Unit two respiratory EAQ

In which order would the nurse take these actions when suctioning a client who is receiving mechanical ventilation ? 1. Hyperoxygenate for 30 sec 2. Obtain VS 3. Auscultate lung sounds 4. Rotate catheter during withdrawl 5. Suction for 10 sec

2, 3, 1, 5, 4

Which early sign or symptom would the nurse expect while obtaining a health history for a patient with suspected tuberculosis ( TB ) ? Select all that apply . A. Anorexia B. Fatigue C. Dizziness D. Night sweats E. Chest tightness

A, B, D

Which is an adverse effect of albuterol ? Select all that apply . A. Tremors B. Skin rashes C. Palpitations D. Tachycardia E. Hypoglycemia

A, C, and D

Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery? A. Assist client to use the IS B. Administer prescribed IV antibiotic C. Take client vital signs every 4 hours D. Auscultate breath sounds every 4 hours

A. Assist client to use the IS

When a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate? A. Cordectomy B. Tracheotomy C. Total laryngectomy D. Orophayngeal resections

A. Cordectomy

When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary exercises, which response by the nurse is best? A. Tell me about your typical day before you were diagnosed with chronic lung disease B. Smoking and not doing the exercises will make your lung disease to continue to get worse C. I can't make you stop doing what you are doing, it's your choice to be sick or well D. Your SOB is probably because of your smoking and not doing the exercises

A. Tell me about your typical day before you were diagnosed with chronic lung disease

Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply Facial edema Septal defect Clear nasal drainage Oxygenation saturation 89% Bilateral periorbital bruising

All of them

Which risk factor for head and neck cancer would the nurse assess for a client with a persistent nagging cough? Select all that apply A. Type of employment B. Presence of ear pain C. History of tobacco use D. Oral hygiene practices E. Amount of alcohol intake

All of them

When caring for a client with emphysema who becomes more restless , which action would the nurse take first ? A. Auscultate lung sounds B. Check O2 saturation C. Observe for increased respriatory effort D. Ask about increased SOB

B. Check O2 saturation

Which parameter describes the maximum volume of air in a clients lungs may contain? A. Vital capacity B. Total lung capacity C. Inspiratory capacity D. Functional residual capacity

B. Total lung capacity

Which term will the nurse use to document when percussion results in a moderately low-pitched sound over the chest? A. Dull B. Tympany C. Resonance D. Hyperresonance

C. Resonance

The nurse anticipates that which procedure will be prescribed as the main diagnostic test for cystic fibrosis ? A. Chest xray B. Lung biopsy C. Sweat chloride test D. Sputum culture and gram stain

C. Sweat chloride test

Which type of emergency equipment would the nurse ensure is readily available at the bedside after a client has surgery for a malignant lesion on a vocal cord ? A. Crash cart with bed board B. Airway and rebreathing mask C. Tracheostomy set and oxygen D. Ampule of sodium bicarbonate

C. Tracheostomy set and oxygen

A patient with human immunodeficiency virus ( HIV ) infection has been admitted with pneumonia . For which type of pneumonia would the nurse anticipate that the patient will receive treatment ? A. Aspiration pneumonia B. Hospital-associated pneumonia C. Community-acquired pneumonia D. Oppotunistic pneumonia caused by pneumoncystis jioveci

D. Oppotunistic pneumonia caused by pneumoncystis jioveci

Which patient is experiencing restrictive lung disease from an intrapleural cause Patient 1- antobiotic therapy for bacterial pneumonia Patient 2- mechanical ventilation for opiate overdose Patient 3- oxygen therapy for obesity-hypoventilation Patient 4- acute exacerbation for muscular dystrophy

Patient 1

Which instruction would the nurse include when teaching a client how to perform diaphragmatic breathing? A. Take rapid, deep breaths B. Breath with hands on the hips C. Expand the abdomen on inhalation D. Lean forward from a sitting position

C. Expand the abdomen on inhalation

What information would the nurse provide to decrease allergen exposure in the home? A. Remove carpeting B. Eliminate charging cords C. Leave clothing on hangers D. Store bedding in dark room

A. Remove carpeting

Which question will the nurse ask when assessing a patient's sleep test pattern related to respiratory health? Select all that apply A. Do you have trouble falling asleep B. Do you urinate during night C. Do awake abruptly throughout night D. Do you sleep more than 8 hours a night E. Do you need to sleep with the head elevated

A, C, and E

Which type of fremitus will the nurse expect in a patient with a pneumothorax? A. Absent B. Normal C. Increased D. Decreased

A. Absent

The nurse is caring for a 75 year old patient who had radial head and neck surgery. Thirty minutes after awakening from anesthesia, client becomes agitated, disoriented, and confused. Which action should the nurse take? A. Administer prescribed oxygen B. Administer prescribed anxiety medication C. Notify health care provider immediately D. Record observations and continue to observe

A. Administer prescribed oxygen

A newly hired nurse provides post op care to a client after a laryngectomy. The new nurse reminds the client not to eat or drink anything until instructed to do so. How would the preceptor evaluate the instructions given by the new nurse? A. Appropriate; oral intake after a procedure may result in aspiration B. Appropriate; it is important to limit painful swallowing C. Inappropriate; the client is too groggy after general anesthesia to comprehend information D. Inappropriate; fluid replacement should begin immediately after procedure

A. Appropriate; oral intake after a procedure may result in aspiration

A patient is hospitalized with a diagnosis of pneumonia . When reviewing the patient's history , the nurse finds that the patient experienced a seizure with profuse vomiting 4 days prior to the hospital admission . Which type of pneumonia does the nurse suspect ? A. Aspiration pneumonia B. Opprtunistic pneumonia C. Hospital associated penumonia D. Community-acquired pneumonia

A. Aspiration pneumonia

A client who is receiving peritoneal dialysis reports severe difficulty breathing. What immediate action would the nurse implement? A. Auscultation lungs B. Obtain ABG C. Notify health care provider D. Apply pressure to the abdomen

A. Auscultation lungs

Which instructions would the nurse share with the client being discharged after rhinoplasty? A. Avoid items that may trigger sneezing B. Consume fluids at a tepid temperature C. Brush the teeth thoroughly after each food intake D. Sleep on the back using one pillow underneath

A. Avoid items that may trigger sneezing

A client with a history of hemoptysis and cough for the past 6 months is suspected of having lung cancer . A bronchoscopy is performed . Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum . Which is the nurse's priority ? A. Contact HCP B. Document amount of sputum C. Monitoe VS every hour D. Increase frequency of cough and deep breathinf exercises

A. Contact HCP

The nurse will recommend that which activity should be avoided while the parent is taking diphenhydramine for recurrent rhinitis? A. Driving B. Exercising C. Sexual activity D. Watching TV

A. Driving

Which lung issue aligns with these assessment findings in the postoperative patient ? Respirations- 20, pulse ox- 92%, left sided chest tube drainage- purulent A. Empyema B. Atelectasis C. Pulmonary embolism D. Idopathic pulmonary fibrosis

A. Empyema

The treatment plan for a patient with tuberculosis includes isoniazid ( INH ) and rifampin . Which data found in the patient's health history would cause the nurse to question the medication prescriptions ? A. Hepatitis B. Asthma attacks C. Rheumatic fever D. Allergy to penicillin

A. Hepatitis

Administration of the season influenza vaccine would be contraindicated for the adult with which condition? A. Hypersensitivity to eggs B. Age greater than 80 years C. History of URI D. COPD

A. Hypersensitivity to eggs

A patient with a 10 - year history of regular ( three beers per week ) alcohol consumption began taking rifampin to treat tuberculosis ( TB ) . During a follow - up visit 1 week after starting the medication , the patient tells the nurse , " In the last week , my urine turned orange , and I am very worried about it . " Which action would the nurse perform based on this information ? A. Inform the patient that this is an expected side effect B. Recognize that the TB may have spread to the liver C. Instruct the patient to stop taking immediately D. Recignize that the liver may be damaged from alcohol consumption

A. Inform the patient that this is an expected side effect

While in the post anesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? A. Initiate oxygen via a nasal cannula. B. Administer the prescribed morphine. C. Prepare the client for endotracheal intubation. D. Place a nitroglycerin tablet under the client's tongue.

A. Initiate oxygen via a nasal cannula.

A client who has a history of emphysema is transported back to the nursing unit after a radical neck dissection for cancer of the tongue . The client is receiving oxygen and an intravenous infusion . Within the first hour , the client has 50 mL of sanguineous drainage in the portable wound drainage system . Which initial action would the nurse take ? A. Inspect the dressing B. Increase the oxygen flow rate C. Notify HCP D. Place client in the supine position

A. Inspect the dressing

Which type of surgery involves the removal of one lobe of the lung ? A. Lobectomy B. Pneumonectomy C. Wedge resection D. Segmental resection

A. Lobectomy

Which vaccine would the nurse recommend to a 65 year old patient with COPD? A. Penumococcal B. Staphylococcus aureus C. Haemophilus influenzae D. Bacille calmette- guerin

A. Penumococcal

When caring for a client after a thoracotomy , which action would the nurse take to keep the chest tube and closed chest drainage system patent ? A. Position the drainage below the level of the clients heart B. Empty the collection chamber and measure contents every 12 hours C. Assure a daily chest x-ray is done to check for placement D. Keep the client on bed rest unril chest tube is disconnected

A. Position the drainage below the level of the clients heart

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suction? A. Pre-oxygenated the client before suctioning B. Employ gentle suctioning as the catheter is being inserted C. Loosen the client's secretions before suctioning by instilling saline D. Ensure that the cuff of the tracheostomy is inflated during suctioning

A. Pre-oxygenated the client before suctioning

What color tag would the triage nurse working at a train accident use to label a client experiencing respiratory distress? A. Red B. Black C. Green D. Yellow

A. Red

Which factor places a patient at risk for aspiration? A. Seizures B. Gillian- barre syndrome C. Illicit drug use D. Recent abdominal surgery

A. Seizures

Which statement describes a client's tidal volume? A. Tidal volume is the volume of air inhaled and exhaled with each breath B. Tidal volume is the amount of air remaining in the lungs after forced expiration C. Tidal volume is the additional air forcefully inhaled after normal inhalation D. Tidal volume is the additional air forcefully exhaled after normal exhalation

A. Tidal volume is the volume of air inhaled and exhaled with each breath

Which assessment finding is consistent with bronchospasms? A. Wheezing B. Rhonchi C. Pleural friction rub D. Low- pitched crackles

A. Wheezing

Which intervention would the implement to help prevent atelectasis in a client with fractured rib as a result of chest trauma? A. Apply a thoracic binder for support B. Encourage coughing and deep breathing C. Defer pain medication the first day after injury D. Position the client face- down on a soft mattress

B. Encourage coughing and deep breathing

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest? A. Crackling B. Wheezing C. Decreased sounds D. Vesicular sounds

C. Decreased sounds

When a client who has had a thoracotomy develops respiratory acidosis , which action would the nurse take ? A. Administer oral fluids B. Encoruage deep breathing C. Increase oxyegn flow rate D. Perform nasotracheal suctioning

B. Encoruage deep breathing

Which nursing action will help a client obtain maximum benefits after postural drainage? A. Administer oxygen B. Encourage cough deeply C. Place a client in a sitting position D. Encourage the client to rest for 30 minutes

B. Encourage cough deeply

When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention? A. Maintains a sterile field B. Applies suction during insertion of the catheter C. Preoxgenate with 100% oxygen for 1 minute D. Tests suction pressure at 100 mm Hg before inserting catheter

B. Applies suction during insertion of the catheter

A client with COPD is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention? A. Administer opioids frequently B. Assess for signs of pneumonia C. Give medications to suppress coughing D. Limit fluid intake to prevent pulmonary edema

B. Assess for signs of pneumonia

Which condition would the assessment findings below indicate in the postoperative? Respirations-20, pulse ox 92%, auscultation- diminshed bases, percussion- dullness in bases A. Pleuisy B. Atelectasis C. Pulmonary embolism D. Idiopathic pulmonary fibrosis

B. Atelectasis

Which action by a client who has had a radical neck surgery for laryngeal cancer is the best indicator that the client is reaching acceptance of the laryngectomy ? A. Smiles and knteracts with nursing staff B. Attempts self- care of the tracheal stoma C. Ambulates in hospital hallway D. Allows the spouse to suction the stoma

B. Attempts self- care of the tracheal stoma

Which finding by the home health nurse who is visiting a client who has had laryngeal cancer surgery indicates a need for further intervention? A. Client leans forward while coughing B. Client smokes 4 cigarettes per day C. Client avoids showering and swimming D. Client uses a water based ointment to lubricate the stoma

B. Client smokes 4 cigarettes per day

What muscle primarily drives respirations? A. Accessory B. Intercostal C. Diaphragm D. Abdominal

C. Diaphragm

A client appears anxious , exhibiting 40 shallow respirations per minute . The client reports dizziness , light - headedness , and tingling sensations of the fingertips and around the lips . The nurse concludes that the client's symptoms are most likely related to which condition ? A. Eupnea B. Hyperventilation C. Kussmaul respirations D. Carbon dioxide intoxication

B. Hyperventilation

Which statement by a client who is being discharged with a new prescription for home oxygen therapy indicates the need for further instruction by the nurse ? A. I will use only grounded electrical equipment B. I have a new woolen blanket to keep me warm C. I have told my family they cannot smoke in the house D. I will keep a pitcher of water near me so I drink enough

B. I have a new woolen blanket to keep me warm

The nurse provides education about self-care management to a client who was recently diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement? A. I will try to avoid smoking B. I will maintain complete bed rest C. I'll control the temp in my home D. I'll need to clean my mouth several times a day

B. I will maintain complete bed rest

The nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What would the nurse include? A. Purpose of bronchodilators B. Importance of meticulous oral hygiene C. Technique of purse- lip breathing D. Methods used to maintain dust free environment

B. Importance of meticulous oral hygiene

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system . If the chest tube and closed chest drainage system are effective , which type of pressure will be reestablished ? A. Neurtal pressure in the pleural space B. Negative pressure in the pleural space C. Atmospheric pressure in the thoracic cavity D. Intrapulmonic pressure in the thoracic cavity

B. Negative pressure in the pleural space

When a client with pneumonia is experiencing dyspnea because of difficulty expectorating thick respiratory secretions , which action by the nurse will be most helpful ? A. Administer continuous oxygen B. Offer fluids and frequent intervals C. Place client in high fowlers D. Administer prescribed steriod inhaler

B. Offer fluids and frequent intervals

Which response is appropriate when a patient complains of worsening nasal congestion despite the use of oxymetazoline nasal spray every 2 hours ? A. Oxymetazoline is not an effective nasal decongestant B. Overuse of nasal congestants results in rebound congestion C. You are probably displaying an unexpected reaction D. Oxymetazoline should be administered every hour for severe congestion

B. Overuse of nasal congestants results in rebound congestion

For which condition would the nurse monitor for signs and symptoms of a patient that just got a thoracentesis? A. Brochospasm B. Pneumothorax C. Pulmonary edema D. Respiratory acidosis

B. Pneumothorax

Which is the function of the waterseal chamber on a closed chest drainage system for a client with a hemothorax? A. Collects drainage from pleural space B. Prevents reflux of air back into the pleural space C. Promotes drainage of blood from pleural space D. Controls level of suction applied to intrapleural space

B. Prevents reflux of air back into the pleural space

A client is admitted to the emergency department with a stab wound of the chest . Which is a priority nursing assessment ? A. Level of pain B. Quality and depth of respirations C. Amount of seroanginous fluid D. BP and pupillary response

B. Quality and depth of respirations

A client is experiencing an acute episode of bronchial asthma . The nurse would focus on which goal when creating the client's plan of care ? A. Curing the condition permanently B. Removing mucous secertions from the chest C. Limiting pulmonary secretions by decreasing fluid intake D. Helping the client recognize that the condition is emotionally based

B. Removing mucous secertions from the chest

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? A. Respiratory acidosis B. Respiratory alkalosis C. Respiratory compensation D. Respiratory decompression

B. Respiratory alkalosis

When the nurse is using the Transtheoretical Model of Health Behavior Change , which assessment finding indicates that the client is the preparation stage for tobacco cessation ? A. Client states i know i should quit smoking B. The client purchases nicotine gum and lozenges C. The client reports smoking to help with relaxation D. The client has not smoked since hospital admission

B. The client purchases nicotine gum and lozenges

Which finding while palpating the chest will prompt the nurse to contact the HCP immediately? A. Increase tactile fremitus B. Trachea moved to the left C. Decreased tactile fremitus D. Diminished chest movement

B. Trachea moved to the left

Which assessment finding is the most common clinical manifestation of an asthma attack ? A. Hypoxia B. Wheezing C. Tachypnea D. Hypertension

B. Wheezing

The nurse expects which medication may be prescribed for a patient who presents with fever , muscle aches , cough , sore throat , chills , and a positive rapid diagnostic influenza test ? A. Zileuton B. Zanamivir C. Loratadine D. Diphenhydramine

B. Zanamivir

Which action would the nurse take to prevent aspiration recurrence in a client with aspiration pneumonia who is NPO status with a nasogastric tube and a prescription for antibiotics ? A. Obtaining VS after feeding B. Administering IV antibiotics C. Elevating the HOB to 30 degrees D. Determining residual every 4 hours

C. Elevating the HOB to 30 degrees

Which diagnostic test will the nurse expect the HCP to run to measure the efficiency of gas transfer in the lung and tissue oxygenation? A. Thoracentesis B. Bronchoscopy C. ABG D. Pulmonary function test

C. ABG

A client is admitted to the ED after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. The nurse would monitor the client for which life threatening response? A. Ischemia B. Lactic acidosis C. Anaphylaxis D. Increased BP

C. Anaphylaxis

Which action would the nurse take to prevent postoperative respiratory complications after abdominal surgery ? A. Implement postural drainage B. Encourage pursed- lip breathing C. Assist with IS D. Teach sustained exhalation

C. Assist with IS

Which information would the nurse include when educating a patient with newly diagnosed active tuberculosis ( TB ) about the medication regimen of rifampin , ethambutol , and isoniazid ? A. Monitor intake and output B. Report orange colored urine C. Complete the entire regimen D. Inform that the drugs can cause dysrhythmias

C. Complete the entire regimen

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, what is appropriate to include? A. They are indicative of pleural rubbing B. They are signs of bronchial constriction C. Crackles are located in smaller air passages D. Crackles are heard during respiratory expiration

C. Crackles are located in smaller air passages Crackles are heard during inspiration

When the nurse assesses a closed chest drainage system for a postoperative client after thoracotomy , which finding indicates correct functioning of the water - seal chamber ? A. Comtains many small air bubbles B. Bubbles vigorously on inspiration C. Fluid rises wirh inspiration and falls with expiration D. Remains at a consistent level during the respiratory cycle

C. Fluid rises wirh inspiration and falls with expiration

Which action would the nurse anticipate taking when a client with anxiety begins hyperventilation and reports feeling dizzy? A. Admin oxyegn B. Offering IS C. Having client breath in and out paper bag D. Administering IV sodium bicarb

C. Having client breath in and out paper bag

When caring for a client with a possible pulmonary embolism , the nurse will anticipate preparing the client for which test ? A. Chest XR B. Thoracic ultrasound C. Helical computed tomography (CT) D. Magnetic resonance imaging (MRI)

C. Helical computed tomography (CT)

Which instruction would the nurse teach the client concerned about dislodging a laryngectomy tube at a 3- week post op follow- up visit? A. Reinsert another tube immediately B. Notify the health care provider immediately C. Keep calm because this is not immediate emergency D. Quickly take action to prevent the tracheal stoma from closing

C. Keep calm because this is not immediate emergency

When caring for a client who has had a bronchoscopy in the ambulatory surgery unit , which action would the nurse take ? A. Offer ice chips to decrease throat pain B. Avoid turning the head from side to side C. Keep client in semi- folwer position D. Suggest medicated lozenges for sore throat

C. Keep client in semi- folwer position

A client with a chest tube is to be transported via stretcher. When transporting the client, what should the nurse do? A. Keep collection device attached to mechanical suction B. Keep chest tube clamped distal to water- seal chamber C. Keep collection device below the level of the clients chest D. Keep chest tube end covered with sterile gauze pads taped to clients chest

C. Keep collection device below the level of the clients chest

During a clients immediate post op period after a laryngectomy, which is a nursing priority? A. Provide emotional support B. Observe for signs of infection C. Keep the trachea free of secretions D. Promote a means of communication

C. Keep the trachea free of secretions

During an assessment of a patient with asthma , the nurse notes wheezing and dyspnea . The nurse interprets these symptoms as related to which pathophysiologic change ? A. Layrgopasm B. Pulmonary edema C. Narrowing of airway D. Overdistension of alvoeli

C. Narrowing of airway

When a nurse needs to administer oxygen at a fraction of inspired oxygen ( FiO 2 ) of about 40 % to keep a client's oxygen saturation greater than 94 % , which method would be best ? A. Face tent B. Venturi mask C. Nasal cannula D. Simple face mask

C. Nasal cannula

How would the nurse plan to position a client with a diagnosis of emphysema who is experiencing dyspnea ? A. Supine B. Contour C. Orthopenic D. Semi-fowler

C. Orthopenic

After reviewing information about oxygenation for four clients with COPD disease which client will the nurse plan to teach about use of home long term oxygen therapy A. PaO2 72, SpO2 96 B. PaO2 60, SpO2 90 C. PaO2 55, SpO2 88 D. PaO2 70, Sp O2 92

C. PaO2 55, SpO2 88

A client is admitted to the hospital with a diagnosis of emphysema. When teaching the client about breathing exercises, the nurse would include which instruction? A. Spend more time inhaling than exhaling to blow odd carbon dioxide B. Perform sit ups to strengthen abdominal muscles to improve breathing C. Perform diaphragmatic exercises to improve contraction of the diaphragm D. Use abdominal exercises to limit the use of accessory muscles of respiration

C. Perform diaphragmatic exercises to improve contraction of the diaphragm

A client has a closed drainage system in place. How would the nurse determine the amount of chest tube drainage? A. Aspirate the drainage from the collection chamber B. Clamp the chest tube and empty the fluid from the collection chamber C. Refer to the date and time markings on the outside the collection chamber D. Replace the existing system with a new one to access the drainage in the existing system

C. Refer to the date and time markings on the outside the collection chamber

A client with COPD has a blood ph of 7.25 and pCO2 of 60 mm Hg. These blood gas results require attention because they indicate which condition? A. Metabolic acidosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis

Which intervention would the nurse offer the client to help relieve symptoms of sinusitis? A. Repositioning B. Humidified air C. Saline irrigation D. Frequent suctioning

C. Saline irrigation

A client is admitted to the hospital with a diagnosis of COPD. Which action would the nurse take to prevent fatigue? A. Provide small, frequent meals B. Encourage purse lip breathing C. Schedule nursing activities to allow for rest D. Encourage best rest until energy level improves

C. Schedule nursing activities to allow for rest

Which position will the nurse use when caring for a patient who is experiencing an asthma exacerbation ? A. Prone B. Supine C. Semi-high fowler's D. Trendelburg

C. Semi-high fowler's

The nurse provides teaching to a client who is being treated for a pneumothorax. The nurse instructs the client to notify the health care provider immediately if experiencing which symptom of a recurring pneumothorax? A. Substernal chest pain B. Episodes of palpitation C. Severe SOB D. Dizziness when standing up

C. Severe SOB

Which condition may cause diaphragm paralysis and need mechanical vent? A. Dysrhythmias B. Alveolar collapse C. Spinal cord injury D. COPD

C. Spinal cord injury

Which data would the nurse document for a client who returns to the clinic with induration of the skin 48 hours after receiving a purified protein derivative ( PPD ) test ? A. The client has active TB B. The client has recieved a PPD in the past C. The client has been exposed to tuberculosis D. The client has an allergic reaction to the test

C. The client has been exposed to tuberculosis

Which topic would the nurse include when teaching a client who is being treated for active tuberculosis and has a productive cough ? A. Reasons to avoid going outside B. Need for cotninued hospitalization C. Use of disposable tissues when coughing D. Benefits od attending community events

C. Use of disposable tissues when coughing

When auscultating a clients chest, the nurse hears swishing sounds of normal breathing, how would the nurse document this finding? A. Adventitious sounds B. Fine crackling sound C. Vesicular breath sounds D. Diminished breath sounds

C. Vesicular breath sounds

Which action would the nurse take when a client with TB is admitted to the nursing unit? A. Put on a gown when entering the room B. Place the client with another client who has TB C. Wear a particulate respirator when caring for the client D. Don a surgical mask with a face shield when entering the room

C. Wear a particulate respirator when caring for the client

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that nurse administers oxygen? A. Prevent dyspnea B. Prevent cyanosis C. Increase oxygen to heart cells D. Increase oxygen tension in circulating blood

D. Increase oxygen tension in circulating blood

The nurse collaborates with the health care team to arrange for home care for a patient with pulmonary tuberculosis ( TB ) . Which family member who lives with the patient is at greatest risk for contracting the disease ? A. A 15 year old who has history of asthma B. A 25 year old who is pregnant C. A 50 year old spouse who is 20 lb over weight D. A 75 year old who takes prednisone

D. A 75 year old who takes prednisone (bc of age and immunosuppression by the corticosteriod)

Nursing actions after a client has had general anesthesia are directed at preventing which post op respiratory complication? A. Pleural effusion B. Empyema C. Pneumothorax D. Atelectasis

D. Atelectasis

The nurse is caring for a patient with a diagnosis of active tuberculosis ( TB ) . Which item would the nurse anticipate will be included in the patient's treatment plan ? A. Use directly observed therapy in the initial phase B. Administer drug therapy in 3 phases C. Initiate liver function test 14 days after start of treatment D. Avoid alcohol because it increases heptatoxicity associated with INH

D. Avoid alcohol because it increases heptatoxicity associated with INH

Which condition will the nurse associated with wheezing? A. Atelectasis B. Pleural effusion C. Pulmonary edema D. COPD

D. COPD

Which disorder would the nurse recognize as the likely cause of cor pulmonale? A. Left ventricle failure B. Renal failure C. Liver failure D. COPD

D. COPD

Which receptors cause an increase in RR related to an increased partial pressure of arterial carbon dioxide level and a decreased pH level? A. Irritant receptors B. Stretch receptors C. Juxtacapillaey receptors D. Central chemoreceptors

D. Central chemoreceptors

When a client is scheduled for a mediastinoscopy , which action will the nurse plan to take ? A. Ask about iodine or shellfish allergy B. Teach that local anethsia will be used C. Keep client on bedrest before procedure D. Check that informed consent is signed

D. Check that informed consent is signed

Which phrase describes the primary function of the nose? A. Assist in deep breathing B. Help with phonation and vocalization C. Remove humidity from entering the upper airway D. Filter small particles from entering the lower lungs

D. Filter small particles from entering the lower lungs

A client presenting with an acute asthma attack is being assessed in the emergency department. The client's spouse reports that the client is currently undergoing treatment for an upper respiratory infection. The nurse would understand that the client most likely has what type of asthma? A. Allergic B. Emotional C. Extrinsic D. Intrinsic

D. Intrinsic

What is the purpose of an occlusive dressing over a client's sucking chest wound? A. Protects the lungs B. Seals off major vessels C. Prevents additional contamination of the wound D. Maintains negative pressure within the chest cavity

D. Maintains negative pressure within the chest cavity

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? A. Emptying the drainage system when full B. Keeping the drainage system at heart level C. Notifying the healthcare provider of drainage greater than 50 mL/h D. Marking the time on the drainage unit every shift

D. Marking the time on the drainage unit every shift

Which substance would the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site? A. Sterile saline B. Steroid cream C. Oil- based lubricant D. Mild soap and water

D. Mild soap and water

The nurse obtains a laboratory report that shows acid-fast rods in a clients sputum. Which disorder would the nurse consider may be related to these results? A. Influenza virus B. Diphtheria bacillus C. Bordetella pertussis D. Mycobacterium Tuberculosis

D. Mycobacterium Tuberculosis

Which diagnostic study is used to distinguish benign and cancerous lung nodules? A. Thoracentesis B. Pulmonary angiogram C. CT scan of patient's chest D. PET scan

D. PET scan

Which action will the nurse take to support safe oral intake after tracheostomy? A. Include thin liquid B. Provide large meals C. Inflate the tracheostomy cuff fully D. Position client as up right as possible

D. Position client as up right as possible

The nurse provides education to a group of student nurses about pursed- lip breathing. The nurse would include which primary purpose of the respiratory exercise? A. Decreases chest pain B. Conserves energy C. Increases oxygen saturation D. Promotes elimination of CO2

D. Promotes elimination of CO2

The nurse is caring for a client who has experienced a near - drowning . For which potential danger would the nurse assess the client ? A. Alkalosis B. Renal failure C. Hypervolemia D. Pulmonary edema

D. Pulmonary edema

Which assessment finding would the nurse expect for a patient with a suspected lung abscess? A. Vomiting B. Weight gain C. Crackles on auscultation D. Purulent sputum with a foul odor

D. Purulent sputum with a foul odor

Which physiologic response is expected for a patient experiencing metabolic acidosis secondary to type 1 diabetes? A. Vomiting B. Increased urinating C. Decreased HR D. Rapid RR

D. Rapid RR

Which action would the nurse include when performing tracheostomy care on a client receiving mechanical ventilation ? A. Using hydrogen peroxide B. Inserting a catheter without suction C. Placing the client in the recumbent position D. Rinsing the inner cannula with normal saline

D. Rinsing the inner cannula with normal saline

Into which position would the nurse prepare a patient for a thoracentesis? A. Lying in the fetal position on the unaffected side B. Sitting in bed with knees flexed and feet turned out C. Lying flat on the unaffected side with knees flexed D. Sitting upright with elbows over an over bed table and feet supported

D. Sitting upright with elbows over an over bed table and feet supported

The nurse is providing immediate post op care to a client that has undergone a total laryngectomy. It is appropriate for the plan of care to include which intervention A. Instructing the client to whisper B. Placing the client in the orthopenic position C. Removing the outer tracheostomy tube as needed D. Suctioning the trach tube whenever necessary

D. Suctioning the trach tube whenever necessary

The nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is most important intervention to include? A. Ensuring sufficient rest B. Changing lifestyle routines C. Breathing clean outdoor air D. Taking medications as prescribed

D. Taking medications as prescribed

Which statement about a deviated septum is correct? A. All septal deviations are symptomatic B. A septoplasty will not correct a deviated septum C. Epistaxis is a rare manifestation of a deviated septum D. The aim of medical management is symptom control

D. The aim of medical management is symptom control

Why does the nurse ask the patient ro rinse mouth after each dose in inhaled corticosteriods? A. To relieve dry mouth B. To minimize change of nasal congestion C. To reduce risk of sore throat and infection D. To prevent development of oral candidiasis

D. To prevent development of oral candidiasis