Respiratory
The home care nurse assesses a client diagnosed with chronic obstructive
pulmonary disease (COPD) who is reporting increased dyspnea. The client is
on home oxygen via a concentrator at 2 L per minute, and has a respiratory
rate of 22 breaths per minute. Which action should the nurse take?
1. Determine the need to increase the oxygen.
2. Reassure the client that there is no need to worry.
3. Conduct further assessment of the client’s respiratory status.
4. Call emergency services to take the client to the emergency department.
3. Conduct further assessment of the client’s respiratory status.
The nurse is caring for a client who sustained a spinal cord injury that has
resulted in spinal shock. Which assessment will provide relevant information
about recovery from spinal shock?
1. Reflexes
2. Pulse rate
3. Temperature
4. Blood pressure
1. Reflexes
The nurse is monitoring a client with hypertension who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?
1. Report of infrequent insomnia
2. Development of expiratory wheezes
3. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication
4. A baseline resting heart rate of 88 beats per minute followed by a resting heart rate of 72 beats per minute after two doses of the medication
2. Development of expiratory wheezes
A client’s cardiac rhythm suddenly changes on the monitor. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm?
1. Atrial fibrillation
2. Sinus tachycardia
3. Ventricular fibrillation
4. Ventricular tachycardia
1. Atrial fibrillation
The nurse reviews the arterial blood gas results of a client and notes the
following: pH of 7.30 (7.30), Paco2 of 50 mm Hg (50 mm Hg), and bicarbonate
(HCO3) of 22 mEq/L (22 mmol/L). The nurse analyzes these results as indicating
which condition?
1. Metabolic acidosis, compensated
2. Respiratory alkalosis, compensated
3. Metabolic alkalosis, uncompensated
4. Respiratory acidosis, uncompensated
4. Respiratory acidosis, uncompensated
The nurse is performing a respiratory assessment on a client being treated
for an asthma attack. The nurse determines that the client’s respiratory status
is worsening based upon which finding?
1. Loud wheezing
2. Wheezing on expiration
3. Noticeably diminished breath sounds
4. Increased displays of emotional apprehension
3. Noticeably diminished breath sounds
A client with myocardial infarction is developing cardiogenic shock. Which potential condition would the nurse anticipate and monitor the client for to detect cardiogenic shock?
1. Pulsus paradoxus
2. Ventricular dysrhythmias
3. Rising diastolic blood pressure
4. Falling central venous pressure
2. Ventricular dysrhythmias
A coronary care unit (CCU) nurse is caring for a client admitted with acute
myocardial infarction (MI). The nurse should monitor the client for which
most common complication of MI?
1. Heart failure
2. Cardiogenic shock
3. Cardiac dysrhythmias
4. Recurrent myocardial infarction
3. Cardiac dysrhythmias
The nurse is caring for a client who is receiving blood transfusion therapy.
Which clinical manifestations should alert the nurse to a hemolytic
transfusion reaction? Select all that apply.
1. Headache
2. Tachycardia
3. Hypertension
4. Apprehension
5. Distended neck veins
6. A sense of impending doom
1. Headache
2. Tachycardia
4. Apprehension
6. A sense of impending doom
Which arterial blood gas (ABG) values should the nurse anticipate in the
client with a nasogastric tube attached to continuous suction?
1. pH 7.25, Paco2 55, HCO3 24
2. pH 7.30, Paco2 38, HCO3 20
3. pH 7.48, Paco2 30, HCO3 23
4. pH 7.49, Paco2 38, HCO3 30
4. pH 7.49, Paco2 38, HCO3 30
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, would the nurse immediately report to the primary health care provider?
1. Dry cough
2. Hematuria
3. Bronchospasm
4. Blood-streaked sputum
3. Bronchospasm
The nurse suspecting that a client is developing cardiogenic shock should
assess for which peripheral vascular manifestation of this complication?
Select all that apply.
1. Warm, moist skin
2. Flushed, dry skin
3. Cool, clammy skin
4. Irregular pedal pulses
5. Bounding pedal pulses
6. Weak or thready pedal pulses
3. Cool, clammy skin
6. Weak or thready pedal pulses
Intravenous heparin therapy is prescribed for a client with atrial fibrillation. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?
1. Vitamin K
2. Protamine sulfate
3. Potassium chloride
4. Aminocaproic acid
2. Protamine sulfate
The nurse is monitoring a client who is receiving a blood transfusion
when the client reports diaphoresis, warmth, and a backache. The nurse
should take which actions? Select all that apply.
1. Remove the IV catheter.
2. Document the occurrence.
3. Stop the blood transfusion.
4. Contact the primary health care provider.
5. Hang 0.9% sodium chloride solution.
2. Document the occurrence.
3. Stop the blood transfusion.
4. Contact the primary health care provider.
5. Hang 0.9% sodium chloride solution.
A client had arterial blood gases drawn. The results are a pH of 7.34, a
partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial
pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of
19 mEq/L (19 mmol/L). Which disorder should the nurse interpret that the
client is experiencing?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
1. Metabolic acidosis
A client was admitted to the hospital 24 hours ago after sustaining blunt
chest trauma. Which is the earliest clinical manifestation of acute respiratory
distress syndrome (ARDS) the nurse should monitor for?
1. Cyanosis with accompanying pallor
2. Diffuse crackles and rhonchi on chest auscultation
3. Increase in respiratory rate from 18 to 30 breaths per minute
4. Haziness or “white-out” appearance of lungs on chest radiograph
3. Increase in respiratory rate from 18 to 30 breaths per minute
A client in shock develops a central venous pressure (CVP) of 2 mm Hg and mean arterial pressure (MAP) of 60 mm Hg. Which prescribed intervention would the nurse implement first?
1. Increase the rate of O2 flow.
2. Obtain arterial blood gas results.
3. Insert an indwelling urinary catheter.
4. Increase the rate of intravenous (IV) fluids.
4. Increase the rate of intravenous (IV) fluids.
The nurse would report which assessment finding to the primary health care provider (PHCP) before initiating thrombolytic therapy in a client with pulmonary embolism?
1. Adventitious breath sounds
2. Temperature of 99.4° F (37.4° C) orally
3. Blood pressure of 198/110 mm Hg
4. Respiratory rate of 28 breaths per minute
3. Blood pressure of 198/110 mm Hg
A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased, and the blood pressure is 92/68 mm Hg. The nurse suspects which stage of shock based on this data?
1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
2. Stage 2
The nurse is reviewing the client’s arterial blood gas results. Which
finding would indicate that the client is experiencing respiratory acidosis?
1. pH 7.5, Pco2 of 30
2. pH 7.3, Pco2 of 50
3. pH 7.3, HCO3 of 19
4. pH 7.5, HCO3 of 30
2. pH 7.3, Pco2 of 50
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.
1. A low arterial PCO 2 level
2. A hyperinflated chest noted on the chest x-ray
3. Decreased oxygen saturation with mild exercise
4. A widened diaphragm noted on the chest x-ray
5. Pulmonary function tests that demonstrate increased vital capacity
2. A hyperinflated chest noted on the chest x-ray
3. Decreased oxygen saturation with mild exercise
Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply.
1. Urine output 50 mL/hr
2. Hypoactive bowel sounds
3. Temperature of 102° F (38.9° C)
4. Heart rate of 96 beats per minute
5. Mean arterial pressure 65 mm Hg
6. Systolic blood pressure 110 mm Hg
3. Temperature of 102° F (38.9° C)
4. Heart rate of 96 beats per minute
5. Mean arterial pressure 65 mm Hg
A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions would the nurse take? Select all that apply.
1. Stop the infusion.
2. Raise the head of the bed.
3. Administer protamine sulfate.
4. Administer diphenhydramine.
5. Call for the Rapid Response Team (RRT).
1. Stop the infusion.
4. Administer diphenhydramine.
5. Call for the Rapid Response Team (RRT).
A client develops an anaphylactic reaction after receiving morphine. The nurse would plan to institute which actions? Select all that apply.
1. Administer oxygen.
2. Quickly assess the client’s respiratory status.
3. Document the event, interventions, and client’s response.
4. Keep the client supine regardless of the blood pressure readings.
5. Leave the client briefly to contact a primary health care provider (PHCP).
6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.
1. Administer oxygen.
2. Quickly assess the client’s respiratory status.
3. Document the event, interventions, and client’s response.
A client with a 3-day history of nausea and vomiting and suspected gastroenteritis presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn, and the nurse reviews the results, expecting to note which finding?
1. A decreased pH and an increased PaCO 2
2. An increased pH and a decreased PaCO 2
3. A decreased pH and a decreased HCO3 –
4. An increased pH and an increased HCO3 –
4. An increased pH and an increased HCO3 –