1. The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? Show
a. Place the end of the chest tube in a container of sterile saline. 2. A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza? a. Septicemia 3. A female client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: a. 15 to 60 seconds. 4. Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a. Hypoxia 5. A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a. pH, 5.0; PaCO2 30 mm Hg 6. A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience: a. hyperglycemia and glycosuria. 7. A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? a. Activity intolerance related to fatigue 8. A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? a. Simple mask 9. A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? a. Immediately before a meal 10. On arrival at the intensive care unit, a critically ill female client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? a. Fever 11. The nurse is caring for a male client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a. helping him communicate. 12. For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? a. Restricting fluid intake to 1,000 ml/day 13. The amount of air inspired and expired with each breath is called: a. tidal volume. 14. A male client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than: a. 0.21 15. Nurse Mickey is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true? a. A
positive reaction indicates that the client has active tuberculosis (TB). 16. Before weaning a male client from a ventilator, which assessment parameter is most important for the nurse to review? a. Fluid intake for the last 24 hours 17. Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg? a. Administer a prescribed decongestant. 18. A female client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a. pH 19. Nurse Julia is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which of the following interventions will most likely lower the client's arterial blood oxygen saturation? a. Endotracheal suctioning 20. For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care? a. Measuring and documenting the drainage in the collection
chamber 21. Nurse Eve formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include: a.
drinking more than 1,500 ml of fluid daily. 22. A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: a. lips. 23. A female client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range? a. 1 to 2 mcg/ml 24. A male client is to receive I.V. vancomycin (Vancocin). When preparing to administer this drug, the nurse should keep in mind that: a. vancomycin should be infused over 60 to 90 minutes in a large volume of fluid. 25. Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? a. Myasthenia gravis 26. At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86% and he's still wheezing. The nurse should plan to administer: a. alprazolam (Xanax). 27. Pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? a. Encouraging the client to drink three glasses of fluid daily 28. Nurse Joana is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? a. It helps prevent early airway collapse. 29. A male client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy if the client's baseline theophylline level was: a. 10
mcg/mL 30. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. 31. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? a. Inform the physician. 32. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician. 33. Nurse Paul is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: a. Exhale slowly. 34. While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube. 35. A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Stridor 36. An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory 37. A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia 38. A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea 39. A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis? a. Bronchoscopy 40. The nursing instructor asks a nursing student to describe the route of transmission of tuberculosis. The instructor concludes that the student understands this information if the student states that the tuberculosis is transmitted by: a. Hand and mouth 41. A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min 42. A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake. 43. Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluids 44. A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians? a. Dry cough 45. A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the a. 1 minute 46.
A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing a. Continue to suction. 47. An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: a. Metabolic acidosis 48. A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. Dyspnea 49. A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? a. Inhales the mist and quickly exhales 50. A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client? a. Administering atropine intravenously 51. A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations 52. A female client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest? a. Cyanosis 53. A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax 54. A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to: a. Inhale quickly 55. A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing 56. A nurse is taking pulmonary artery catheter measurements of a male client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12mm Hg. The nurse interprets that this readings is: a. High and expected 57. A nurse is assessing a male client with chronic airflow limitations and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitations? a. Emphysema 58. A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent a. Cough 59. A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client's chest wall, the nurse expects to elicit: a.
Resonant sounds. 60. Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a. The system is functioning normally 61. For a male client with an endotracheal (ET) tube, which nursing action is most essential? 62. The nurse assesses a male client's respiratory status. Which observation indicates that the client is experiencing difficulty
breathing? a. Diaphragmatic breathing 63. A female client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess: a. Lung vibrations. 64. A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: a. Pleural effusion. 65. A male client with
pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature? a. Inflamed lung tissue 66. A male client admitted to an acute care facility with pneumonia
is receiving supplemental oxygen, 2 L/minute via nasal cannula. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client's respiratory status. Which complication may arise if the client receives a high oxygen concentration? a. Apnea 67. After undergoing a thoracotomy, a male client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia? a. Heightened alertness What actions does the nurse include in teaching a patient to use an inhaler with a spacer select all that apply?Breathe in Slowly. Put the spacer between your teeth and close your lips tightly around it.. Keep your chin up.. Start breathing in slowly through your mouth.. Spray one puff into the spacer by pressing down on the inhaler.. Keep breathing in slowly. Breathe as deeply as you can.. Which of the following would the nurse identify as the long term goal for a patient diagnosed with COPD?The goal of COPD management is to improve a patient's functional status and quality of life by preserving optimal lung function, improving symptoms, and preventing the recurrence of exacerbations.
How would the nurse plan to position a client with a diagnosis of emphysema who is experiencing dyspnea?Place patients who are experiencing dyspnea in a high Fowler position to improve lung expansion. Placing pillows on the overhead table and having the patient lean over in the orthopneic position may also be helpful. Teach the patient pursed-lip and diaphragmatic breathing.
Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?Cheeks, nose, ears, and oral mucosa are the best areas to assess cyanosis as the skin in these areas is thin, and blood supply is good.
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A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate
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