MS: Respiratory

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% O2 by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS) A. Tympanic temperature 38° C (100.4° F) B. PaO2 50 mm Hg C. Rhonchi D Hypopnea

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

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

B The nurse should apply the nursing process priority-setting framework

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

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

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

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

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

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

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

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

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

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

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

B. The purpose of chest physiotherapy is to loosen the client's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity.

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

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

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

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

A nurse in a provider's office is assessing a client who states he was recently exposed to TB. Which of the following findings is a clinical manifestation of pulmonary TB? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips

C. Night sweats and fevers are clinical manifestations of tuberculosis.

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

C. The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hr indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hr, another tuberculin skin test is necessary.

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

C. The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first.

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

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

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

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

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

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

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

D. The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.

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

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

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

Tinnitus

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

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