NCLEX-RN O2
The client is a 12-year-old girl with a history of asthma who was brought to the emergency department (ED) by the parents for increasingly severe wheezing and fatigue despite the use of an albuterol inhaler at home. For each potential nursing intervention, click to specify whether the intervention is indicated, nonessential, or contraindicated in the first hour of care for this client.
Nonessential: education on triggers for status asthmaticus Indicated: nebulized short-acting beta2-agonist, intravenous corticosteroids, high-flow oxygen, reassurance Contraindicated: oral long-acting beta2-agonist, fluid restriction
A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. The nurse is assessing the client's respiratory status. Which sign indicates a possible complication that the nurse should report to the health care provider immediately?
Correct response: absent breath sounds on the affected side
The nurse is assisting with spirometry testing for a 6-year-old child with asthma. What instruction is most important for the nurse to give the child to obtain an accurate reading?
"Breathe out as hard as possible, and then breathe in deeply."
A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions?
"I should try to eat several small meals during the day."
A nurse working in a pediatric cardiac unit is teaching the parents of a child with a cardiac disorder about cardiac arrest among children. Which statement by the parents informs the nurse that the teaching has been successful?
"We will be alert to respiratory problems to decrease the risk of cardiac arrest."
The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?
28 breaths/min and audible
The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate?
A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device.
A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first?
Administer oxygen.
The nurse assesses that a client is restless and becoming agitated in the immediate postoperative period. The client's oxygen saturation is 91%. What should the nurse do next?
Administer oxygen.
The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first?
Administer oxygen.
A client with malignant pleural effusions has dyspnea and chest pain. In which order of priority from first to last should the nurse manage the client's care? All options must be used.
Apply oxygen at 2 L via nasal cannula. Administer morphine sulfate 2 mg IV. Coach the client on deep breathing exercise. Educate the client in anticipation of a thoracentesis.
A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. What is the likely cause of these assessment findings?
Bronchial edema and constriction have worsened.
A nurse is caring for a client with a chest tube connected to a three-chamber drainage system without suction. On the illustration below, identify which chamber the nurse will mark to record the current drainage level.
CLICK ON THE WHITE AREA [RIGHT SIDE] A chest tube drains blood, fluid, and air from around the lungs. The drainage system, which the nurse measures each shift, is on the right. It has three calibrated chambers that show the amount of drainage collected. When the first chamber fills, drainage empties into the second; when the second chamber fills, drainage flows into the third. The water seal chamber is located in the center. The suction control chamber is on the left.
A client has a chest tube attached to suction. Which interventions would the nurse perform? Select all that apply
Change the dressing as ordered using aseptic technique. Palpate the surrounding area of the chest tube for crepitus. Mark the amount of drainage in the chamber at the end of the shift.
A nurse is teaching the parent of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective?
Correct response: "I know that this disease is serious and can lead to asthma."
Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first?
Correct response: Activate the Rapid Response Team (RRT).
The nurse assesses that a client is restless and becoming agitated in the immediate postoperative period. The client's oxygen saturation is 91%. What should the nurse do next?
Correct response: Administer oxygen.
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Correct response: Apply a dressing over the wound and tape it on three sides.
A client with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which action should the nurse take?
Correct response: Assess oxygen saturation using pulse oximetry.
The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?
Correct response: Assess respiratory status.
A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment?
Correct response: Assess the vital signs and oxygen saturation levels.
A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention?
Correct response: Control the pain and support breathing and oxygenation.
Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks' gestation is admitted to the hospital in active labor. Her cervix is 7 cm dilated with the presenting part at +1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which action would be most appropriate?
Correct response: Give the client a paper bag and have her breathe into it.
A 3-year-old client is admitted to the pediatric unit with pneumonia. The child has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the child has not been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should the nurse include in the care plan? Select all that apply.
Correct response: Perform chest physiotherapy as ordered. Encourage coughing and deep breathing. Perform postural drainage. Maintain humidification with a cool mist humidifier.
A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply. You Selected: Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Monitor the client's vital signs.
Correct response: Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Monitor the client's vital signs.
A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action best explains the main function and goal of surfactant use?
Correct response: helps lungs remain expanded after the initiation of breathing improving oxygenation
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
Correct response: lung auscultation and measurement of vital capacity and tidal volume
A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?
Correct response: nasal flaring
A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations?
Correct response: nonrebreather mask
A nurse working in the emergency department receives arterial blood gas results on four clients. Which laboratory result requires immediate nursing intervention?
Correct response: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg
The nurse carefully documents the premature neonate's response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which complication? You Selected: retinopathy of prematurity
Correct response: retinopathy of prematurity
For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
Correct response: using a Venturi mask to deliver oxygen as ordered
A 56-year-old-male client on the surgical unit had a large bowel resection to resolve complications of diverticulitis. The nurse is performing a postoperative reassessment at 1330. For each assessment finding below, click to specify if the finding is consistent with the process of hypoventilation, hypopharyngeal obstruction, or asthma. Each finding may support more than 1 disease process.
Hypoventilation: decreased oxygen saturation, shallow respirations, increased respiratory rate Hypopharyngeal: decreased oxygen saturation, choking ObstructionAsthma: decreased oxygen saturation, increased respiratory rate, wheezing
A 56-year-old-male client on the surgical unit had a large bowel resection to resolve complications of diverticulitis. The nurse is reviewing the client's medical record while preparing the client for discharge. For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined.
Improved: Lungs are clear in all lobes. Oxygen saturation is 97% on room air. Client is passing flatus from the rectum. Pain is rated as a 1 on a scale of 0 to 10. The client is ambulating without assistance. No Change: The abdomen is firm. Declined: The dressing has 3 × 5-cm yellow drainage.
The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate?
Position in high Fowler's position and administer an albuterol sulfate inhaler.
The emergency department (ED) nurse is caring for a 22-year-old male client who was in a motor vehicle accident with internal abdominal bleeding and fractured ribs.
The ED nurse reports that the client's ABG report from 2100 represents respiratory acidosis as evidenced by acidic pH, acidic PaCO2 and normal HCO3-. Following treatment, the ED nurse reports that the client's ABG report from 2300 represents --- results.
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
A client is diagnosed with cystic fibrosis. Which intervention would be performed to prevent nutrition complications?
administration of pancreatic enzymes
A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)?
arterial oxygen level of 46 mm Hg (6.1 kPa)
A nurse has received a change-of-shift report on four clients. Which client should the nurse assess first?
client experiencing tracheal deviation following a subclavian catheter insertion
The nurse is performing a respiratory assessment on a client who has a pleural effusion. Which breath sound is expected for this client?
decreased breath sounds on the affected side
A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position?
knee-to-chest
The nurse is caring for a child with history of strep throat. Upon current assessment, the child reports abdominal pain and joint achiness. Which laboratory data would the nurse communicate to the health care provider immediately?
leukocytosis
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
light-headedness or paresthesia
The client is a 12-year-old girl with a history of asthma who was brought to the emergency department (ED) by the parents for increasingly severe wheezing and fatigue despite the use of an albuterol inhaler at home. Click the findings that require follow-up.
oxygen saturation is 89% on room air. The respiration rate (RR) is 30 breaths/minute supraclavicular retractions and the use of neck muscles are noted. The heart rate (HR) is 120 beats/min The fingernails are cyanotic; the skin is pale and diaphoretic The client and parents are visibly anxious
A nurse is caring for a client with bronchogenic carcinoma. Which nursing intervention takes highest priority?
removing pulmonary secretions
The nurse is preparing a teaching plan for a 14-year-old child who is newly diagnosed with asthma. Which content should be taught first?
when to seek immediate medical attention
The client is a 12-year-old girl with a history of asthma who was brought to the emergency department (ED) by the parents for increasingly severe wheezing and fatigue despite the use of an albuterol inhaler at home. The nurse is planning and prioritizing care for this client. Complete the following sentence by choosing from the lists of options.
respiratory failure respiratory acidosis
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs:
Correct response: are unable to blow off carbon dioxide.
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?
Correct response: endotracheal suctioning
After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis?
Correct response: fat embolism
A child with asthma has a heart rate of 160 bpm and a respiratory rate of 36 breaths/minute. The child appears restless and anxious and is given albuterol via nebulizer. Which finding would indicate that the nebulizer treatment has been effective?
Correct response: increase in peak expiratory flow rate
A client had a Mantoux test result of an 8-mm induration. When should the nurse interpret the test as positive? When the client:
Correct response: is immunocompromised.
Which nursing action addresses the primary concern for a client with Guillain-Barré syndrome?
Correct response: preparing for mechanical ventilation
A 7-year-old child is admitted with epiglottitis. When reviewing the lateral neck X-ray, what finding will the nurse anticipate?
Correct response: thickened mass
The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which change on the client's chart to the health care provider?
Correct response: urine output
A client with chest pain doesn't respond to nitroglycerin. When the client is admitted to the emergency department, the healthcare team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?
Correct response: within 6 hours
The nurse is caring for a client who has just returned to the postpartum unit after a cesarean birth. Which action is a priority for the nurse to teach the client to perform over the next 24 hours to prevent complications?
deep breathing and coughing exercises every 2 hours
A child is being seen in the emergency department for reports of severe sore throat, trouble swallowing, and fever. The child has swollen cervical lymph nodes and a fiery red pharynx on examination. Which assessment findings below should be reported immediately to the healthcare provider?
drooling and not swallowing
A client is receiving a blood transfusion, and 1 hour after starting the transfusion the client reports dyspnea and has crackles on lung auscultation. Which medication would be most important for the nurse to give?
furosemide 40 mg I.V.
A 56-year-old-male client on the surgical unit had a large bowel resection to resolve complications of diverticulitis. The nurse is performing a postoperative reassessment at 1330. Drag the assessment findings that require follow-up to the box on the right.
Assessment Findings That Require Follow-up: decrease breath sounds... smoking history RR 24 shallow respirations oxygen saturation 92%
A client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate?
Attach the ties of the restraints to the bedframe.
A preschool child immobilized in a hip spica cast has trouble breathing after meals. Which action would be best?
Correct response: Offer the child small feedings several times a day.
A nurse is reviewing orders for a client having an acute asthma attack. Which medication should the nurse administer?
Correct response: albuterol 2.5 mg per nebulizer
The nurse is caring for a client with emphysema. The client asks about the reason for persistent respiratory acidosis. What is the best response by the nurse?
Correct response: "Your alveoli have lost elasticity, which causes retained carbon dioxide."
A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client?
Correct response: Acute respiratory distress syndrome (ARDS)
A nurse is caring for a client diagnosed with a deep vein thrombosis (DVT). The client begins to experience symptoms of chest pain, dyspnea, and restlessness. Physical assessment reveals a heart rate of 140 beats per minute, blood pressure of 100/60 mm Hg, and respirations of 40 breaths per minute. What is the nurse's priority action?
Correct response: Assess the client's oxygen saturation (SaO2) level.
An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important?
applying an oximeter and initiating respiratory therapy
After suctioning a client with a tracheotomy tube, the nurse performs an assessment to determine the effectiveness of the suctioning. Which findings indicate that no further interventions are needed?
Respiratory rate drops from 24 breaths/minute to 16 breaths/minute.
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, what should the nurse do?
Correct response: Lower the drainage system to maintain gravity flow.
A 56-year-old-male client on the surgical unit had a large bowel resection to resolve complications of diverticulitis. Following the 1400 assessment, which potential complication would the nurse continue to monitor for? Select all that apply.
atelectasis paralytic ileus surgical site infection
The client is a 12-year-old girl with a history of asthma who was brought to the emergency department (ED) by the parents for increasingly severe wheezing and fatigue despite the use of an albuterol inhaler at home. For each client finding, click to specify if the finding is consistent with the disease process of-
status asthmaticus: chest tightness, wheezing, prolonged exhalation spontaneous pneumothorax: pleuritic chest pain, asymmetrical chest wall movement pulmonary tuberculosis: night sweats, fever, weight loss
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean them from sedation therapy. A nurse needs further assessment data to determine whether
the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.
The nurse is reconciling the prescriptions for a client diagnosed recently with pulmonary tuberculosis who is being admitted to the hospital for a total hip replacement (see medication prescription sheet). The client asks if it is necessary to take all of these medications while in the hospital. What should the nurse tell the client?
"It's important to continue to take the medications because the combination of drugs prevents bacterial resistance."
The nurse is caring for a 35-year-old client who had an open appendectomy following a ruptured appendix 8 hours earlier. The nurse is reviewing the client's assessment from 0900 to prepare a plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Actions to Take: Teach the client to splint the incision with a pillow while performing deep-breathing exercises. Potential Conditions: atelectasis Parameters to Monitor: pulse oximetry breath sounds
A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do?
Notify the health care provider (HCP) of the client's breathing pattern.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which statement is true concerning oxygen administration to a client with COPD?
Correct response: High oxygen concentrations may inhibit the hypoxic stimulus to breathe.
The nurse is planning care for a client 1 day after having surgery to create a tracheostomy. Which nursing action is the priority goal for the client at this time?
Correct response: Maintain a patent airway.
A client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes restless and dyspneic and has chest pain radiating to the middle of the back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. What should the nurse further assess?
Correct response: a pneumothorax
The nurse is assessing a client newly transferred from the recovery room and notes a low-grade temperature, tachycardia, tachypnea, and crackles. Which action is the nurse's priority?
Encourage client to cough and take a deep breath.
A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect?
trace peripheral edema, previously +2
A 56-year-old-male client on the surgical unit had a large bowel resection to resolve complications of diverticulitis. Upon creating the plan of care for the client, the nurse would include which intervention? Drag the nursing interventions that the nurse should take to the box on the right.
Intervention the Nurse Should Perform Administer prescribed narcotic analgesic medication as needed. Encourage the use of an incentive spirometer. Assist the client with turning while in bed. split abdomen
The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation?
Medicate the client with prescribed morphine.
A child is being discharged after being diagnosed with an asthma attack. What information regarding the rescue inhaler is most important for the nurse to include in discharge teaching?
Monitor heart rate.
The nurse in the pulmonary clinic is caring for a 58-year-old male client with chronic obstructive pulmonary disease (COPD).
Nursing Interventions to Perform: Administer influenza vaccine. Discuss smoking cessation and resources available. Explain how to administer salmeterol powder discus every 12 hours, as prescribed. Teach pursed-lip breathing. Discuss use of varenicline, as prescribed.
The nurse is caring for a client with cystic fibrosis (CF) who has increased dyspnea. Which intervention should the nurse include in the plan of care?
Perform chest physiotherapy.
A nurse is assessing a client with pneumonia. The nurse asks the client to say "99." What is the next action by the nurse?
Place the ulnar surface of the hand on the chest to detect vibration.
A 56-year-old-male client on the surgical unit had a large bowel resection to resolve complications of diverticulitis.For each potential intervention, click to specify whether the intervention is priority, nonessential, or contraindicated for the next 24 hours.
Priority: Have the client perform coughing and deep-breathing exercises. Encourage the use of incentive spirometry. Have the client change position. Nonessential: Begin smoking cessation education. Contraindicated: Initiate intubation and mechanical ventilation. Withhold narcotic analgesic medications.
Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth?
Provide warm, humidified oxygen in a warm environment.
A nurse is assessing a client using a tracheostomy tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which action should the nurse take?
Use a sterile suction kit to suction the client.
A client appears flushed and has shallow respirations. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial carbon dioxide (PaCO2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3-), 24 mEq/L (24 mmol/L). These findings are indicative of which acid-base imbalance? Correct response: respiratory acidosis
You Selected: respiratory acidosis
A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about?
heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24
A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale had been prescribed a loop diuretic to treat peripheral edema. The nurse should monitor the client closely for what side effect of loop diuretic therapy that could worsen the client's hypercapnia?
hypokalemia
As part of the respiratory assessment, a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because
neonates are obligate nose breathers.
The nurse is caring for a client with end-stage kidney disease. What arterial blood gas results are most closely associated with this disorder?
pH 7.20, PaCO2 36, HCO3 14-
The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of arterial blood gas values does the nurse expect for this client?
pH 7.25, PaCO2 48, HCO3 24
A client who has just had a triple-lumen catheter placed in their right subclavian vein complains of chest pain and shortness of breath. The client's blood pressure is decreased from baseline and, on auscultation of the chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
pneumothorax
A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:
promote fetal lung maturity.
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?
returning bicarbonate to the body's circulation
A community health nurse is administering pneumococcal polysaccharide vaccinations and flu vaccinations to clients with asthma, chronic bronchitis, and emphysema. A client asks the nurse why these vaccines are recommended. What is the nurse's best response?
Correct response: Respiratory infections can cause severe hypoxia and possibly death in these clients.
A nurse administers the first dose of nadolol to a client with a blood pressure of 180/96. During an assessment 4 hours later, which information indicates that the client needs immediate intervention?
Correct response: The client has wheezing throughout the lung fields.
A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
Correct response: Ineffective airway clearance related to anesthesia
For a client with asthma, the health care provider (HCP) prescribes albuterol, two puffs twice a day via a metered-dose inhaler (MDI), and beclomethasone, two puffs twice a day via MDI. How should the nurse instruct the client to administer these drugs?
"Take the albuterol first and follow with beclomethasone two times a day."
The nurse is educating parents of a child diagnosed with seasonal allergies. The nurse discusses therapeutic management of the child's allergies and works with the parents to set goals that best support a quality childhood experience. Which of the following goals is most important for the nurse to set with the parents?
Correct response: identifying ways to reduce the child's exposure to the allergens
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the medical record for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 1530 is 75% taken on the infant's right wrist. What should the nurse do first?
Correct response: Administer oxygen via mask.
When teaching the parents of an infant how to perform back slaps to dislodge a foreign body, what should the nurse tell the parents to use to deliver the blows?
Correct response: heel of the hand
The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used.
Correct response: Hello. My name is Nurse Jones from Unit D. I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon. Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment.
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first?
Correct response: Increase the oxygen flow rate from 2 to 4 L/min.
A six-month-old infant with uncorrected tetralogy of Fallot suddenly becomes increasingly cyanotic and diaphoretic with weak peripheral pulses and an increased respiratory rate. In what order should the nurse perform the actions? Place each action in order from first to last. All options must be used.
Correct response: Place the infant in a knee-chest position. Administer oxygen as prescribed. Administer morphine sulfate as prescribed. Calm or comfort the infant.
The nurse is caring for a multigravid client and observes the woman squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, the nurse should perform which action next?
Correct response: Provide gentle support to the fetal head.
A client with a clamped chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The nurse understands that the most likely cause is:
Correct response: a tension pneumothorax.
The nurse has received lab reports for several clients undergoing care. Which set of arterial blood gas (ABG) results will the nurse investigate first?
Correct response: pH 7.49, PaCO2 30 mmHg, PaO2 75 mmHg, and HCO3- 22 mEq/L
The friend of a client brought to the emergency department states, "I guess she had some bad heroin today." The client is drowsy and verbally nonresponsive. Which finding is of immediate concern to the nurse?
Correct response: respiratory rate of 9 breaths/min
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?
Correct response: returning bicarbonate to the body's circulation
A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?
Correct response: suction machine with catheters
A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis? You Selected: tripod position
Correct response: tripod position
Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate in a client with these arterial blood gas results?
increase in rate and depth of respirations
A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer.
Correct response: "Take off the cap and shake the inhaler." "Attach the spacer." "Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." "Press down on the inhaler once and breathe in slowly." "Hold your breath for at least 10 seconds, then breathe in and out slowly." "Rinse your mouth."
