Respiratory PP

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be a. Ineffective airway clearance. b. Risk for falls. c. Impaired tissue integrity. d. Ineffective breathing pattern.

a. Ineffective airway clearance.

The nurse is auscultating the lung sounds of a client with long-standing emphysema. Which lung sounds are expected for this client? a. stridor b. diminished breath sounds c. pleural friction rub d. fine crackles

b. diminished breath sounds

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority? a. Impaired airway clearance b. Impaired physical mobility c. Impaired gas exchange d. Ineffective breathing pattern

c. Impaired gas exchange

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first? a. difficulty breathing b. activity intolerance c. nonproductive cough d. impaired gas exchange

d. impaired gas exchange

A client presents to a health care provider's office reporting of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the health care provider will make which diagnosis? a. empyema b. pulmonary tuberculosis c. chronic obstructive pulmonary disease (COPD) d. pulmonary hypertension

d. pulmonary hypertension

The nurse is caring for a client who has undergone a pulmonary lobectomy 2 days ago. Which finding indicates the client may be experiencing internal bleeding? a. increased blood pressure and decreased pulse and respiratory rates b. sanguineous drainage from the chest tube at a rate of 50 mL/hr during the past 3 hours c. urine output of 180 mL during the past 3 hours d. restlessness and shortness of breath

d. restlessness and shortness of breath

A client has been in an automobile accident, and the nurse is assessing the client for possible pneumothorax. What finding should the nurse immediately report to the health care provider? a. cyanosis b. wheezing breath sounds over affected side c. hemoptysis d. sudden, sharp chest pain

d. sudden, sharp chest pain

The nurse is assessing the breath sounds of a client with emphysema and hears crackles. What does this finding indicate? a. normal sounds produced by increased airflow out of the lungs b. normal sounds caused by the elevation of the diaphragm c. abnormal sounds because of constricted airspaces in the lungs d. abnormal sounds due to destruction of alveolar walls

d. abnormal sounds due to destruction of alveolar walls

The nurse is conducting a health history with a client with active tuberculosis. The nurse should ask the client about which symptom? a. dyspnea on exertion b. mental status changes c. increased appetite d. weight loss

d. weight loss

An adult with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse determines the client has a temperature of 103°F (39.4°C), body chills, and leukocytosis. The client begins to have difficulty breathing. In what order from first to last should the nurse perform the actions? All options must be used. 1. Explain the situation to the family 2. Open the airway 3. Call the HCP 4. Start an IV access site

1. Open the airway 2. Start an IV access site 3. Call the HCP 4. Explain the situation to the family

The nurse is caring for an older adult client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. a. Keep the client oriented. b. Obtain vital signs. c. Apply antiembolic stockings. d. Initiate oxygen therapy as needed. e. Assess the client's breath sounds.

a. Keep the client oriented. b. Obtain vital signs. c. Apply antiembolic stockings.

A client has been diagnosed with bacterial pneumonia. After 1 day of IV antibiotic therapy, the client's white blood cell count is still 14,000/mm3 (14 × 109/L). What should the nurse do next? Normal WBC- 4,500-11,000 a. Notify the health care provider. b. Recheck the client's white blood cell count in 24 hours. c. Administer the next scheduled antibiotic dose early. d. Initiate reverse isolation precautions.

a. Notify the health care provider.

A client has a chest tube attached to a water-seal drainage system, and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. How should the nurse interpret this finding? a. The lung has fully expanded. b. The lung has collapsed. c. The chest tube is in the pleural space. d. The mediastinal space has decreased.

a. The lung has fully expanded.

A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin. Which instruction(s) should the nurse give the client about the potential adverse effects of rifampin? Select all that apply. a. The urine may have an orange color. b. Maintain follow-up monitoring of liver enzymes. c. Decrease protein intake in the diet. d. Avoid alcohol intake. e. Have eye examinations every 6 months.

a. The urine may have an orange color. b. Maintain follow-up monitoring of liver enzymes. d. Avoid alcohol intake.

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? a. decreased breath sounds b. wheezes c. rhonchi d. Crackles

a. decreased breath sounds

A client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the nurse should observe the client for which finding? a. hypoventilation b. Bell palsy c. loss of gag reflex d. Vertigo

a. hypoventilation

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention? a. inability to speak b. distant heart sounds c. diminished lung sounds d. pursed lip breathing

a. inability to speak

The nurse auscultates the lungs of a client who has been diagnosed with a tumor in the lung and notes wheezing over one lung. What additional assessment should the nurse make? a. obstruction of the airway b. the presence of exudate in the airways c. an indication of pleural effusion d. the client's history of smoking

a. obstruction of the airway

Arterial blood gas analysis would reveal which finding related to acute respiratory failure? a. pH 7.24 b. PaO2 80 mm Hg c. pH 7.35 d. PaCO2 32 mm Hg

a. pH 7.24

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention? a. partial pressure of arterial oxygen (PaO2) of 69 mm Hg b. bicarbonate (HCO3-) of 28 mEq/L c. partial pressure of arterial carbon dioxide (PaCO2) of 51 mm Hg d. pH of 7.29

a. partial pressure of arterial oxygen (PaO2) of 69 mm Hg

Which sign is an early indicator of hypoxia in an unconscious client? a. restlessness b. decreased respirations c. cyanosis d. Hypotension

a. restlessness

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication is associated with respiratory acidosis? a. shock b. seizures c. stroke d. Hyperglycemia

a. shock

What factor has the potential to lead to chronic respiratory acidosis in older adults? a. thoracic skeletal changes b. decreased renal function c. .overuse of sodium bicarbonate d. erratic meal patterns

a. thoracic skeletal changes

The nurse monitors a client following the insertion of a chest tube for a hemopneumothorax. Which observation should the nurse report to the health care provider? a.intermittent bubbling in the water seal chamber b. 600 mL of blood in the collection chamber in 1 hour c. subcutaneous emphysema at the insertion site d. continuous bubbling in the suction-control chamber

b. 600 mL of blood in the collection chamber in 1 hour

The nurse includes developing a teaching plan for the client newly diagnosed with chronic obstructive pulmonary disease (COPD). Which information should be included in the plan? Select all that apply a. Pneumococcal vaccination is contraindicated for clients with lung disease. b. Smoking cessation is important to slow or stop disease progression. c. A bronchodilator with a metered-dose inhaler should be readily available. d. Pulmonary rehabilitation programs offer very little benefit. e. High humidity increases the effort of breathing.

b. Smoking cessation is important to slow or stop disease progression. c. A bronchodilator with a metered-dose inhaler should be readily available. e. High humidity increases the effort of breathing.

The nurse is assessing a client with a right pneumothorax. Which assessment findings would be expected? Select all that apply a. bilateral pleural friction rub b. absence of breath sounds in the right thorax c. inspiratory wheezes in the right thorax d. tracheal shift to the right e. chest pain on inspiration

b. absence of breath sounds in the right thorax e. chest pain on inspiration

A client who has asthma is taking albuterol to treat bronchospasms. The nurse should assess the client for which adverse effect(s) that can occur as a result of taking this drug? Select all that apply a. lethargy b. nausea c. nervousness d. constipation e. Headache

b. nausea c. nervousness e. Headache

The nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed? a. moist saline b. petrolatum gauze c. adhesive strips d. 4 x 4 gauze

b. petrolatum gauze

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? a. bradycardia b. reduced cardiac output c. tachycardia d. increased blood pressure

b. reduced cardiac output

A client with chronic obstructive pulmonary disease tells a nurse that they feel short of breath. The client's respiratory rate is 36 breaths/minute and the nurse auscultates diffuse wheezes. The client's arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer an ordered nebulizer treatment. The therapist says, "I have several more nebulizer treatments to do on the unit where I am now. As soon as I'm finished, I'll come and assess the client." The nurse's most appropriate action is to a. administer the treatment by metered-dose inhaler. b. the nurse gives the nebulizer treatment. c. stay with the client until the therapist arrives. d. notify the primary health care provider immediately.

b. the nurse gives the nebulizer treatment.

A client with asthma who has wheezing and shortness of breath asks the nurse if it is all right to use the salmeterol inhaler during exercise. What is the nurse's best response? a. "Use the inhaler 5 minutes before you exercise to prevent the wheezing." b. "Yes, use the inhaler immediately for these symptoms." c. "No, this drug is a maintenance drug, not a rescue inhaler." d. "This inhaler is for allergic rhinitis, not asthma."

c. "No, this drug is a maintenance drug, not a rescue inhaler."

The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. What should the nurse do next? a. Continue monitoring as usual; this is expected. b. Decrease the suction and continue observing the system for changes in bubbling during the next several hours. c. Check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system. d. Notify the health care provider (HCP).

c. Check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system.

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? a. Medicate with acetaminophen. b. Administer an albuterol inhaler. c. Encourage client to cough and take a deep breath. d. Administer oxygen at 100% nonrebreather mask.

c. Encourage client to cough and take a deep breath.

A client who has had a pulmonary lobectomy is having pain when coughing. What action should the nurse take to help the client manage their pain? a. Place the bed in a slight Trendelenburg position, and help the client turn onto the operative side to splint the incision. b. Keep the bed flat, and tell the client to place the hands over the incision before taking a deep breath. c. Raise the bed to semi-Fowler position, and position the client's hands so that the incision is supported anteriorly and posteriorly. d. Raise the bed to complete Fowler position, and help the client turn onto the operative side to splint the incision.

c. Raise the bed to semi-Fowler position, and position the client's hands so that the incision is supported anteriorly and posteriorly.

A client is scheduled to undergo a bronchoscopy. Which nursing interventions would be included on the care plan? Select all that apply. a. Explain to the client that a tube will be inserted through the nose and into the stomach. b. Instruct that the client will be awake during the procedure. c. Report hemoptysis, stridor, or dyspnea immediately. d. Keep suction equipment available. e. Assess cough and gag reflexes after the procedure. f. Feed the client immediately after the procedure.

c. Report hemoptysis, stridor, or dyspnea immediately. d. Keep suction equipment available. e. Assess cough and gag reflexes after the procedure.

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer? a. an oral corticosteroid b. an inhaled corticosteroid c. an inhaled beta2-adrenergic agonist d. an I.V. beta2-adrenergic agonist

c. an inhaled beta2-adrenergic agonist

A nurse is caring for a client who had a chest tube inserted 12 hours ago for treatment of a pleural effusion. Which assessment is most important in determining the client's response to the treatment? a. serous drainage in the collection chamber b. client resting quietly without reports of pain c. client verbalization of decreased dyspnea d. intermittent bubbling in the water seal chamber

c. client verbalization of decreased dyspnea

The nurse is developing a discharge plan with a client with chronic obstructive pulmonary disease (COPD). What information should the nurse include in the plan? People with COPD: a. usually maintain their current status. b. require less supplemental oxygen. c. develop respiratory infections easily. d. show permanent improvement.

c. develop respiratory infections easily.

The nurse is caring for a client with an acute exacerbation of advanced chronic obstructive pulmonary disease (COPD). Which assessment findings does the nurse expect? a. prolonged inspiratory phase and peripheral edema b. rhinitis, frequent coughing, and low oxygen saturation c. dyspnea, wheezing on auscultation, and polycythemia d. crackles on auscultation and increased blood pressure

c. dyspnea, wheezing on auscultation, and polycythemia

The nurse is teaching a client with asthma to avoid situations that will precipitate an asthma attack. Which situation should the nurse instruct the client to avoid? a. Valsalva maneuver b. occupational exposure to toxins c. exposure to cigarette smoke d. exercising in cold temperatures

c. exposure to cigarette smoke

A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse's next action is based on the principle that: a. Encouraging the client to void before the medication takes effect will promote safety. b. this client may need intubation. c. it may be necessary to raise the head of this client's bed. d. a quiet environment should be provided.

c. it may be necessary to raise the head of this client's bed.

Which finding in a client diagnosed with asthma would require a nurse to take immediate action? a. diaphoresis b. anhidrosis c. lethargy d. Cough

c. lethargy

The nurse is assessing a client who has a chronic obstructive respiratory disorder. Which finding should be immediately reported to the health care provider? a. clubbing of fingernails b. barrel chest c. pedal edema d. decreased tactile fremitus

c. pedal edema

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? a. turning the client every 4 hours to prevent fatigue b. providing oral hygiene daily c. using strict hand hygiene d. keeping the head of the bed at 15 degrees or less

c. using strict hand hygiene

A homeless client comes to the clinic coughing up blood and is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the pharmacological treatment regimen? a. Provide the client with written instructions about the importance of adherence to the treatment plan. b. Arrange for the client to pick up the medication in unit dose packaging at a local pharmacy. c. Recommend having the client admitted to the hospital until the medication regimen is completed. d. Arrange for the client to come to a community center each day to receive a meal and medication.

d. Arrange for the client to come to a community center each day to receive a meal and medication.

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up? a. a 42-year-old client who has left lower lobe pneumonia and an I.V. line b. an 84-year-old client with heart failure who's on telemetry and 2 L/minute of oxygen c. a 48-year-old client with chronic obstructive pulmonary disease with occasional atrial fibrillation d. a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line

d. a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line