review resp quiz
A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best? (Select all that apply.) a.Administer oxygen and place client on an oximeter. b.Assess the client's lung sounds after administering the inhaler. c.Assess the client for a tracheal deviation. d.Administer prescribed salmeterol inhaler. e.Perform peak expiratory flow readings. f.Administer prescribed albuterol inhaler.
a, b, f
A nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms would the nurse be aware of? (Select all that apply.) a. General edema b. Expectorating purulent sputum c. "Moon" face and "buffalo" hump d. Gynecomastia in male patients e. Frequent shaking and sweating relieved by eating f. Positive Chvostek and Trousseau signs
a, c, d, e
*A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Swollen chin c. Nasal stuffiness d. Edema of the cheek e. Eye pain f. Ecchymosis behind the ear
a, f
A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.) a. Diabetes b. pulmonary disease c. Hypertension d. Weight gain e. Cognitive deficits f. Stroke
a,b,c,d,e,f
A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a.Allow visitors at the client's bedside. b.Keep the television tuned to a favorite channel. c.Provide back and hand massages when turning. d.Turn the client every 2 hours or more. e.Ensure that the client can communicate if awake.
a,c,d,e
A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)? a. Report any new onset of cough. b. Provide oral care every 4 hours. c. Encourage between-meal snacks. d. Monitor temperature every 4 hours.
b
A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a.Apply oxygen at 100%. b.Ensure a patent airway. c.Start two large-bore IV lines. d.Assess the respiratory rate.
b
A client is admitted with a PaO 2 of 54 mmHg and an arterial oxygen saturation of 80%. The nurse recognizes that which is the most likely cause for this type of acute respiratory failure? a. obesity b. pneumothorax c. oversedation d. cervical spinal cord injury
b
A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse to determine the best course of action. What will the new nurse do? a.Request an increase in the IV rate. b.Give the ordered diuretic as scheduled. c.Calculate the client's 24-hour fluid balance. d.Contact the primary health care provider.
b
A client with Guillain-Barre syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a. pH 7.50; PaCO2 30 mm Hg b. pH 7.25; PaCO2 50 mm Hg c. pH 7.40; PaCO2 35 mm Hg d. pH 7.35; PaCO2 40 mm Hg
b
A 58-year-old woman who has been diagnosed with throat cancer 1 week ago comes to the clinic today to discuss surgical options with her health care provider. Based on this diagnosis, which assessment finding does the nurse anticipate? a. Hoarseness b. Severe chest pain c. Low hemoglobin level (anemia) d. Numbness and tingling of the face
a
A client is demonstrating hypoxia and has arterial blood gases that indicate alkalosis. The chest x-ray shows bilateral patchy infiltrates. What other assessment findings might the nurse anticipate if the client's condition continues to worsen? a. hypotension b. hypertension c. decreasing HCO 3 d. hyperventilation
a
A new nurse asks for an explanation of "refractory hypoxemia." What answer by the staff development nurse is best? a."It is hypoxemia that persists even with 100% oxygen administration." b."It is chronic hypoxemia that accompanies restrictive airway disease." c."It is hypoxemia that continues even after the client is weaned from oxygen." d."It is hypoxemia from lung damage due to mechanical ventilation."
a
A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action? a. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. b. Cromone—disrupts the production of pathways of inflammatory mediators. c. Bronchodilator—stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. d. Corticosteroid—relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors.
a
A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient's teaching? a. "Make sure you clean the humidifier to prevent infection." b. "Add peppermint oil to the humidifier to relax the airway." c. "Keep the humidifier filled with water at all times." d. "Use the humidifier when you sleep, even during daytime naps."
a
An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The primary health care provider orders a chest x-ray. The family member questions why this is needed since the symptoms seem so vague. What response by the nurse is best? a. "Older people often have vague symptoms, so an x-ray is essential." b. "We are testing for any possible source of infection in the client." c. "The x-ray can be done and read before laboratory work is reported." d. "Chest x-rays are always ordered when we suspect pneumonia."
a
What should the nurse teach a child about using an albuterol metered-dose inhaler for exercise-induced asthma? a.Use the inhaler 30 minutes before exercise. b.Take one to two puffs every morning upon awakening. c.Use the inhaler only when the child is short of breath. d.Take two puffs every 6 hours around the clock.
a
Which assessment finding is most important for the nurse caring for a client with laryngeal trauma to report immediately to health care provider to prevent harm? a. Stridor b. Aphonia c. Productive cough d. Hoarseness
a
Which associated health problems will the nurse expect a client with long-term obstructive sleep apnea (OSA) to have? a. Hypertension and weight gain b. Cancer and autoimmune disorders c. Hypotension and chronic hypoglycemia d. Asthma and chronic obstructive pulmonary disease
a
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Disconnection at Y site b. Tracheal deviation c. Pain at insertion site d. Drainage greater than 70 mL/hr e. Sudden onset of shortness of breath f. Production of pink sputum
a, b, d, e
The nurse is assessing a child for epiglottitis. What findings are consistent with this condition? (Select all that apply.) a.Dysphonia b.Drooling c.Decreased oxygenation d.Dysphagia e.Distressed inspiratory efforts
a, b, d, e
A client has been diagnosed with an empyema. What interventions would the nurse anticipate providing to this client? (Select all that apply.) a. Facilitating pleural fluid sampling b. Performing frequent respiratory assessment c. Suctioning deeply every 4 hours d. Assisting with chest tube insertion e. Providing antipyretics as needed
a, b, d, e,
A client who is diagnosed with pertussis reports right-sided thoracic pain. The nurse should assess the client for which condition(s)? Select all that apply. a. rib fractures b. pneumothorax c. pulmonary emboli d. pleural effusion e. pleurisy
a, b, e
A nurse admits a client from the emergency department. Client data are listed below: History - Physical Assessment - Laboratory Values ° 70 years of age ° History of diabetes ° On insulin twice a day ° Reports new onset dyspnea and productive cough ° Crackles and rhonchi heard throughout the lungs ° Dullness to percussion LLL ° Afebrile ° Oriented to person only ° WBC 5,200/mm3 (5.2 × 109/L) ° PaO2 on room air 85 mm Hg What action by the nurse is the priority? a. Collect a sputum sample for culture. b. Administer oxygen at 4 L per nasal cannula. c. Begin broad-spectrum antibiotics. d. Start an IV of normal saline at 50 mL/hr.
b
A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate? a.Administer IV fluid boluses every 2 hours. b.Explain that xerostomia may be a permanent side effect. c.Ask the client to gargle with mouthwash containing lidocaine. d.Assess the client's neck for redness and swelling.
b
The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Nursing actions should include which of the following? a. Forcing fluids b. Monitoring pulse oximetry c. Instituting seizure precautions d. Encouraging a high-protein diet
b
Which primary health care provider's instruction will the nurse question for a client being discharged with nasal packing in place after a posterior nosebleed? a. Sleep in a recliner or with the head in an elevated position. b. Take ibuprofen 800 mg every 8 hours as needed for pain. c. Use a home humidifier for at least 5 days. d. Go to the nearest emergency room if bleeding recurs.
b
A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this client's evaluation? (Select all that apply.) a. Check peripheral veins for distention while at rest b. Determine the client's need and use of oxygen c. Examination of mucous membranes and nail beds d. Ability to perform activities of daily living e. Auscultation of bowel sounds for abnormal sounds f. Measurement of rate, depth, and rhythm of respirations
b, c, d, f
A nurse assesses a client with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the client's activity tolerance? (Select all that apply.) a."Do you walk upstairs every day?" b."How does your activity compare to this time last year?" c."What color is your sputum?" d. "How long does it take to perform your morning routine?" e. "Do you have any difficulty sleeping?" f. "Have you lost any weight lately?"
b,d,e,f
A client being mechanically ventilated has the following ventilator settings: SIMV 16, PEEP 20 cm of H 2O, FiO 2 45%, tidal volume .450 liters. What concerns will the nurse have for this client? a. oxygen toxicity b. volutrauma c. barotrauma d. sinusitis
c
A client diagnosed with chronic obstructive lung disease tells the nurse that their prescribed home oxygen is cumbersome and is not used because shortness of breath is seldom experienced. Which is the nurse's best response to this client? a. "I'm so glad that it seems like you are doing fine without it - so keep up this current regimen." b. "Keep the oxygen at home and if you become short of breath, you know to put it on until you are able to breath normally again." c. "Wearing the oxygen will help keep your blood oxygen saturation levels up so your heart does not have to work at hard and will not become enlarged." d. "You really should wear it at least while sleeping - even if you do not experience very much shortness of breath."
c
A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a."The client needs immediate intubation and mechanical ventilation." b."Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "Breathing so rapidly interferes with oxygenation."
c
A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action does the nurse take first? a. Facilitate a portable chest x-ray. b. Administer oxygen and reassess. c. Prepare to assist with intubation. d. Auscultate the client's lung sounds.
c
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL (142 g/L) b. White blood cell count: 8700/mm3 (8.7 × 109/L) c. Platelet count: 82,000/L (82 × 109/L) d. Red blood cell count: 4.8/mm3 (4.8 × 1012/L)
c
A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. What home care measure does the nurse educate parents about? a.Treating any fever with aspirin b.Isolation from family until symptoms resolve c.Providing humidity and increased fluids d.Taking the full course of antibiotics
c
Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome? a.Pulse more than 160 beats/min b.Circumoral cyanosis c.Grunting d.Substernal retractions
c
Which action will the nurse take first when a client with obstructive sleep apnea (OSA) who has been using continuous positive airway pressure (CPAP) with a facemask, returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness? a. Suggesting that a nasal mask be used instead of a nose and mouth facemask b. Reminding the client that sleep is important and to go ahead and take daytime naps c. Asking the client whether the mask fits tightly over the mouth and nose d. Encouraging the client to consider using over-the-counter sleep aids for deeper sleeping at night
c
Which questions are most relevant for the nurse to ask a client when assessing for risk factors and indications for head and neck cancer? (Select all that apply.) a."When was the last time you saw your dentist?" b."Have you had frequent episodes of acute or chronic visual problems?" c."Do you have recurrent laryngitis or frequent episodes of sore throat?" d."How many servings per day of alcohol do you typically drink?" e."Have you had a problem with sores in your mouth?" f."How many packs per day do you smoke and for how many years?"
c, d, e, f
A client is on mechanical ventilation and the client's spouse wonders why ranitidine is needed since the client "only has lung problems." What response by the nurse is best? a. "It will prepare the gastrointestinal tract for enteral feedings." b. "It will keep the gastrointestinal tract functioning normally." c. "It will increase the motility of the gastrointestinal tract." d. "It will prevent ulcers from the stress of mechanical ventilation."
d
A client with interstitial lung disease is prescribed prednisone to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly to avoid: a. restlessness and seizures b. hyperglycemia and glycosuria c. gastrointestinal bleeding d. adrenocortical insufficiency
d
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next? a. Palpate the nose, face, and neck. b. Perform a test focused on a neurologic examination. c. Encourage the client to blow his or her nose. d. Collect the nasal drainage on a piece of filter paper.
d
A nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which earliest sign of ARDS? a. inspiratory crackles b. intercostal retractions c. bilateral wheezing d. increased respiratory rate
d
A parent of a child with asthma asks if his child can still participate in sports. What response by the nurse is best? a. "Even with good asthma control, I would advise limiting the child to one athletic activity per school year." b. "Avoid swimming because exhaling underwater is dangerous for people with asthma." c. "Children with asthma are usually restricted from physical activities." d. "Children can usually play any type of sport if their asthma is well controlled."
d
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a.Determine if the tube is kinked. b.Suction the endotracheal tube. c.Ensure that all connections are patent. d.Listen to the client's lung sounds.
d
What is the nurse's best first action when the clear fluid draining from the nose of a client with a nasal fracture dries on a piece of filter paper and leaves a yellow "halo" ring at the dried edge of the fluid? a. Elevate the head of the bed to 90 degrees. b. Culture the sample. c. Document the finding as the only action. d. Notify the primary health care provider.
d
What is the nurse's best response to a client with obstructive sleep apnea (OSA) who asks, "Why does it feel like I wake up every 5 minutes?" a. "Excessive sleeping during the day interferes with deeper sleep at night." b. "You really aren't waking up that often. It just feels that way." c. "Your tongue may be blocking your throat, and you wake up because you are choking." d. "Carbon dioxide builds up while you are not breathing, which stimulates your body to wake up and breathe."
d
Which behavior indicates to the nurse that a client preparing for discharge after surgery understands how to perform self-care to prevent harm from aspiration? a. Chooses thin liquids that cause coughing but knows to take small sips. b. Eats small frequent meals that include a variety of textures and nutrients. c. Uses a straw when drinking liquid nutrition supplements. d. Positions self upright before eating or drinking anything.
d
