NCLEX RN - Respiratory

tidal volume

Amount of air that moves in and out of the lungs during a normal breath

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason the that the nurse administers oxygen? A. Prevent dyspnea B. Prevent cyanosis C. Increase oxygen concentration to heart cells D. Increase oxygen tension in the circulating blood

C. Increase oxygen concentration to heart cells

After reviewing information about oxygenation for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy? A. Partial pressure of oxygen (PaO2) of 72; peripheral capillary oxygen saturation (SpO2) of 96 B. PaO2 of 60; SpO2 of 90 C. PaO2 of 55; SpO2 of 88 D. PaO2 of 70; SpO2 of 92

C. PaO2 of 55; SpO2 of 88

The nurse obtains a laboratory report that shows acid-fast rods in a client's sputum. Which disorder would the nurse consider may be related to these results?

Mycobacterium tuberculosis

vesicular breath sounds

Normal breath sounds made by air moving in and out of the alveoli.

intrinsic asthma

Not an allergic reaction Usually presents after age 35 years Triggers: upper respiratory infections, air pollution, emotional stress, smoke, exercise, and cold exposure

When a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate?

cordectomy

Which nursing action will help a client obtain maximum benefits after a postural drainage?

2 Encourage coughing deeply.

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? 1 Supine 2 Orthopneic 3 Low-Fowler 4 Semi-Fowler

2 Orthopneic

When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention?

applies suction during insertion of the catheter

Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?

atelectasis(occurs after general anesthesia because of decreased respiratory depth and resulting collapse of alveoli)

Which change in arterial blood gases does the nurse expect in a client with hyperventilation due to anxiety? a. respiratory acidosis b. respiratory alkalosis c. respiratory compensation d. respiratory decompensation

b. respiratory alkalosis

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which is appropriate to include?

crackles are located in the smaller air passages

Which instruction would the nurse include when teaching a client how to perform diaphragmatic breathing?

expand the abdomen on inhalation

adventitious sounds

extra breath sounds that are not normally heard, such as crackles, rhonchi, wheezes, and pleural friction rubs.

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse?

initiate oxygen via a nasal cannula

The nurse provides education to a group of students about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise?

promotes elimination of CO 2

Which color tag would the triage nurse working at a train accident use to label a client experiencing respiratory distress?

red tag

Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis?

saline irrigation

In which position will the nurse place a client who has been transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection?

semi-fowler

The nurse provides teaching to a client who is being discharged after treatment for a pneumothorax. The nurse instructs the client to notify the health care provider immediately if experiencing which symptom of a recurring pneumothorax?

severe shortness of breath

thoracentesis

the surgical puncture of the chest wall with a needle to obtain fluid from the pleural cavity

How would the nurse position a client to practice supraglottic swallowing after tracheostomy?

upright

How would a nurse position a client with epistaxis?

upright leaning forward

mediastinoscopy

visual examination of the mediastinal structures, including the heart, trachea, esophagus, bronchus, thymus, and lymph nodes

Which assessment finding is consistent with bronchospasm?

wheezing

At which interval are humidified oxygen systems replaced to prevent infection?

1 days

Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place?

3. "Restraints are a last resort to prevent accidental extubation.

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest? 1. Crackling2. Wheezing3. Decreased sounds4. Vesicular sounds

3. Decreased sounds

Which is the purpose of an occlusive dressing over a client's sucking chest wound?

Maintains negative pressure within the chest cavity

A client is admitted to the hospital with a diagnosis of emphysema. When teaching the client about breathing exercises, the nurse would include which instruction?

Perform diaphragmatic exercises to improve contraction of the diaphragm.

Which action will the nurse take to support safe oral intake after tracheostomy?

Position client as upright as possible.

The nurse provides immediate postoperative care to a client. The client reports a sudden onset of shortness of breath and chest pain. Which action would the nurse take? Provide supplemental oxygen Administer intravenous morphine Prepare for endotracheal intubation Administer sublingual nitroglycerin

Provide supplemental oxygen

Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. A. Facial edema B. Septal deviation C. Clear nasal drainage D. Oxygen saturation 89% E. Bilateral periorbital bruising

all are correct

Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? Select all that may apply. 1 Type of employment 2 Presence of ear pain 3 History of tobacco use 4 Oral hygiene practices 5 Amount of alcohol intake

all are correct

Which instruction would the nurse teach the client concerned about dislodging a laryngectomy tube at a 3-week postoperative follow-up visit?

keep calm because this is not an immediate emergency

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system pneumothorax?

marking the time on the drainage unit every shift

Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site?

mild soap and water