Review 1
A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which assessment findings are expected? Select all that apply.
A.) Barrel-shaped chest
B.) Bradypnea
C.) Use of accessory muscles
D.) Clubbing of fingers
E.) Diminished breath sounds
What is A, C, D, E
A 74-year-old client with pneumonia has the following assessment findings:
RR: 30/min
HR: 108 bpm
BP: 140/82
SpO₂: 86% on room air
Crackles in bilateral lower lobes
Restlessness noted
The provider has prescribed oxygen at 2 L/min via nasal cannula and IV antibiotics.
What is the nurse’s priority action?
A.) Administer IV antibiotic
B.) Apply oxygen at 2 L/min
C.) Obtain sputum culture
D.) Document findings
What is B.) Apply oxygen at 2 L/min
A client with COPD is receiving IV methylprednisolone. Which finding requires immediate reporting?
A.) Blood glucose 90 mg/dL
B.) White patches in mouth
C.) Mild weight gain
D.) Decreased appetite
What is B.) White patches in mouth
A client is prescribed albuterol via nebulizer for wheezing. Which assessment finding indicates the medication is effective?
A.) Heart rate decreases from 110 to 88
B.) Wheezing decreases after treatment
C.) Blood pressure decreases
D.) Respiratory rate increases
What is B.) Wheezing decreases after treatment
A post-operative client suddenly reports sharp chest pain and shortness of breath.
Assessment findings:
RR: 34/min
HR: 122 bpm
BP: 90/60
SpO₂: 84%
Clear lung sounds
What does the nurse suspect?
A.) Pneumonia
B.) Pulmonary embolism
C.) Atelectasis
D.) Heart failure
What is B.) Pulmonary embolism
A patient with Chronic Obstructive Pulmonary Disease is prescribed oxygen. Which nursing actions are appropriate? (Select all that apply.)
A.) Administer oxygen at 1–2 L/min via nasal cannula
B.) Monitor oxygen saturation
C.) Encourage pursed-lip breathing
D.) Maintain oxygen at 6 L/min routinely
E.) Monitor for decreased level of consciousness
What is A, B, C, E
A nurse is teaching a client with COPD about home oxygen therapy. Which statement by the client indicates the need for further teaching?
A.) “I should use water-based lubricants on my lips and nose.”
B.) “I can increase my oxygen flow rate when I feel short of breath.”
C.) “I need to avoid smoking while using oxygen.”
D.) “I should clean my nasal cannula regularly with soap and water.”
What is B.) “I can increase my oxygen flow rate when I feel short of breath.”
A nurse is caring for an older adult client admitted with bacterial pneumonia. Which nursing intervention is the priority?
A.) Administering antibiotics as prescribed
B.) Encouraging fluid intake of 2-3 liters daily
C.) Teaching effective coughing techniques
D.) Monitoring oxygen saturation levels
What is A.) Administering antibiotics as prescribed
A nurse is teaching a client newly diagnosed with active pulmonary tuberculosis. Which instruction is most important to include?
A.) “Eat a high-calorie, high-protein diet to promote healing.”
B.) “Take all prescribed medications for the full duration, even if you feel better.”
C.) “Wear a mask when leaving your home for appointments.”
D.) “Avoid contact with children and pregnant women.”
What is B.) “Take all prescribed medications for the full duration, even if you feel better.”
A nurse is caring for a client with a chest tube for a pneumothorax. Which assessment finding requires immediate notification of the healthcare provider?
A.) Continuous bubbling in the water seal chamber
B.) Tidaling (fluctuation) in the water seal chamber
C.) 100 mL of serosanguineous drainage in the last hour
D.) Client reports pain at the insertion site
What is A.) Continuous bubbling in the water seal chamber
A patient presents with restlessness, tachycardia, nasal flaring, and an SpO₂ of 84% on room air. The patient is anxious and using accessory muscles to breathe. What problem is the patient experiencing?
What is Hypoxemia
A patient with severe COPD is placed on high-flow oxygen. Shortly after, the patient becomes drowsy, has a decreased respiratory rate, and ABGs show elevated PaCO₂ levels. What complication is the patient experiencing?
What is Respiratory Acidosis (CO₂ narcosis)
A patient is hyperventilating after a panic attack. ABGs show pH 7.48, PaCO₂ 30 mmHg, HCO₃ 24 mEq/L. What condition is the patient experiencing?
What is Respiratory Alkalosis
A patient suddenly develops sharp unilateral chest pain and severe shortness of breath. Assessment reveals absent breath sounds on the right side and tracheal deviation to the left. What condition is the patient experiencing?
What is a Tension Pneumothorax
A postoperative patient is shallow breathing due to incisional pain. The nurse notes diminished breath sounds at the lung bases and a low-grade fever on postoperative day 1. What complication is most likely developing?
What is Atelectasis