer oxygen via a nasal cannula. 2. Assess the client's lung sounds. 3. Encourage the client to cough and deep breathe. 4. Monitor the client's pulse oximeter reading. 5. Increase the client's fluid intake.

1. Administer oxygen via a nasal cannula. 2. Assess the client's lung sounds. 3. Encourage the client to cough and deep breathe. 4. Monitor the client's pulse oximeter reading. 5. Increase the client's fluid intake. 1. A client diagnosed with a respiratory disorder may have decreased oxygen saturation; therefore, administering oxygen via a nasal cannula is appropriate. 2. The client's lung sounds should be assessed to determine how much air is being exchanged in the lungs. 3. Coughing and deep breathing will help the client expectorate sputum, thus clearing the bronchial tree. 4. The pulse oximeter evaluates how much oxygen is reaching the periphery. 5. Increasing fluids will help thin secretions, making them easier to expectorate.

116. The client diagnosed with respiratory distress has the following ABG laboratory results. Which should the nurse implement? Select all that apply. 1. Apply oxygen via nonrebreather mask. 2. Call the rapid response team (RRT). 3. Elevate the head of the bed. 4. Stay with the client. 5. Notify the health-care provider (HCP).

1. Apply oxygen via nonrebreather mask. 2. Call the rapid response team (RRT). 3. Elevate the head of the bed. 4. Stay with the client. 5. Notify the health-care provider (HCP).

23. The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement? 1. Assess respiratory rate and depth. 2. Provide for an adequate rest period. 3. Administer oxygen as prescribed. 4. Teach slow abdominal breathing.

1. Assess respiratory rate and depth. 1. The assessment of respiratory rate and depth is the priority intervention because tachypnea and dyspnea may be early indicators of respiratory compromise. 2. Rest reduces metabolic demands, fatigue, and the work of breathing, which promotes a more effective breathing pattern, but it is not a priority over assessment. 3. Oxygen therapy increases the alveolar oxygen concentration, reducing hypoxia and anxiety, but it is not a priority over assessment in this situation. 4. This breathing pattern promotes lung expansion, but it is not a priority over assessment.

96. Which intervention should the nurse implement first for the client diagnosed with a hemothorax, having a right-sided chest tube for 3 days, and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT CXR. 3. Notify the HCP as soon as possible. 4. Document the findings in the client's EHR.

1. Assess the client's bilateral lung sounds. 1. Assessment of the lung sounds could indicate the client's lung has re-expanded because it has been 3 days since the chest tube has been inserted. 2. This should be done to ensure the lung has re-expanded, but it is not the first intervention. 3. The HCP will need to be notified so the chest tube can be removed, but it is not the first intervention. 4. This situation needs to be documented, but it is not the first intervention.

106. The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every 2 hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the prone position.

1. Assess the client's level of consciousness. 3. Turn the client every 2 hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the prone position. 1. Altered level of consciousness is the earliest sign of hypoxemia. 2. Urine output of less than 30 mL/hr indicates decreased cardiac output, which requires immediate intervention; it should be assessed every 1 or 2 hours, not once during a shift. 3. The client is at risk for complications of immobility; therefore, the nurse should turn the client at least every 2 hours to prevent pressure ulcers. 4. The client is at risk for fluid volume overload, so the nurse should monitor and maintain fluid intake. 5. The prone position has been demonstrated to facilitate lung expansion and improve oxygenation by opening more alveoli (Hoffman & Sullivan, 2020)

120. The 75-year-old male nursing home resident is found wandering in the hall and has a new onset of confusion. Which should the RN implement first? 1. Assess the resident's lung fields and temperature. 2. Have the resident return to his room. 3. Notify the resident's family to come and sit with him. 4. Ask the UAP to push fluids.

1. Assess the resident's lung fields and temperature.

26. The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client to a sitting position at 90 degrees. 2. Administer oxygen at 6 LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health-care provider about the client's status.

1. Assist the client to a sitting position at 90 degrees. 1. The client should be assisted to a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain the client's safety. 2. Oxygen will be applied as soon as possible, but the least amount possible. If levels of oxygen are too high, the client may stop breathing. 3. Vital signs need to be monitored, but this is not the first priority. If the equipment is not in the room, another member of the health-care team should bring it to the nurse. The nurse should stay with the client. 4. The HCP needs to be notified, but the client must be treated first. The nurse should get assistance if possible, so the nurse can treat this client quickly.

107. Which instruction is a priority for the nurse to discuss with the client diagnosed with ARDS being discharged from the hospital? 1. Avoid smoking and exposure to smoke. 2. Do not receive flu or pneumonia vaccines. 3. Avoid any type of alcohol intake. 4. It will take about 1 month to recuperate.

1. Avoid smoking and exposure to smoke.

91. Which action should the nurse implement for the client diagnosed with a hemothorax complicated by a right-sided chest tube with excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

1. Check the amount of wall suction being applied. 1. Checking to see if someone has increased the suction rate is the simplest and a noninvasive action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system. 2. No fluctuation (tidaling) would cause the nurse to assess the tubing for a blood clot. 3. The tube is milked to help dislodge a blood clot that may be blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment. The chest tube is never stripped, which creates negative air pressure and could suck lung tissue into the chest tube. 4. Encouraging the client to cough forcefully will help dislodge a blood clot blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment.

108. The client diagnosed with ARDS is on a ventilator, and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

1. Check the tubing for any kinks.

104. Which procedure or test should the nurse anticipate the HCP ordering to diagnose ARDS? 1. Chest x-ray. 2. Complete blood count. 3. Airway pressure-release ventilation test. 4. Sputum culture.

1. Chest x-ray. 1. The CRX will identify bilateral infiltrates in the lungs, the classic sign of ARDS. 2. A complete blood count can determine if the cause of ARDS is an infection but is not diagnostic of ARDS. 3. Airway pressure-release ventilation is a ventilator mode with a longer inspiration-to-expiration ratio that facilitates oxygenation and gas exchange. 4. A sputum culture is not diagnostic of ARDS

114. The nurse is reviewing the EHRs of the clients. Which data should the nurse report to the HCP? 1. Client A. 2. Client B. 3. Client C. 4. Client D.

1. Client A. 1. This client has an elevated platelet count, which is not an expected result for a client diagnosed with pneumonia. The nurse should notify the HCP so that the client can be evaluated for a comorbid problem. The WBC count is high, but it is expected in a client diagnosed with pneumonia. 2. The only value that is abnormal is the Hco3 level, which indicates that complete compensation has occurred by the client's body. This is a good ABG report. There is no reason to notify the HCP. 3. A client diagnosed with an exacerbation of COPD would be on steroid medication, which can cause an increase in blood glucose. 4. Cultures take 24 to 48 hours to obtain results. The client should already be on antibiotic medication. The information provided did not mention which antibiotics the client is on.

13. The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which clinical manifestations should the nurse expect to assess in the client? Select all that apply. 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention. 5. Low body temperature and cough.

1. Confusion and lethargy. 2. High fever and chills. 5. Low body temperature and cough. 1. The older client diagnosed with pneumonia may present with weakness, fatigue, lethargy, confusion, and poor appetite but not have any of the classic clinical manifestations of pneumonia. 2. Fever and chills are classic symptoms of pneumonia and can be present in the older client. 3. Frothy sputum and edema are clinical manifestations of heart failure, not pneumonia. 4. The client has tachypnea (fast respirations), not bradypnea (slow respirations), and jugular vein distention accompanies heart failure. 5. Low body temperature is an atypical sign of pneumonia in older clients. Cough is a common symptom of pneumonia.

102. The HCP ordered STAT ABGs for the client diagnosed with ARDS. The results are populated in the chart below. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.

1. Continue to monitor the client without taking any action.

48. The nurse is preparing to hang the next bag of aminophylline for the client diagnosed with asthma. The current theophylline level is 18 mcg/mL. Which intervention should the nurse implement? 1. Hang the next bag and continue the infusion. 2. Do not hang the next bag and decrease the rate. 3. Notify the HCP of the level. 4. Confirm the current serum theophylline level.

1. Hang the next bag and continue the infusion.

43. The nurse is caring for an anxious female client with a respiratory rate of 40, and who is reporting her fingers tingling and her lips feeling numb. Which intervention should the nurse implement first? 1. Have the client take slow, deep breaths. 2. Instruct her to put her head between her legs. 3. Determine why she is feeling so anxious. 4. Administer alprazolam.

1. Have the client take slow, deep breaths. 1. The client is hyperventilating and blowing off too much CO2, which is why her fingers are tingling and her mouth is numb; she needs to retain CO2 by taking slow, deep breaths. 2. Putting the head between the legs sometimes helps a client about to faint, but it is not the first intervention. 3. The client is hyperventilating; determining why is not appropriate at this time. 4. Medications such as alprazolam (Xanax), an antianxiety agent, take up to 30 minutes to 1 hour to work and are not the first intervention for the hyperventilating client.

87. Which intervention should the nurse implement for a male client with a left-sided chest tube in place for 6 hours refusing to take deep breaths because of pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain that deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die.

1. Medicate the client and have the client take deep breaths. 1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis. 2. The client must take deep breaths; shallow breaths could lead to complications. 3. Deep breaths must be taken to prevent complications. 4. This is a cruel intervention; the nurse can medicate the client and then encourage deep breathing.

31. Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply. 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.

1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition. 1. The client diagnosed with COPD has difficulty exchanging oxygen with carbon dioxide, which is manifested by physical signs such as fingernail clubbing and respiratory acidosis, as seen on ABGs. 2. The client should avoid extremes in temperatures. Warm temperatures cause an increase in metabolism and increase the need for oxygen. Cold temperatures cause bronchospasms. 3. The client has increased respiratory effort during activities and can be fatigued. Activities should be timed, so rest periods are scheduled to prevent fatigue. 4. The client may have difficulty adapting to the role changes brought about because of the disease process. Many cannot maintain the activities involved in meeting responsibilities at home and at work. Clients should be assessed for these issues. 5. Clients often lose weight because of the effort expended to breathe.

82. The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? Select all that apply. 1. Increase fluid intake to 2 to 3 L/day. 2. Eat a low-sodium, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines. 5. Stop smoking.

1. Increase fluid intake to 2 to 3 L/day. 2. Eat a low-sodium, low-fat diet. 5. Stop smoking. 1. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of DVT, the most common cause of PE. 2. Pulmonary emboli are not caused by atherosclerosis, but a diet low in fat and sodium is an appropriate discharge instruction for a client diagnosed with a PE because a heart-healthy diet can reduce damage to the vasculature. A clot forms in response to damage to blood vessels. 3. Infection does not cause a PE; this is not an appropriate teaching instruction. 4. Pneumonia and flu do not cause a pulmonary embolism. 5. Smoking causes damage to the vascular system and vasoconstriction, which increases the risk of clot formation.

80. Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.

1. Keep protamine sulfate readily available. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered. 1. Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant. 2. Firm pressure reduces the risk of bleeding into the tissues. 3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. 4. Invasive procedures increase the risk of tissue trauma and bleeding. 5. Stool softeners help prevent constipation and straining, which may precipitate bleeding from hemorrhoids.

20. The RN and a UAP are caring for a client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? Select all that apply. 1. Keep the head of the bed elevated. 2. Encourage deep breathing exercises. 3. Record pulse oximeter reading. 4. Assess the level of consciousness. 5. Auscultate breath sounds.

1. Keep the head of the bed elevated. 2. Encourage deep breathing exercises. 3. Record pulse oximeter reading. 1. Keeping the head of the bed elevated maximizes lung excursion and improves gas exchange and can be delegated. 2. Encouraging breathing exercises can be delegated. 3. Recording pulse oximeter readings can be delegated. Evaluating is the responsibility of the nurse. 4. Assessment cannot be delegated. Confusion is one of the first symptoms of hypoxia. 5. Auscultation is a technique of assessment and cannot be delegated.

99. The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering a high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear, and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.

1. Low arterial oxygen when administering a high concentration of oxygen. 1. The classic sign of ARDS is decreased arterial oxygen level (Pao2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane. 2. These are early signs of ARDS, but they could also indicate pneumonia, atelectasis, and other pulmonary complications, so they do not confirm the diagnosis of ARDS. 3. Clear breath sounds and the oxygen saturation indicate the client is not experiencing any respiratory difficulty or compromise. 4. These are signs of congestive heart failure; ARDS is noncardiogenic (without signs of cardiac involvement) pulmonary edema.

19. The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. 1. Place the client on oxygen delivered by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1,000 mL/day. 4. Restrict the client's smoking to two to three cigarettes per day. 5. Monitor the client's pulse oximetry readings every 4 hours.

1. Place the client on oxygen delivered by nasal cannula. 2. Plan for periods of rest during activities of daily living. 5. Monitor the client's pulse oximetry readings every 4 hours. 1. The client diagnosed with pneumonia will have some degree of gas-exchange deficit. Administering oxygen would help the client. 2. Activities of daily living require energy and therefore oxygen consumption. Spacing the activities allows the client to rebuild oxygen reserves between activities. 3. Clients are encouraged to drink at least 2,000 mL daily to thin secretions. 4. Cigarette smoking depresses the action of the cilia in the lungs. Any smoking should be prohibited. 5. Pulse oximetry readings provide the nurse with an estimate of oxygenation in the periphery.

74. The client is suspected of having a PE. Which diagnostic test suggests the presence of a pulmonary embolus and requires further investigation? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray (CXR). 4. Magnetic resonance imaging (MRI).

1. Plasma D-dimer test. 1. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis. This result would require a computed tomography (CT) or ventilation and perfusion VQ scan to confirm the diagnosis. 2. An ABG evaluates the oxygenation level, but it does not diagnose a PE. 3. A CXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE. 4. An MRI is a noninvasive test that detects a deep vein thrombosis (DVT), but it does not diagnose a PE. A CT scan or VQ scan would be used to confirm the diagnosis.

32. Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD? 1. The client demonstrates the correct way to perform pursed-lip breathing. 2. The client lists three clinical manifestations to report to the HCP. 3. The client will drink at least 2,500 mL of water daily. 4. The client will be able to ambulate 100 feet with dyspnea.

1. The client demonstrates the correct way to perform pursed-lip breathing.

52. The nurse is checking the vital signs flowsheet in the EHR at 0800 on a client diagnosed with pneumonia secondary to COPD who has received prednisone therapy for several years. Which flowsheet should the nurse expect to see?

1. This client has an immune system that is responding to an infection, not one suppressed by steroids. 2. This client's graphic indicates that the client was admitted without an infection and now has developed one, and the immune system is responding. 3. This client's pattern of temperatures does not indicate an infection exists. 4. The client diagnosed with COPD on long-term prednisone therapy, a glucocorticoid steroid, has a suppressed immune system. Temperatures are in the normal range because steroids mask the symptoms of infection by suppressing the immune system. The only common symptoms would be rusty-colored sputum or a change in sputum color and confusion.

39. The HCP has ordered a continuous intravenous infusion of aminophylline. The client weighs 165 pounds. The infusion order is 0.3 mg/kg/hr. The bag is mixed with 500 mg of aminophylline in 250 mL of D5W. At which rate should the nurse set the pump?

11.25 mL/hr > 11 mL/hr

12. Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy? 1. "I must avoid hair spray and powders." 2. "I should take a shower instead of a tub bath." 3. "I will need to cleanse around the stoma daily." 4. "I can use an electric larynx to speak."

2. "I should take a shower instead of a tub bath." 1. The client should not let any spray or powder enter the stoma because it goes directly into the lung. 2. The client should not allow water to enter the stoma; therefore, the client should take a tub bath, not a shower. 3. The stoma site should be cleaned to help prevent infection. 4. The client's vocal cords were removed; therefore, the client must use an alternate form of communication.

42. Which intervention should the nurse implement for the client experiencing bronchospasms? 1. Administer intravenous epinephrine. 2. Administer albuterol via nebulizer. 3. Request a STAT portable CXR at the bedside. 4. Insert a small nasal trumpet in the right nostril.

2. Administer albuterol via nebulizer. 1. Epinephrine, a bronchodilator, is administered intravenously during an arrest in a code situation, but it is not a treatment of choice for bronchospasms. 2. Albuterol, a bronchodilator, given via nebulizer, is administered to stop the bronchospasms. If the client continues to have the bronchospasms, intubation may be needed. 3. A STAT portable x-ray will be ordered, but the goal is to prevent respiratory arrest. 4. Nasal trumpet airways would not be helpful in stopping the bronchospasm and respiratory arrest.

79. The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

2. Assess skin color and temperature. 1. Arterial blood gases would be included in the client problem "impaired gas exchange." 2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output. 3. This would be appropriate for the client problem "high risk for bleeding." 4. The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing.

93. The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess the chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

2. Assess the chest tube drainage system frequently 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema. 1. The client should be in the high Fowler's position to facilitate lung expansion. 2. The system must be patent and intact to function properly. 3. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion. 4. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and a potential clogging of the tube. 5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.

113. The client is diagnosed with COPD and pneumonia. Which medication should the day nurse question administering? 1. Methylprednisolone. 2. Ceftriaxone. 3. Benzonatate. 4. Morphine.

2. Ceftriaxone. 1. The client should be on a form of glucocorticosteroid medication. The nurse would not question administering this medication. 2. A client diagnosed with COPD and pneumonia would be placed on an antibiotic, but the client lists an allergy to cephalosporin antibiotics; ceftriaxone is a third-generation cephalosporin. The nurse should investigate further before administering the medication. 3. Benzonatate (Tessalon Perles) is an antitussive cough suppressant; the nurse would not question this medication. 4. Continuous release morphine is prescribed for the mild bronchodilating effect of morphine over a sustained period of time. The nurse would not question administering this medication.

38. The nurse is caring for a client diagnosed with a pneumothorax and chest tubes inserted 4 hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.

2. Check the tubing for kinks. 1. No fluctuation in the water-seal chamber 4 hours postinsertion indicates the tubing is blocked; the nurse should not milk the chest tube. 2. The nurse should implement the least invasive intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle. 3. Coughing may help push a clot in the tubing into the drainage bottle, but the first intervention is to check and see if the client is lying on the tubing or the tube is kinked somewhere. 4. The insertion site can be assessed, but it will not help determine why there is no fluctuation in the water-seal drainage compartment.

15. The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube used for bolus feedings. Which intervention should the nurse include in the plan of care? 1. Inspect the insertion line at the naris before instilling formula. 2. Elevate the head of the bed (HOB) while feeding the client. 3. Place the client in the Sims position following each feeding. 4. Change the dressing on the feeding tube every 3 days.

2. Elevate the head of the bed (HOB) while feeding the client. 1. A gastrostomy tube is placed directly into the stomach through the abdominal wall; the naris is the opening of the nostril. 2. Elevating the head of the bed uses gravity to keep the formula in the gastric cavity and help prevent it from refluxing into the esophagus, which predisposes the client to aspiration. 3. The Sims position is the left lateral side-lying flat position. This position is used for administering enemas and can be used to prevent aspiration in clients sedated by anesthesia. The sedated client would not have a full stomach. 4. Dressings on PEG tubes should be changed at least daily. If there is no dressing, the insertion site is still assessed daily

92. Which assessment data indicate to the nurse the chest tubes inserted 3 days ago have been effective in treating the client diagnosed with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood. 4. The client is able to deep breathe without any pain.

2. No fluctuation (tidaling) in the water-seal compartment. 1. This is an expected finding in the suction compartment of the drainage system, indicating adequate suctioning is being applied. 2. At 3 days postinsertion, no fluctuation (tidaling) indicates the lung has re-expanded, which indicates the treatment has been effective. 3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have re-expanded the lung. 4. Taking a deep breath without pain is good, but it does not mean the lungs have re-expanded.

95. The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the HCP is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client to a side-lying position. 4. Discuss the procedure with the client.

2. Obtain a signed informed consent form. 1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client's bedside, but it is not the first intervention. 2. The insertion of a chest tube is an invasive procedure and requires informed consent. Without a consent form, this procedure should not be done on an alert and oriented client. 3. This is a correct position to place the client in for a chest tube insertion, but it is not the first intervention. 4. The HCP will discuss the procedure with the client, then informed consent must be obtained, and the nurse can do further teaching.

27. The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amounts of thick white sputum. 2. Oxygen flowmeter set on 8 liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.

2. Oxygen flowmeter set on 8 liters. 1. A large amount of thick sputum is a common symptom of COPD. There is no cause for immediate intervention. 2. The nurse should decrease the oxygen rate to 2 to 3 L. Hypoxemia is the stimulus for breathing in the client diagnosed with COPD. If the hypoxemia improves and the oxygen level increases, the drive to breathe may be eliminated. 3. It is common for clients diagnosed with COPD to use accessory muscles when inhaling. These clients tend to lean forward. 4. In clients diagnosed with COPD, there is a characteristic barrel chest from chronic hyperinflation, and dyspnea is common.

109. The client is admitted to the emergency department reporting shortness of breath and fever. The vital signs are populated in the chart below. Which concept should the nurse identify as a concern for the client? Select all that apply. 1. Clotting. 2. Oxygenation. 3. Infection. 4. Perfusion. 5. Coping.

2. Oxygenation. 3. Infection. 1. These symptoms indicate a respiratory and an infection problem, not clotting. 2. Shortness of breath and a low-grade fever indicate pneumonia; the oxygenation concept applies to this client. 3. Shortness of breath and a low-grade fever indicate pneumonia; the infection concept applies to this client. 4. Perfusion does not apply for this client based on the presenting symptoms. 5. Coping does not apply for this client based on the presenting symptoms.

84. The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first? 1. Administer oxygen 10 L via nasal cannula. 2. Place the client in high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.

2. Place the client in high Fowler's position. 1. The client needs oxygen, but the nurse can intervene to help the client before applying oxygen. 2. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system. 3. A pulse oximeter reading is needed, but it is not the first intervention. 4. Assessing the client is indicated, but it is not the first intervention in this situation.

33. The nurse observes the UAP removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the RN implement? 1. Praise the UAP because this prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the UAP in front of the client oxygen must be left in place at all times. 4. Discuss the UAP's action with the charge nurse so appropriate action can be taken.

2. Place the oxygen back on the client while sitting in the bathroom and say nothing.

118. The charge nurse receives morning laboratory and respiratory data on the clients. Which data requires immediate intervention? 1. ABG results of pH 7.35, Pco2 56, Hco3 29, Po2 78 for a client diagnosed with COPD. 2. Pulse oximetry reading of 89% on a 2-day postsurgical total knee replacement client. 3. Hgb of 9 g/dL and Hct of 28% on a client receiving the second unit of blood. 4. B-type natriuretic peptide (BNP) of 100 on a client diagnosed with stage 4 congestive heart failure.

2. Pulse oximetry reading of 89% on a 2-day postsurgical total knee replacement client. 1. The body has compensated for the abnormally high level of carbon dioxide (acid) in the blood by holding on to the base (Hco3), and the pH is within the normal range. This is an expected blood gas for the client diagnosed with COPD. 2. This pulse oximetry reading indicates arterial blood oxygen of less than 60. The client should be seen immediately to prevent respiratory failure. 3. This client is receiving blood to correct the lower levels of H&H. 4. A BNP of less than 100 is considered within normal limits. A BNP of 100 would not be a concern to report for a client diagnosed with stage 4 heart failure.

75. Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

2. Sudden onset of chest pain and dyspnea. 1. This is a sign of a DVT, which is a precursor to a PE, but it is not a sign of a pulmonary embolism. 2. The most common signs of a PE are sudden onset of chest pain when taking a deep breath and shortness of breath. 3. These are signs of myocardial infarction. 4. These could be signs of pneumonia or other pulmonary complications but not specifically a PE.

88. The UAP assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the RN? 1. The UAP keeps the chest tube below the chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of bed. 4. The UAP uses a bedside commode for the client.

2. The UAP has the chest tube attached to suction.

6. The nurse suspects the client admitted with a near-drowning is developing ARDS. Which data support the nurse's suspicion? 1. The client's arterial blood gases are within normal limits. 2. The client appears anxious, has dyspnea, and is tachypneic. 3. The client has intercostal retractions and is using accessory muscles. 4. The client's bilateral lung sounds have crackles and rhonchi.

2. The client appears anxious, has dyspnea, and is tachypneic. 1. The client would have low arterial oxygen when developing ARDS. 2. Initial clinical manifestations of ARDS usually develop 24 to 48 hours after the initial insult leading to hypoxia and include anxiety, dyspnea, and tachypnea. 3. As ARDS progresses, the client has more difficulty breathing, resulting in intercostal retractions and the use of accessory muscles. 4. Lungs are initially clear; crackles and rhonchi develop in later stages of ARDS.

37. The nurse is preparing to administer warfarin to a client diagnosed with a PE. Which laboratory data would cause the nurse to question administering the medication? 1. The client's activated partial thromboplastin time (aPTT). 2. The client's international normalized ratio (INR). 3. The client's prothrombin time (PT). 4. The client's erythrocyte sedimentation rate (ESR).

2. The client's international normalized ratio (INR). 1. The aPTT is not monitored to determine a therapeutic serum level for warfarin (Coumadin), an oral anticoagulant; normal aPTT is 25 to 35. 2. The INR therapeutic range is 2 to 3 for a client receiving warfarin (Coumadin), an oral anticoagulant. The INR may be allowed to go to 3.5 if the client has a mechanical cardiac valve, but nothing in the stem of the question indicates this. 3. The PT is monitored for oral anticoagulant therapy and should be 1.5 to 2 times the normal of 12; therefore, 22 is within therapeutic range and would not warrant the nurse questioning administering this medication. 4. The ESR is not monitored for oral anticoagulant therapy.

20. The nurse is feeding a client diagnosed with aspiration pneumonia. The client becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first? 1. Suction the client's nares. 2. Turn the client to the side. 3. Place the client in the Trendelenburg position. 4. Notify the health-care provider.

2. Turn the client to the side. 1. The nares are the openings of the nostrils. Suctioning, if done, would be of the posterior pharynx. 2. Turning the client to the side allows for the food to be coughed up and come out of the mouth, rather than be aspirated into the lungs. 3. Placing the client in the Trendelenburg position increases the risk of aspiration. 4. An immediate action is needed to protect the client.

85. The client is admitted to the emergency department with chest trauma. Which clinical manifestations indicate to the nurse the diagnosis of a pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum, and consolidation. 4. Barrel chest and polycythemia.

2. Unequal lung expansion and dyspnea.

105. The client diagnosed with ARDS is in respiratory distress, and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Request STAT arterial blood gases. 4. Auscultate the client's lung sounds.

2. Ventilate with a manual resuscitation bag.

40. The client diagnosed with a cold is taking an antihistamine. Which statement indicates to the nurse the client needs more teaching concerning the medication? 1. "If my mouth gets dry I will suck on hard candy." 2. "I will not drink beer or any type of alcohol." 3. "I need to be careful when I drive my car." 4. "This medication will make me sleepy.

3. "I need to be careful when I drive my car." 1. Antihistamines dry respiratory secretions through an anticholinergic effect; therefore, the client will have a dry mouth. 2. Antihistamines cause drowsiness; therefore, the client should not drink any type of alcohol. 3. Antihistamines cause drowsiness, so the client should not drive or operate any type of machinery. 4. Antihistamines cause drowsiness; therefore, the client understands the teaching.

7. Which client's ABG results support the diagnosis of ARDS after the client has received O2 at 10 LPM?

3. 1. This ABG is within normal limits and would not be expected in a client diagnosed with ARDS. 2. These ABG levels indicate respiratory alkalosis, but the oxygen level is within normal limits and would not be expected in a client diagnosed with ARDS. 3. ABGs initially show hypoxemia with a Pao2 of less than 60 mmHg and respiratory alkalosis resulting from tachypnea in a client diagnosed with ARDS. 4. This ABG is metabolic acidosis and would not be expected in a client diagnosed with ARDS.

100. The two-pack-a-day cigarette smoker develops ARDS after a near-drowning. The client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is most appropriate? 1. "Most people develop ARDS after a near-drowning." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your lungs are filling up with fluid, causing breathing problems." 4. "Smoking has caused your lungs to become weakened, so you got ARDS."

3. "Your lungs are filling up with fluid, causing breathing problems."

24. The nurse is caring for a client diagnosed with pneumonia, having shortness of breath, and difficulty breathing. Which intervention should the nurse implement first? 1. Take the client's vital signs. 2. Check the client's pulse oximeter reading. 3. Administer oxygen via a nasal cannula. 4. Notify the respiratory therapist STAT.

3. Administer oxygen via a nasal cannula 1. Taking the client's vital signs will not help the client's shortness of breath and difficulty in breathing. 2. Checking the pulse oximeter reading will not help the client's shortness of breath and difficulty breathing. 3. After elevating the head of the bed, the nurse should administer oxygen to the client in respiratory difficulty. 4. Notifying the respiratory therapist will not help the client's shortness of breath and difficulty breathing.

78. The nurse is preparing to administer warfarin to a client with the laboratory results populated in the chart below. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K. 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose

3. Administer the medication as ordered 1. The client would not be experiencing abnormal bleeding with this INR. 2. Vitamin K (AquaMephyton) is the antidote for an overdose of anticoagulant, and the INR does not indicate this. 3. A therapeutic INR is 2 to 3; therefore, the nurse should administer the oral anticoagulant warfarin (Coumadin). 4. There is no need to increase the dose; this result is within the therapeutic range.

98. The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.

3. Assess the respiratory status and pulse oximeter reading. 1. Maintaining ventilator settings and checking to ensure they are specifically set as prescribed is appropriate, but it is not the first intervention. 2. Making sure alarms are functioning properly is appropriate, but checking a machine is not the priority. 3. Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator. 4. Monitoring laboratory results is an appropriate intervention for the client on a ventilator, but monitoring laboratory data is not the priority intervention.

86. The client had a right-sided chest tube inserted 2 hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT CXR. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.

3. Check the tubing for kinks or clots. 1. A STAT CXR would not be needed to determine why there is no fluctuation in the water-seal compartment. 2. Increasing the amount of wall suction does not address why there is no fluctuation in the water-seal compartment. 3. The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually, the client is lying on the tube, it is kinked, or there is a dependent loop. 4. The stem does not state the client is in respiratory distress, and a pulse oximeter reading detects hypoxemia but does not address any fluctuation in the water-seal compartment.

34. Which clinical manifestations should the nurse expect to assess in the client recently diagnosed with COPD? Select all that apply. 1. Clubbing of the client's fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough. 5. Shortness of breath.

3. Chronic sputum production. 5. Shortness of breath. 1. Clubbing of the fingers is the result of chronic hypoxemia, which is expected with chronic COPD but not recently diagnosed COPD. 2. These clients have frequent respiratory infections. 3. Sputum production, along with cough and dyspnea on exertion, are the early clinical manifestations of COPD. 4. These clients have a productive cough, not a nonproductive cough. 5. Shortness of breath is the classic symptom of COPD due to the increased work to breathe.

49. Which intervention should the nurse implement first when administering the first dose of intravenous antibiotic to the client diagnosed with a respiratory infection? 1. Monitor the client's current temperature. 2. Monitor the client's white blood cells. 3. Determine if a culture has been collected. 4. Determine the compatibility of fluids.

3. Determine if a culture has been collected. 1. The client's current temperature would not affect the administration of the antibiotic. 2. The client's WBCs may be elevated because of the infection, but this would not affect administering the medication. 3. A culture needs to be collected before the first dose of antibiotics, or the culture and sensitivity will be skewed and the appropriate antibiotic needed to treat the respiratory infection may not be identified. 4. Compatibility of fluids should be assessed before administering each intravenous antibiotic, but when administering the first dose of an antibiotic, the nurse must check to make sure the sputum culture was obtained.

83. The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? 1. Warfarin to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hang the heparin bag on a client with a PT/aPTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

3. Hang the heparin bag on a client with a PT/aPTT of 12.9/98. 1. An INR of 2 to 3 is therapeutic; therefore, the nurse would administer the oral coagulant warfarin (Coumadin). 2. This is an elevated blood glucose level; therefore, the nurse should administer the insulin. 3. A normal aPTT is 25 to 35 seconds, and for heparin to be therapeutic, it should be 1.5 to 2 times the normal value or 37.5 to 70. A PTT of 98 indicates the client is not clotting, and the medication should be held. 4. This is normal blood pressure, and the nurse should administer the medication.

44. The client diagnosed with pneumonia has the following ABGs. Which intervention should the nurse implement? 1. Administer sodium bicarbonate. 2. Administer oxygen via nasal cannula. 3. Have the client cough and deep breathe. 4. Instruct the client to breathe into a paper bag.

3. Have the client cough and deep breathe. 1. Sodium bicarbonate is administered for metabolic acidosis. 2. The arterial oxygen level is within normal limits (80 to 100); therefore, the client does not need oxygen. 3. The client is retaining CO2, which causes respiratory acidosis, and the nurse should help the client remove the CO2 by instructing the client to cough and deep breathe. 4. Breathing into a paper bag is not recommended for clients diagnosed with respiratory acidosis.

16. The client diagnosed with community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? 1. Administer the ordered oral antibiotic immediately (STAT). 2. Order the meal tray to be delivered as soon as possible. 3. Obtain a sputum specimen for culture and sensitivity. 4. Have the unlicensed assistive personnel weigh the client.

3. Obtain a sputum specimen for culture and sensitivity. 1. Broad-spectrum IV antibiotics are a priority, but before antibiotics are administered, it is important to obtain culture specimens to determine the correct antibiotic for the client's infection. Clients are placed on oral medications only after several days of IVPB therapy. 2. Meal trays are not a priority over cultures. 3. Specimens for culture are taken before beginning the medication to determine the antibiotic that will effectively treat an infection. Administering antibiotics before cultures may make it impossible to determine the actual agent causing the pneumonia. 4. Admission weights are important to determine the appropriate dosing of medication, but they are not a priority over sputum collection.

111. The client diagnosed with community-acquired pneumonia is admitted to the medical unit. Which HCP order should the nurse implement first? 1. Start IV with 1,000 mL 0.9% saline. 2. Ceftriaxone 1 gm IVPB every 12 hours. 3. Obtain sputum and blood cultures. 4. CBC and basic metabolic panel.

3. Obtain sputum and blood cultures. 1. This is the second order to implement; an IVPB cannot be administered without IV access. 2. This is the third order to implement; the goal is to initiate the IV antibiotic 1 to 2 hours from when the order was written by the HCP. 3. Culture specimens should be obtained before the initiation of antibiotic medication to prevent skewing of results. 4. This is the fourth order for the nurse to initiate.

36. The client diagnosed with DVT suddenly reports severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced? 1. Myocardial infarction. 2. Pneumonia. 3. Pulmonary embolus. 4. Pneumothorax.

3. Pulmonary embolus. 1. The nurse would not suspect a myocardial infarction for a client diagnosed with a DVT and sudden chest pain. 2. These clinical manifestations should not make the nurse think the client has pneumonia. 3. Part of the clot in the deep veins of the legs dislodges and travels up the inferior vena cava, lodges in the pulmonary arterial system, and causes the chest pain; the client often has feelings of impending doom or death. 4. Chest pain is a sign of pneumothorax, but it is not a complication of DVT.

115. Which intervention should the nurse institute for the client diagnosed with COPD and cor pulmonale based on the intake and output record? 1. Administer methylprednisolone IVP. 2. Administer guaifenesin orally. 3. Request an order to reduce the IV rate. 4. Continue to monitor the client.

3. Request an order to reduce the IV rate 1. This EHR graphic indicates the client is not processing the amount of fluid being taken in. A steroid medication will not affect this situation. 2. Guaifenesin is an antitussive medication. This medication will not affect fluid balance. 3. The client is not processing the amount of fluid received via the oral or parenteral route. The nurse should request the HCP to change the fluid to a saline lock. Cor pulmonale is heart failure resulting from increased pressure in the lungs from COPD. 4. The nurse should take action to prevent further fluid overload.

21. The day shift charge nurse on a medical unit is making rounds after the report. Which client should be seen first? 1. The 65-year-old client diagnosed with tuberculosis has a sputum specimen to be sent to the laboratory. 2. The 76-year-old client diagnosed with aspiration pneumonia has a clogged feeding tube. 3. The 45-year-old client diagnosed with pneumonia has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis has an arterial oxygenation level of 89%.

3. The 45-year-old client diagnosed with pneumonia has a pulse oximetry reading of 92%. 1. The specimen needs to be taken to the laboratory within a reasonable time frame, but a UAP can take specimens to the laboratory. 2. Clogged feeding tubes occur with some regularity. Delay in feeding a client will not result in permanent damage. 3. A pulse oximetry reading of 92% means that the arterial blood oxygen saturation is somewhere around 60% to 70%. 4. Arterial oxygenation normal values are 80% to 100%.

36. Which referral is most appropriate for a client diagnosed with end-stage COPD? 1. The Asthma Foundation of America. 2. The American Cancer Society. 3. The American Lung Association. 4. The American Heart Association.

3. The American Lung Association.

28. The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care? 1. The client has no signs of respiratory distress. 2. The client shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.

3. The client demonstrates intolerance to activity.

119. The nurse is caring for clients in the medical unit. Which assessment data indicate a critical oxygenation problem for the client? 1. The client with an anterior upper left chest tube is splinting the dressing with a pillow. 2. The male client on oxygen is coughing forcefully, making it hard to catch his breath. 3. The client diagnosed with circumoral cyanosis at rest and is difficult to arouse. 4. The female client reports shortness of breath while ambulating in the hallway.

3. The client diagnosed with circumoral cyanosis at rest and is difficult to arouse.

101. Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100 mL in 4 hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

3. The client has asymmetrical chest expansion. 1. A urine output of 30 mL/hr or 120 mL in 4 hours indicates the kidneys are functioning properly. 2. This indicates the client is being adequately oxygenated. 3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation. 4. An increased heart rate does not indicate a complication; this could result from numerous reasons, not specifically because of the ventilator.

76. The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, Po2 95, Pco2 38, Hco3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions (PVCs). 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

3. The client's pulse oximeter reading is 90%. 1. The ABGs are within normal limits and would not warrant immediate intervention. 2. Occasional PVCs are not unusual for any client and would not warrant immediate intervention. 3. The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an arterial oxygen level of around 60. 4. Urinary output of 800 mL over 12 hours indicates an output of greater than 30 mL/hour and would not warrant immediate intervention by the nurse.

90. The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during central line placement.

3. The injury allows air into the pleural space but prevents it from escaping from the pleural space.

30. Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required? 1. "I should contact my health-care provider if my sputum changes color or amount." 2. "I will take my bronchodilator regularly to prevent having bronchospasms." 3. "This metered-dose inhaler gives a precise amount of medication with each dose." 4. "I need to return to the HCP to have my blood drawn with my annual physical."

4. "I need to return to the HCP to have my blood drawn with my annual physical." 1. When sputum changes in color or amount, or both, this indicates infection, and the client should report this information to the HCPs. This statement indicates the client understands the teaching. 2. Bronchodilators should be taken routinely to prevent bronchospasms. This statement indicates the client understands the teaching. 3. Clients use metered-dose inhalers because they deliver a precise amount of medication with correct use. This statement indicates the client understands the teaching. 4. Clients should have blood levels drawn every 6 months when taking bronchodilators, not yearly. This indicates the client needs more teaching.

81. Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective? 1. "I am going to use a hard-bristle toothbrush." 2. "I will take antibiotics before having my teeth cleaned." 3. "I can take enteric-coated acetylsalicylic acid for my headache." 4. "I will wear a medical alert bracelet at all times."

4. "I will wear a medical alert bracelet at all times." 1. The client should use a soft-bristle toothbrush to reduce the risk of bleeding, so teaching is not effective. 2. This is appropriate for a client with a mechanical valve replacement, not a client receiving anticoagulant therapy, so the teaching is not effective. 3. Acetylsalicylic acid [ASA] (aspirin), enteric-coated or not, is an antiplatelet, which may increase bleeding tendencies and should be avoided, so the teaching is not effective. 4. The client should wear a medical alert bracelet (Medic Alert band) at all times so that, if any accident or situation occurs, the HCPs will know the client is receiving anticoagulant therapy. The client understands the teaching.

14. The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which is an expected outcome for this problem? 1. Performs chest physiotherapy three times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall several times during each shift. 4. Alert and oriented to person, place, time, and events.

4. Alert and oriented to person, place, time, and events. 1. Clients do not perform chest physiotherapy; this is normally done by the respiratory therapist. This is a staff goal, not a client goal. 2. This would be a goal for self-care deficit but not for impaired gas exchange. 3. This would be a goal for the problem of activity intolerance. 4. Impaired gas exchange results in hypoxia, the earliest clinical manifestation of which is a change in the level of consciousness.

47. Which intervention should the nurse implement first when caring for a client diagnosed with a respiratory disorder? 1. Administer a respiratory treatment. 2. Check the client's radial pulses daily. 3. Monitor the client's vital signs daily. 4. Assess the client's capillary refill time.

4. Assess the client's capillary refill time. 1. Nurses are responsible for accounting for medications, but it is not the rationale for DOT. 2. Nurses complete forms as required by all governmental agencies, but this is not the rationale for DOT. 3. Documentation of events concerning the client's treatment is completed, but this is not the rationale for DOT. 4. To ensure compliance with all medications regimens, the health department has adapted a DOT where the nurse actually observes the client taking the medication every day.

103. The client diagnosed with ARDS is on a mechanical ventilator. Which interventions should be included in the nursing care plan addressing the endotracheal tube (ET) care? Select all that apply. 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure. 5. Assess lung sounds every 2 hours.

4. Ensure that the ET tube is secure. 5. Assess lung sounds every 2 hours. 1. Alternating the ET tube position will help prevent a pressure ulcer on the client's tongue and mouth. 2. A CXR is performed immediately after the insertion of the ET tube but not daily. 3. The cuff should be inflated but no more than 25 cm H2O to ensure no air leakage and must be checked every 4 to 8 hours, not daily. 4. The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be 1 inch above the bifurcation of the bronchi. 5. The lung sounds should be assessed every 2 hours to determine if suctioning is needed and to confirm ET tube placement

77. The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? Select all that apply. 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bedrest. 5. Provide oxygen therapy.

4. Institute and maintain bedrest. 5. Provide oxygen therapy. 1. The intravenous anticoagulant heparin will be administered immediately after the diagnosis of a PE, not oral anticoagulants. 2. The client's respiratory system will be assessed, not the gastrointestinal system. 3. Thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE. 4. Bedrest reduces the risk of another clot becoming an embolus leading to a PE. Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs. 5. The nurse should administer oxygen therapy to the client as ordered by the HCP.

110. The nurse observes the client sitting on the side of the bed with the arms propped on the over-bed table. The chest is barrel-shaped and the client is breathing through lips spaced close together and is exhaling slowly. Which concept is the priority for this client? 1. Mobility. 2. Nutrition. 3. Activity intolerance. 4. Oxygenation.

4. Oxygenation.

89. The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the HCP to have chest tubes reinserted STAT. 2. Instruct the client to take slow, shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly or dry sterile dressing to the insertion site.

4. Tape a petroleum jelly or dry sterile dressing to the insertion site. 1. The HCP will have to be notified, but this is not the first intervention. Air must be prevented from entering the pleural space from the outside atmosphere. 2. The client should breathe regularly or take deep breaths until the tubes are reinserted. 3. The nurse must take action and prevent air from entering the pleural space. 4. The nurse should immediately apply pressure to the insertion site, have the client perform the Valsalva maneuver, and cover the site with petroleum gauze or dry sterile dressing (per hospital policy).

94. The charge nurse is making client assignments on a medical floor. Which client should the RN charge nurse assign to the LPN? 1. The client diagnosed with pneumonia, pulse oximeter reading of 91%. 2. The client diagnosed with a hemothorax, Hb of 9 g/dL, and Hct of 20%. 3. The client with chest tubes, jugular vein distention, and BP of 96/60. 4. The client 2 hours postbronchoscopy procedure.

4. The client 2 hours postbronchoscopy procedure

29. The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? 1. The client's pulse oximeter reading is 92%. 2. The client's arterial blood gas level is 74. 3. The client has SOB when walking to the bathroom. 4. The client's sputum is rusty colored.

4. The client's sputum is rusty colored. 1. The client diagnosed with end-stage COPD has decreased peripheral oxygen levels; therefore, this would not warrant immediate intervention. 2. The client's ABGs would normally indicate a low oxygen level; therefore, this would not warrant immediate intervention. 3. The client diagnosed with dyspnea on exertion should stop the exertion but does not require intervention by the nurse if the dyspnea resolves. 4. Rusty-colored sputum indicates blood in the sputum and requires further assessment by the nurse.

25. The nurse is assessing the client diagnosed with COPD. Which health-promotion information is most important for the nurse to obtain? 1. The number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medication. 4. Willingness to modify lifestyle.

4. Willingness to modify lifestyle. 1. The number of years of smoking is information needed to treat the client but not the most important in health promotion. 2. The risk factors for complications are important in planning care. 3. Assessing the ability to deliver medications is an important consideration when teaching the client. 4. The client's attitude toward lifestyle changes is the most important consideration in health promotion, in this case, smoking cessation. The nurse should assess if the client is willing to consider cessation of smoking and carry out the plan.

51. The client in the intensive care unit (ICU) on a mechanical ventilator is bucking the ventilator, causing the alarms to sound, and is in respiratory distress. Which assessment data should the nurse obtain? Rank in order of priority. 2. Assess the client's pulse oximetry reading. 3. Assess the client's lung sounds. 4. Assess for symmetry of the client's chest expansion. 5. Assess the client's endotracheal tube for secretions.

5. Assess the client's endotracheal tube for secretions. 2. Assess the client's pulse oximetry reading. 3. Assess the client's lung sounds. 4. Assess for symmetry of the client's chest expansion. 1. Assess the ventilator alarms.

73. The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?

880 units per hour