NUR 240 Exam 3 Respy Questions
c
1. A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.4° F), and SaO, 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Prepare for chest tube insertion. C. Administer oxygen via a high-flow mask. D. Initiate IV access.
a, b, e
1. A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) A. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain
a, c, e
1. A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (Select all that apply.) A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation
a, b, e, f
1. A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis
b
1. A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."
a, b, c, e
1. A nurse is preparing to care for a client following a chest tube placement. Which of the following items should be available in the client's room? (Select all that apply.) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing
a
2. A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? A. Obtain baseline vital signs and oxygen saturation. B. Obtain a sputum culture. C. Obtain a complete history from the client. D. Provide a pneumococcal vaccine.
b, d, e
2. A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia
b
2. A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Apply sterile gauze to the insertion site. C. Place tape around the insertion site. D. Assess respiratory status.
b, e
2. A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure
b
2. A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "This medication is given to treat infection. B. "This medication is given to facilitate ventilation." C. "This medication is given to decrease inflammation." D. "This medication is given to reduce anxiety."
b
2. A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain. B. Obtain a large-bore IV needle for decompression. C. Administer lorazepam. D. Prepare for chest tube insertion.
b, c
3. A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration D. Exposed sutures without dressing E. Drainage system upright at chest level
b, c, a, d
3. A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8° C (100° F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and Sa02 91% on room air. Prioritize the following nursing interventions. A. Administer antibiotics. B. Administer oxygen therapy. C. Perform a sputum culture. D. Administer an antipyretic medication to promote client comfort.
d
3. A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hr.
d
3. A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client? A. "Notify your provider if you experience weakness." B. "You should be able to return to work in 1 week." C. "You need to wear a mask when in crowded areas." D. "Notify your provider if you experience a productive cough."
c
3. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? A. Notify the provider. B. Administer heparin via IV infusion. C. Administer oxygen therapy. D. Obtain a spiral CT scan.
a, b, d, e
3. A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced a drug overdose
3
37. The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics scheduled. 2. Hyperoxygenate the patient before suctioning. 3. Maintain the head of bed at a 30- to 45-degree angle. 4. Suction the airway when coarse crackles are audible.
d
4. A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctiva D. Palpation of the orbital areas
b, c, d, e
4. A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement
d
4. A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side. B. Use the incentive spirometer. C. Cough at regular intervals. D. Perform the Valsalva maneuver.
b
4. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day." C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath."
b
4. A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask
d
4. A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will place the adapter on my finger to read my blood oxygen saturation level." B. "I will lie on my back with my knees bent." C. "I will rest my hand over my abdomen to create resistance." D. "I will take in a deep breath and hold it before exhaling."
b, d, e
4. A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply.) A. Administer antibiotics. B. Provide supplemental oxygen. C. Administer antiviral medications. D. Administer of bronchodilators. E. Maintain ventilatory support.
a, c
5. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E. Dexamethasone
a
5. A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count
a, b, e
5. A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) A. Encourage the client to cough every 2 hr. B. Check for continuous bubbling in the suction chamber. C. Strip the drainage tubing every 4 hr. D. Clamp the tube once a day E. Obtain a chest x-ray.
b, c, d
5. A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client's respiratory muscles should the nurse include in the plan of care? (Select all that apply.) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation
c
5. A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? A. Take quick breaths upon inhalation. B. Place your hand over your stomach C. Take a deep breath in through your nose. D. Puff your cheeks upon exhalation.
a
5. A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. "I should wash my hands after blowing my nose to prevent spreading the virus." B. "I need to avoid drinking fluids if I develop symptoms." C."I need a flu shot every 2 years because of the different flu strains." D."I should cover my mouth with my hand when I sneeze."
a
A client has been admitted for dehydration after fasting for five days. For which acid-base imbalance would the nurse assess this client? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
1
A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome
3
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken
b
A client is admitted to the hospital for vomiting for 3 days. Which ABG would the nurse expect? a) pH 7.30; PaCo2 50; HCO3 27 Resp acidosis/partial compensation b) pH 7.47; PaC02 43; HC03 30 ) Losing acid - metabolic alkalosis c) pH 7.34; PaC02 50; HCO3 30 Mixed acid-base - metabolic alkalosis/respiratory acidosis d) pH 7.48; PaC02 30; HCOS 23 Respiratory alkalosis
a, e
A client is admitted to the hospital with a diagnosis of respiratory acidosis secondary to barbiturates. Which assessment would the nurse anticipate? SELECT ALL THAT APPLY a) Slow, shallow respirations b) Tetany symptoms c) Increased deep tendon reflexes. d) Palpitations e) Headache
d
A client is admitted to the hospital with atelectasis and reports chest pain. For which acid-base imbalance would the nurse access this client? a) Respiratory alkalosis b) Metabolic acidosis c) Metabolic alkalosis d) Respiratory acidosis
c, e
A client is admitted to the hospital with respiratory acidosis. The nurse considers that which condition could be an etiology for this client? SELECT ALL THAT APPLY a) Severe diarrhea for several days b) DKA c) Obesity d) Diuretics e) Sedative overdose
c
A client is admitted with the following ABG results: pH 7.50; PaC02 40; HC03 29. Which question should the nurse ask the client to help determine an etiology for these results? a) "Have you had diarrhea lately?" b) "Do you have a history of COPD?" c) "How long have you had nausea and vomiting?" d) "Do you smoke?"
3
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1. Cyanosis 2. Hypotension 3. Paradoxical chest movement 4. Dyspnea, especially on exhalation
d
A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms
a, c, d
A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site
a
A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure. C. Obtain ABG's. D. Administer benzocaine spray.
a, c, d
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply.) A. Oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit
b
A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2, 32 mm Hg, HCO, 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
1, 2, 3, 5
A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the unlicensed assistive personnel (UAP) who will help the patient with activities of daily living (ADLS)? Select all that apply. 1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. 6. Assess the patient for any signs or symptoms of bleeding.
1
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which does the nurse anticipate that the health care provider will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 IV push mg immediately (STAT). 4. Call a code for respiratory arrest.
4
After extubation of a patient, which finding would the nurse report to the health care provider immediately? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4. Crowing noise during inspiration
4
After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4°F (38.6°C)
b
An advantage of a tracheostomy tube over an endotracheal tube for long-term management is that a tracheostomy a) Is safer to perform in an emergency b) Allows for more comfort and mobility. c) Has a lower risk of tracheal pressure necrosis d) Is likely to lead to lower respiratory tract infection
2
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar
c
How does positive end-expiratory pressure (PEEP) improve oxygenation? a) It provides more oxygen to the client b) It opens up the bronchioles during inspiration forcing oxygen into the lungs c) It opens up collapsed alveoli and helps keep them open longer at end-expiration, improving gas exchange. d) It supports each breath during inspiration by overcoming resistance to airflow easing the work of breathing
4
The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a student. The student states that the patient's oral body temper- ature is elevated at 100.8°F (38.2°C). Which state- ment by the student indicates correct understanding of this patient's curve shift? 1. "When a patient's body temperature is elevated, there is no change in the oxygen-hemoglobin dissociation curve." 2. "When a patient's body temperature is elevated, there is a shift to the left because the oxygen tension level is lower." 3. "When a patient's body temperature is elevated, there is no shift in the curve because the patient is using less oxygen.' 4. "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster."
1, 3, 4, 5
The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct understanding of this procedure? Select all that apply. 1. The student nurse uses a sterile catheter and glove. 2. The student nurse applies suction while inserting the catheter. 3. The student nurse applies suction during catheter removal, 4. The student nurses uses a twirling motion when withdrawing the catheter. 5. The student nurse uses a no. 12 French catheter. 6. The student nurse applies suction for at least 20 seconds.
1
The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? 1. A 68-year-old patient with a history of smoking and emphysema 2. A 57-year-old patient who experienced a cardiac arrest 3. A 49-year-old postoperative patient who had a colectomy 4. A 29-year-old patient who is recovering from flail chest
2
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury
b
The first responsibility of the nurse immediately following intubation is to a) Tape the tube securely in place b) Assess for bilateral breath sounds. c) Call for Chest x-ray to determine placement d) Suction the tube to remove secretions
2
The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Încrease the fraction of inspired oxygen (FIO2) on the ventilator to 100% in preparation for endotracheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.
3
The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1. Administer oxygen 2. Check the client's vital signs 3. Ventilate the client manually 4. Start cardiopulmonary resuscitation
2
The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? 1. Call the health care provider (HCP). 2. Place the tube in a bottle of sterile water. 3. Immediately replace the chest tube system. 4. Place a sterile dressing over the disconnection site.
1
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate? 1. Do nothing, because this is an expected finding. 2. Check for an air leak because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4. Immediately clamp the chest tube and notify the health care provider.
b
The nurse determines that a client with a nasogastric tube on low suction for five days is at risk for developing which acid-base balance? a) Respiratory acidosis b) Metabolic alkalosis c) Metabolic acidosis d) Respiratory alkalosis
a
The nurse explains that chronic pulmonary hypertension can lead to: a. Right ventricular hypertrophy b. Left ventricular hypertrophy c. Aortic root distention d. Decreased central venous pressure
3
The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the health care provider (HCP)? 1. The patient starts crying and says she can't go on with treatment much longer. 2. The patient reports sharp, stabbing chest pain with every deep breath. 3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. 4. The dressing at the thoracentesis site has 1 cm of bloody drainage.
4
The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination
1
The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's his- tory and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? 1. The patient was recently in a motor vehicle crash. 2. The patient participated in an aerobic exercise program for 6 months. 3. The patient gave birth to her youngest child 1 year ago. 4. The patient was on bed rest for 6 hours after a diag- nostic procedure.
4
The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate
3, 4, 5, 6
The nurse is assessing the functioning of a chest tube drainage system in client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the patient's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
4
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1. Slow, deep respirations 2. Rapid, deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration
2
The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours
4
The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instrụct the client to take which action? 1. Exhale slowly. 2. Stay very still. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.
3
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-streaked sputum
2, 3
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1. A low arterial PCo2, level 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity
2, 4, 5
The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assess puncture site and dressing for leakage. 2. Check vital signs every 15 minutes for 1 hour. 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 6. Teach the patient symptoms of pneumothorax.
2
The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1. Palpation and clubbing 2. Percussion and vibration 3. Hyperoxygenation and suctioning 4. Administer a bronchodilator and monitor peak flow
4
The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting up and leaning on an overbed table
3
The nurse is making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism (venous thromboembolism). The patient's only medication is enoxaparin subcutaneously. Which assessment information will the nurse need to communicate to the health care provider? 1. The patient says that her right leg aches all night. 2. The right calf is warm to the touch and is larger than the left calf. 3. The patient is unable to remember her husband's first name. 4. There are multiple ecchymotic areas on the patient's abdomen.
2
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1.5 seconds 2. 10 seconds 3. 30 seconds 4. 60 seconds
3
The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? 1. Continue to suction. 2. Notify the health care provider immediately. 3. Stop the procedure and reoxygenate the client. 4. Ensure that the suction is limited to 15 seconds.
2
The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday
3
The nurse is the preceptor for an RN who is undergoing orientation to the intensive care providing care for a patient with acute respiratory unit. The RN is distress syndrome (ARDS) who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct
b, c
The nurse would assess for which signs and symptoms in a client who has metabolic acidosis? SELECT ALL THAT APPLY a) Weight gain b) Rapid, deep respiration c) Drowsiness d) Decreased RR and depth e) Melena
a
The nurse would suspect that a client who frequently uses which medication is at risk of developing metabolic alkalosis? a) Calcium carbonate (Tums) b) Ibuprofen (Motrin) c) Acetylsalicylic acid (ASA) d) Acetaminophen (Tylenol)
4
When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/ min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIo,) and call the health care provider to discuss the patient's status.
c
Which of the following is indicative of the development of pulmonary edema in a client with left heart failure? a. Distended jugular veins and wheezing b. Dependent edema and anorexia c. Coarse crackles and tachycardia. d. Hypotension and tachycardia
d
Which of the following respiratory assessment findings is of greatest concern to the nurse following endotracheal tube extubation? A. Increased respiratory rate B. Scattered bilateral rhonchi C. Expectoration of whitish yellow secretions D. A harsh or crowing sound with inspiration.
a
Which of the following ventilator modes will increase the work of breathing and is therefore indicated for a surgical patient who is to start a weaning protocol? a) Synchronized intermittent mandatory ventilation (SIMV). b) Assist control (AC) c) Continuous positive airway pressure (CPAP) d) Pressure control ventilation
b
Which of the following would expected when the client with pulmonary edema is repositioned from semi-fowlers to supine? a. Atrial Fibrillation b. Orthopnea c. Increased O2 saturation d. Wheezing
b, e
Which statement by the client indicates that discharge teaching for respiratory alkalosis is understood? SELECT ALL THAT APPLY a) "I will not take so many antacids anymore." b) "I will take a stress management class." c) "I will not take any Lasix without taking my K supplement." d) "I will tell the doctor the next time I have diarrhea for so long." e) "I am more aware of how my breathing changes when I get nervous."
b
While suctioning a patient with an endotracheal tube, the nurse notes the occurrence of premature ventricular contractions (PVC's) on the cardiac monitor and a drop in the patient's Sp02. The most appropriate action by the nurse upon this finding is to a) Lower the suction pressure to 60 mm Hg b) Ventilate the patient with 100% oxygen with a bag-valve mask c) Notify the MD of the need for antiarrhythmic medications d) Provide an explanation of the suctioning procedure to decrease the patient's anxiety
b
While suctioning a patient with an endotracheal tube, the nurse notes the occurrence of premature ventricular contractions (PVC's) on the cardiac monitor and a drop in the patient's Sp02. The most appropriate action by the nurse upon this finding is to a) Lower the suction pressure to 60 mm Hg b) Ventilate the patient with 100% oxygen with a bag-valve mask. c) Notify the MD of the need for antiarrhythmic medications d) Provide an explanation of the suctioning procedure to decrease the patient's anxiety
