Respiratory
The nurse has auscultated fine crackles in both the right and left lower lobes of a postoperative client. What is the longest period of time the nurse should allow to pass before auscultating the breath sounds again?
Select one:
a. 2 hours
b. 1 hour
c. 4 hours
d. 8 hours
c. 4 hours
A nurse is caring for a client with a bacterial infection of the lungs. What color of sputum should the nurse anticipate the client to expectorate?
Select one:
a. Clear white
b. Yellow-green
c. Pink frothy
d. Red rust
b. Yellow-green
The nurse enters the room of a client who is taking a nebulizer treatment set up by the respiratory therapist. Which observation by the nurse would be cause for intervening with the treatment?
Select one:
a. Mist is coming out of the end of the nebulizer hose
b. Liquid is seen in the nebulizer cup
c. The client is breathing in and out through the nose
d. The nebulizer is connected to compressor tubing
c. The client is breathing in and out through the nose
A client is scheduled to have pulmonary function tests. What should the nurse instruct the client to do before the test?
Select one:
a. Take a bronchodilator 1 hour before the test
b. Avoid smoking for 6 hours before the test
c. Drink 8 oz of water immediately before the test
d. Abstain from food 2 hours before the test
b. Avoid smoking for 6 hours before the test
A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions. To thin respiratory secretions for easier expectoration, the patient should consume at least __ mL/day.
Select one:
a. 1500 to 2000
b. 500 to 1000
c. 2500 to 3000
d. 1000 to 1500
a. 1500 to 2000
When auscultating breath sounds, the nurse identifies the presence of stridor. What should the nurse do?
Select one:
a. Implement oropharyngeal suctioning
b. Arrange for an x-ray examination
c. Plan to assess the client in one hour
d. Notify the rapid response team immediately
d. Notify the rapid response team immediately
A nurse is caring for a client with compromised respiratory function. The client has a productive cough and sputum appears frothy and pink-tinged. Which conclusion by the nurse causes the greatest concern?
Select one:
a. The client has lung injury related to fire and smoke
b. The client has life-threatening pulmonary edema
c. The client has pneumonia or other infection
d. The client has a lung infection from a bacterial pathogen
b. The client has life-threatening pulmonary edema
The nurse is providing care to a client who is comatose and is on ventilator support, which has been provided for two weeks. Which change does the nurse expect the client’s physician to order?
Select one:
a. Insertion of an endotracheal tube
b. Switch to an oropharyngeal airway
c. Performance of a tracheostomy
d. Placement of a chest tube
c. Performance of a tracheostomy
When obtaining a sputum specimen, the nurse should provide the patient with a sterile sputum cup and teach the patient to rinse her mouth with--
Select one:
a. normal saline
b. water
c. flavored juice
d. mouthwash
b. water
A patient with chronic obstructive pulmonary disease (COPD) is having difficulty breathing. The nurse is aware which of the following positions is best to facilitate optimal breathing?
Select one:
a. Orthopneic position
b. Semi-fowlers position
c. Trendelenburg position
d. Sims position
a. Orthopneic position
The nurse is providing care for a client who becomes short of breath when ambulating to the bathroom. Which documentation should the nurse enter on the client’s medical record?
Select one:
a. Dyspnea noted after walking 15 feet
b. Hypoxemia present after walking to the bathroom
c. Client states inability to walk to the bathroom
d. Cyanotic with ambulation
a. Dyspnea noted after walking 15 feet
A factor in keeping the patient’s secretions thinned so they can be coughed up----other than using a humidifier----is to do which of the following interventions?
Select one:
a. Encourage a sitting position while awake
b. Use chest percussion treatments
c. Increase fluid intake
d. Suction once every 2 hours
c. Increase fluid intake
The nurse has to suction the patient prior to performing tracheostomy care. What is the maximum amount of time suctioning?
Select one:
a. 10 seconds
b. When the patient turns blue
c. Until the patient coughs
d. There is no maximum time
a. 10 seconds
A patient has been placed on a pulse oximeter to measure oxygen saturation. Which nursing intervention should be incorporated into the plan of care for this patient?
Select one:
a. Allow 30 minutes for the machine to warm up
b. Check the machine calibration once per month
c. Rotate the site of the clip-on probe every hour
d. Remove nail polish or artificial nails if fingertip is used
d. Remove nail polish or artificial nails if fingertip is used
One nursing measure that can prevent respiratory insufficiency is to:
Select one:
a. perform postural drainage at least three times a day.
b. assist the patient to turn, cough and deep breathe
c. administer low flow oxygen continuously
d. allow the patient to rest as much as possible
b. assist the patient to turn, cough and deep breathe
Which of the following pH values indicates the presence of acidosis?
Select one:
a. 7.44
b. 7.28
c. 7.42
d. 7.39
b. 7.28
The nurse loosens mucus plugs by using percussion on a patient over the area of the:
Select one:
a. spine between the scapulae.
b. thorax.
c. midaxillary line on the rib cage.
d. sternum.
b. thorax.
A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:
Select one:
a. hold the catheter with the dominant hand after donning sterile gloves.
b. suction the nasotracheal passage after suctioning the mouth.
c. insert the non-lubricated catheter into the nasal passage.
d. apply suction while advancing the catheter into the airway.
a. hold the catheter with the dominant hand after donning sterile gloves.
A nurse is caring for a patient with a tracheostomy tube. The first assessment that is completed prior to suctioning is to perform which of the following?
Select one:
a. Determine the last time the patient was suctioned
b. Auscultate the lung sounds
c. Review the physician’s order for sectioning times
d. Monitor the patient’s temperature
b. Auscultate the lung sounds
There is continuous bubbling in the suction chamber of disposable water-seal drainage unit, with 120 ml of drainage in the last hour. What should the nurse do?
Select one:
a. check the suction tubing for air leaks
b. document the drainage and continue to monitor the patient
c. check your patient’s vital signs
d. call the physician
b. document the drainage and continue to monitor the patient
pH 7.32
PaCo2 29
HCo3 20
ABG Interpretation?
You observe the patient for early signs of hypoxia. You know that the first signs of hypoxia include: Select all that Apply.
Select one or more:
a. cyanosis of the nail beds of the fingers
b. increased respiratory rate
c. increased restlessness or irritability.
d. retraction of muscles used in breathing.
b. increased respiratory rate
c. increased restlessness or irritability.
Your patient is breathing shallowly and seems irritable and restless. A nursing action that might help is to have him to do which of the following?
Select one:
a. Take a good nap
b. Take some pain medication
c. Submit to back rub
d. Turn, cough, and deep-breathe
d. Turn, cough, and deep-breathe
pH 7.50
PaCo2 29
HCo3 22
ABG interpretation?
Uncompensated Respiratory Alkalosis
The nurse is caring for a number of clients on a medical unit. Which client will the nurse identify as the highest priority?
Select one:
a. A young-adult client with pneumonia who is restless and confused
b. An older-adult client with pneumonia expectorating rust-colored sputum
c. A middle-age client with a chest tube who has noticeable tidaling
d. An adult client with chronic obstructive pulmonary disease and a nonproductive cough
a. A young-adult client with pneumonia who is restless and confused