select all that apply resp
The nurse is preparing a list of homecare instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse reinforce? Select all that apply.
1.Activities should be resumed gradually. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4.Respiratory isolation is not necessary because family members have already been exposed. 5.Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags.
The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply.
1.Apply suction for up to 10 seconds. 2.Hyperoxygenate the client before suctioning 5.Apply intermittent suction while rotating and withdrawing the catheter 6.Advance the catheter until resistance is met and then pull the catheter back 1 cm.
A client at risk for pulmonary embolism (PE) suddenly develops respiratory distress, chest pain, and anxiety. The nurse should plan to take which actions? Select all that apply.
1.Check vital signs 3.Notify the registered nurse 4.Begin low-flow oxygen therapy.
Which diagnostic tests indicate active tuberculosis? Select all that apply.
1.Chest x-ray 3.Gastric analysis washings 4.Sputum smear and culture
Which are signs and symptoms characteristic of emphysema? Select all that apply
1.Cyanosis 3.Weight loss 4.Barrel chest 5.Shortness of breath 6.Decreased lung sounds
Which are signs and symptoms characteristic of emphysema? Select all that apply.
1.Cyanosis 3.Weight loss 4.Barrel chest 5.Shortness of breath 6.Decreased lung sounds
The nurse is caring for a client with laryngitis. Which interventions should the nurse implement? Select all that apply.
1.Discourage smoking. 2.Use a room humidifier 5.Use lozenges that contain a topical anesthetic agent
The nurse is preparing to assist a primary health care provider with the insertion of a chest tube. The nurse anticipates that which supplies will be required for the chest tube insertion site? Select all that apply.
1.Elastoplast tape 3.Sterile 4 × 4 gauze pads 4.Povidone-iodine solution 5.Petrolatum (Vaseline) gauze
The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply.
1.Enables the client to speak 3.Must have the cuff deflated when capped
A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. Which recommendations by the nurse are therapeutic? Select all that apply.
1.Get plenty of rest. 2.Take antipyretics for fever 3.Increase intake of liquids.
The nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms? Select all that apply.
1.Hemoptysis 4.A sensation of a "lump" in the throat 5.Hoarseness lasting more than 3 weeks
The nurse is collecting data on a client with chronic sinusitis. Which are signs and symptoms of chronic sinusitis? Select all that apply.
1.Loss of smell 2.Chronic cough 3.Nasal stuffiness
A client is admitted to the emergency department with carbon monoxide poisoning. Which signs and symptoms indicate carbon monoxide poisoning? Select all that apply.
1.Mental changes 2.Cardiac irregularities 3.Cherry-red skin color
The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions should the nurse take? Select all that apply.
1.Notify the RN. 4.Discontinue suctioning until the client is stabilized.
The client is diagnosed with pleurisy. The nurse should expect to see which signs and symptoms? Select all that apply.
1.Pleural friction rub 2.Sharp, knife-like pain 5.Pain that occurs most often during inspiration
The nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Which instructions should the nurse provide to the client? Select all that apply.
1.Protect the stoma from water 2.Soaps should be avoided near the stoma 3.Wash the stoma daily using a washcloth 5.Apply a thin layer of petroleum jelly to the skin surrounding the stoma.
The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observations are consistent with the need for suctioning? Select all that apply.
1.Restlessness 2.Gurgling sounds with respiration 3.Presence of congestion in the lungs 4.Increased pulse and respiratory rates
A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. Which statements indicate prevention of transmission of tuberculosis? Select all that apply.
2."My family and I will practice good hand hygiene." 3."I will discard disposable tissues into a plastic bag." 4."I will cover my mouth when I cough, sneeze, or laugh.
The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply.
2.Be sure all connections remain airtight 3.Be sure all connections are taped and secure. 4.Monitor closely for tubing that is kinked or obstructed
The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions should the nurse anticipate performing during this process? Select all that apply.
2.Cover the site with an occlusive dressing after the tube is removed 5.Have the client perform the Valsalva maneuver as the chest tube is pulled out.
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply.
2.Dyspnea during exertion 3.Presence of a productive cough 4.Difficulty breathing while talking
The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis? Select all that apply.
2.Early onset cough 4.Purulent mucous production 5.Mild episodes of dyspnea
The nurse is collecting data from a client who is experiencing the typical signs/symptoms of tuberculosis (TB). Which are signs and symptoms of tuberculosis? Select all that apply.
2.Night sweats 4.Mucopurulent sputum 5.Afternoon low grade fever
Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply.
2.Position on the side until fully recovered 3.Encouraging coughing and deep breathing 4.Monitoring pulse oximetry readings frequently 5.Encouraging the use of an incentive spirometer
The nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention should be included? Select all that apply.
2.Rest 3.Local heat 4.Analgesics
The nurse is assessing a client diagnosed with sinusitis. Which are signs and symptoms of sinusitis? Select all that apply.
3.Headache, especially in the morning 4.Elevated white blood cell (WBC) count 5.Feeling of heaviness over affected areas