Respiratory post test ATI

A nurse is caring for a client who is dying and he's having periods of deep breathing Alternating with Apnea. The nurse should identify this as which of the following types of breathing?

Cheyne-Stokes breathing can occur if the central nervous system is grossly affected by lack of oxygen or disease progression. It appears to have a respiratory "start-stop" breathing pattern. The client will have a deeper breath that might quicken, followed by hypoventilation and progression to apnea. This is an end-of-life breathing pattern

A charge nurse is teaching a new release recognize manifestation of decreased oxygenation In a client. Which of the following statements by the new license nurse indicate an understanding of the teaching?

Clubbing of the ends of the fingers can indicate a chronic state of decreased oxygenation and perfusion.

A nurse in the emergency department is assessing a client who has experience thoracic trauma from a motor vehicle crash. Which of the following findings is an indication of pneumothorax?

The client is experiencing unequal movement of the posterior chest. When a pneumothorax, or collapsed lung, occurs, there is an unequal expansion of the posterior chest. The client will be tachypneic with decreased or absent breath sounds on the affected side. A chest tube to re-inflate the lung is required to reverse a pneumothorax.

A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation?

Inspiratory wheezing auscultated left lateral chest This entry is documented correctly. It is objective, descriptive, and based on facts. This information provides an accurate picture of the client's respiratory assessment for all providers.

A nurse is assessing a client who is dark skinned. In which of the following areas of the clients body should the nurse assess the client for adequate oxygenation?

Nail beds is correct. Clients who are dark-skinned and clients who are light-skinned will have pink nail beds if adequate amounts of oxygen are in the bloodstream. Oral mucosa is correct. The nurse should inspect the oral mucosa of a client who is dark-skinned for adequate oxygenation. Lips is correct. The nurse should inspect the lips of a client who is dark-skinned to assess for adequate oxygenation.

A nurse is caring for a client is experiencing episodes of hyperventilation. Which of the following manifestation sure the nurse expect during hyperventilation?

Numbness and tingling of extremities is correct. A client who is hyperventilating can show manifestations such as numbness and tingling of the extremities, heart palpitations, chest pain, and lightheadedness. Lightheadedness is correct. A client who is hyperventilating can show manifestations such as numbness and tingling of the extremities, heart palpitations, chest pain, and lightheadedness. Chest pain is correct. Clients who are hyperventilating have respirations that are faster and deeper than usual. A client who is hyperventilating can show manifestations such

A nurse is performing to do assessment of a client. Which of the following findings indicates a client might be experiencing respiratory difficulties?

The client is sitting in a tripod position is correct. A client might be sitting in a tripod position to use the abdominal, intercostal, and neck muscles to facilitate oxygen exchange. This is an unexpected finding that can indicate the client is having respiratory difficulty. The client is using pursed-lipped breathing is correct. Pursed-lipped breathing is a technique of expiration used by clients who experience respiratory difficulty, such as those who have COPD. This is an unexpected finding. The client appears confused is correct. Confusion is an unexpected finding and can indicate hypoxia, or a lack of oxygen delivery to the brain. The nurse should assess further to determine the origin of the client's confusion.

Charge nurse Is observing a newly licensed nurse perform an anterior chest auscultation on a client. Which of the following actions should the charge nurse intervene?

The nurse is auscultating through the clients gown The charge nurse should intervene because the stethoscope should be placed directly on the client's skin during auscultation. Auscultating through clothing can produce crackling or other abnormal sounds and obstruct air movement.

A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data? (Select all that apply)

The report from the client says they sleep while propped on two pillows at night is correct. This information is reported by the client and is therefore subjective. Client says they quit smoking 2 years ago is correct. This information is reported by the client and is therefore subjective. Client states, "Being short of breath all of the time is making me depressed" is correct. This information is reported by the client and is therefore subjective.

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub? (Select all the apply)

Coarse grating tone is correct. A pleural friction rub occurs because of inflammation of the pleura. It is a low-pitched, coarse grating tone that sounds like rubbing two pieces of leather together. It can be heard on inspiration and expiration and is very painful. Heard on inspiration and expiration is correct. A pleural friction rub occurs because of inflammation of the pleura. It is a low-pitched, coarse grating tone that sounds like rubbing two pieces of leather together. It can be heard on inspiration and expiration and is very painful. Pain with breathing is correct. A pleural friction rub occurs because of inflammation of the pleura. It is a low-pitched, coarse grating tone that sounds like rubbing two pieces of leather together. It can be heard on inspiration and expiration and is very painful.

A nurse is caring for a client was having difficulty breathing. Which of the following actions should the nurse take first?

Elevate the head of the client's bed According to evidence-based practice, the first action the nurse should take is to elevate the head of the client's bed. Raising the head of the bed to a semi- or high-Fowler's position will allow for improved lung expansion, which can facilitate air and gas exchange.

A nurse is preparing to auscultate a client's posterior and lateral chest. In which order should the nurse perform the following actions.

1. Expose the posterior chest with the client sitting with their arms folded across their chest is the first step. The nurse should first expose the client's posterior chest to auscultate a client's posterior and lateral chest. With the client sitting, the nurse should ask the client to fold their arms across their chest. 2. Auscultate 8 cm (3 in) to one side of the spine around C7, then auscultate the other side of the spine in the same location is the second step. The nurse should begin auscultating 8 cm (3 in) to one side of the spine around C7, and then auscultate to the other side of the spine in the same location. 3. Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine is reached is the third step. The nurse should next auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine is reached. 4. Auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib is the fourth step. The final step is to auscultate the lateral sides slightly below the axillary area, and then auscultate down to the seventh or eighth rib.

The nurse is providing teaching to a client who has a new diagnosis of asthma and reports of smoking history of 20 years. Which of the following statements to the nurse make one counseling the client about her tobacco use?

Smoking is linked to various forms of cancer" is correct. Along with the development of respiratory disease, tobacco use is also associated with cancers of the colon, bladder, kidney, stomach, liver, and pancreas. There are no risks associated with exposure to secondhand smoke" is incorrect. The nurse should inform the client that exposure to secondhand smoke can lead to asthma, heart disease, lung cancer, and respiratory and ear infections. "It might take several attempts to finally stop smoking" is correct. The nurse should inform the client that nicotine is highly addictive and that attempts at smoking cessation are often not successful the first time. "There are pharmacologic therapies that can help a person stop smoking" is correct. The nurse should be prepared with a smoking cessation plan for the client that includes both cognitive and pharmacologic therapies.

A nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statement should the nurse make?

"You should make every effort to receive a flu vaccine every year." The nurse should explain to the client that the Centers for Disease Control and Prevention recommends that everyone older than 6 months of age should receive an annual influenza vaccine. Influenza can cause serious respiratory complications, even death, especially in those who are immunocompromised.