ATI Respiratory Questions – Flashcards
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A nurse is assessing a patient who has a chest tube in place following a thoracic surgery. Which of the following findings indicates a need for intervention: 1. Fluctuation of drainage in the tubing with inspiration. 2. Continuous bubbling in the water seal chamber. 3. Drainage of 75 mL in the first hour after surgery. 4. Several small, dark-red blood clots in the tubing.
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2. Continuous bubbling in the water seal chamber. Continuous bubbling in the water seal chamber suggests an air leak.
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A nurse is caring for an elderly patient who suffers from COPD with pneumonia. The nurse should monitor the patient for which of the following acid-base imbalances? 1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Metabolic acidosis
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2. Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because patients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.
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A nurse is preparing to administer cisplatin IV to a patient with lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? 1. Hallucinations 2. Pruritis 3. Hand and foot syndrome 4. Tinnitis
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4. Tinnitis An adverse effect of cisplatin is ototoxicity, which can cause tinnitis.
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A nurse is preparing to assist a provider to withdraw arterial blood from a patient's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? 1. Hyperventilate the patient with 100% oxygen prior to obtaining the specimen. 2. Apply ice to the site after obtaining the specimen. 3. Perform an Allen's test prior to obtaining the specimen. 4. Release pressure applied to the puncture site 1 minute after the needle is withdrawn.
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3. Perform an Allen's test prior to obtaining the specimen. The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.
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A nurse is providing instructions about pursed-lip breathing for a patient who has COPD with emphysema. The nurse should explain that this breathing technique accomplishes which of the following: 1. Increases oxygen intake 2. Promotes carbon dioxide elimination 3. Uses the intercostal muscles 4. Strengthens the diaphram
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2. Promotes carbon dioxide elimination A patient who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the patient's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.
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A nurse is preparing a patient for a thoracentesis. In which of the following positions should the nurse place the patient: 1. Lying flat on the affected site 2. Prone with arms raised over the head 3. Supine with the head of the bed elevated 4. Sitting while leaning forward over the bedside table
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4. Sitting while leaning forward over the bedside table When preparing a patient for a thoracentesis, the nurse should have the patient sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the patient's ribs and allows for aspiration of accumulated fluid and air.
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A nurse on a med-surg unit is caring for a patient who is postoperative following a hip replacement surgery. The patient reports feeling apprehensive and restless. Which of the follow findings should the nurse recognize as an indication of a PE: 1. Sudden onset of dyspnea 2. Tracheal deviation 3. Bradycardia 4. Difficulty swallowing
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1. Sudden onset of dyspnea Clinical manifestations of a PE have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.
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A nurse is planning care for a patient who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan: 1. Eat high-calorie foods first 2. Increase intake of water at meal times 3. Perform active range of motion exercises before meals 4. Keep saltine crackers nearby for snacking
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1. Eat high-calorie foods first The client who has COPD often experiences early satiety. Therefore, the patient should eat high-calorie foods first.
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A nurse is developing a teaching plan for a patient about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first: 1. How to eliminate environmental triggers that precipitate attacks 2. The patient's perception of the disease process and what might have triggered attacks in the past 3. The patient's medication regimen 4. Manifestations of respiratory infections
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2. The patient's perception of the disease process and what might have triggered attacks in the past The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan patient care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in a patient's status, the nurse must first collect adequate data from the patient. Assessing the patient will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the patient's current knowledge.
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A nurse in a provider's office is assessing a patient who states he was recently exposed to TB. Which of the following findings is a clinical manifestation of pulmonary TB: 1. Pericardial friction rub 2. Weight gain 3. Night sweats 4. Cyanosis of the fingertips
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3. Night sweats Night sweats and fevers are clinical manifestations of TB.
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A nurse is planning care for a patient following placement of a chest tube 1 hour ago. Which of the following actions should the nurse include in the plan of care: 1. Clamp the chest tube if there is continuously bubbling in the water seal chamber 2. Keep the chest tube drainage system at the level of the right atrium 3. Tape all of the connections between the chest tube and the drainage system 4. Empty the collection chamber and record the amount of drainage every 8 hours
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3. Tape all of the connections between the chest tube and the drainage system The nurse should tape all of the connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting.
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A nurse on a medical unit is caring for a patient who apirated gastric contents prior to admission. The nurse administers 100% oxygen by nonbreather mask after the patient reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS): 1. Tympanic temperature of 38 C (100.4 F) 2. PaO2 50 mm Hg 3. Rhonchi 4. Hypopnea
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2. PaO2 50 mm Hg The patient who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS.
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A nurse is providing teaching to a patient about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end maximum inhalation: 1. Total lung capacity 2. Vital lung capacity 3. Functional residual capacity 4. Residual volume
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1. Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.
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A nurse is preparing discharge teaching to a patient who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include: 1. Apply warm compresses to the face 2. Take aspirin 650mg by mouth for mild pain 3. Close your mouth while sneezing 4. Lie on your back with your head elevated 30 degrees while resting
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4. Lie on your back with your head elevated 30 degrees while resting The nurse should instruct the patient to rest in the semi-fowlers position to prevent aspiration of nasal secretions.
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A nurse in the emergency department is assessing a patient for a closed pneumothorax and significant bruising of the left chest following a MVA. The client reports severe left chest pain on inspiration. The nurse should assess the patient for which of the following manifestations of a pneumothorax: 1. Absence of breath sounds 2. Expiratory wheezing 3. Inspiratory stridor 4. Rhronchi
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1. Absence of breath sounds A patient who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.
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A nurse in a clinic is providing teaching for a patient who is to have a tuberculin skin test. Which of the following information should the nurse include: 1. If the test is positive, then you have an active case of TB. 2. If the test is positive, you should have another tuberculin skin test in 3 weeks. 3. You must return to the clinic to have the test read in 2 to 3 days. 4. A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance.
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3. You must return to the clinic to have the test read in 2 to 3 days. The patient should have the test read in 2 to 3 days. An area of induration after 48 to 72 hours indicates exposure to tubercle bacillus. If the patient does not return to have the test read within 72 hours, another skin test is necessary.
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A nurse is teaching about daily chest physiotherapy with a patient who has cystic fibrosis. The nurse should instruct the patient that which of the following is the purpose of the treatments: 1. To encourage deep breaths 2. To mobilize secretions in the airways 3. To dilate the bronchioles 4. To stimulate the cough reflex
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2. To mobilize secretions in the airways The purpose of chest physiotherapy is to loosen the patient's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity.
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A nurse in an urgent care clinical is collecting data from a patient who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax: 1. Dry cough 2. Rhinitis 3. Sore throat 4. Swollen lymph nodes
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1. Dry cough A dry cough is a clinical manifestation found in the prodromal stage of having inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis.
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A nurse is providing preoperative teaching to a patient who is to undergo a pneumoectomy. The patient states "I am afraid it will hurt to cough after surgery." Which of the following statements by the nurse is appropriate: 1. After the surgeon removes your lung you will not need to cough. 2. I'll make sure you get a cough suppressant to keep you from straining the incision when you cough. 3. Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain. 4. I will show you how to splint your incision while you cough.
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4. I will show you how to splint your incision while you cough. The patient who had a pneumoectomy should cough to clear secretions from the remaining lung. The nurse should show how to splint the incision to reduce pain while coughing.
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A patient is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the patient's chest. After notifying the provider, the nurse should document the finding as which of the following: 1. Friction rub 2. Crackles 3. Crepitus 4. Tactile frementis
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3. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the patient's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.
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A nurse is caring for a patient who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the patient's airway secretions: 1. The patient is unable to speak. 2. The patient's airway secretions were last suctioned 2 hours ago. 3. The patient coughs and expectorates a large mucous plug. 4. The nurse auscultates course crackles in the lung field.
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4. The nurse auscultates course crackles in the lung field. The nurse should auscultate coarse crackles of rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the patient's airway secretions.
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A nurse working in the ED is caring for a patient following a chest trauma. Which of the following findings indicates a tension pneumothorax: 1. Collapsed neck veins on the affected side 2. Collapsed neck veins on the unaffected side 3. Tracheal deviation to the affected side 4. Tracheal deviation to the unaffected side
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4. Tracheal deviation to the unaffected side A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.
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A nurse is caring for a patient who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take: 1. Position the client in an upright position, leaning over the bedside table. 2. Explain the procedure. 3. Obtain ABGs. 4. Administer benzocaine spray.
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1. Position the client in an upright position, leaning over the bedside table. Positioning the patient in an upright position and bent over the bedside table widens the intercostal space for the provider to access the pleural fluid.
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A nurse is reviewing ABG laboratory results of a patient who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances: 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
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2. Respiratory alkalosis A patient who is experiencing respiratory alkalosis will have an increased pH and a decreased PaCO2. Possible causes of respiratory alkalosis include hyperventilation, fever, and respiratory infections.
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A nurse is assessing a patient following a bronchoscopy. Which of the following findings should the nurse report to the provider: 1. Blood-tinged sputum 2. Dry, nonproductive cough 3. Sore throat 4. Bronchospasms
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4. Bronchospasms Bronchospasms can indicate the patient is having difficulty maintaining a patent airway. The nurse should notify the provider immediately.
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A nurse is caring for a patient who is scheduled for a throacentesis. Which of the folowing supplies should the nurse ensure are in the patient's room? (Select all that apply) 1. Oxygen equipment 2. Incentive spirometer 3. Pulse oximeter 4. Sterile dressing 5. Suture removal kit
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1. Oxygen equipment Oxygen equipment is necessary to have in the patient's room if the patient becomes short of breath following the procedure. 3. Pule oximeter Pulse oximetry is necessary to monitor oxygen saturation level during the procedure. 4. Sterile dressing A sterile dressing is necessary to apply to the puncture site following the procedure.
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A nurse is caring for a patient following a throacentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply) 1. Dyspnea 2. Localized bloody drainage on the dressing 3. Fever 4. Hypotension 5. Report of pain at the puncture site
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1. Dyspnea Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the provider immediately.
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A nurse is preparing to care for a patient following chest tube placement. Which of the following items should be available in the patient's room? (Select all that apply) 1. Oxygen 2. Sterile water 3. Enclosed hemostat clamps 4. Indwelling urinary catheter 5. Occlusive dressing
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1. Oxygen Oxygen should be readily available in case the patient develops respiratory distress following chest tube placement 2. Sterile water If the chest tubing becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal. 5. Occlusive dressing If the chest tubing becomes disconnected, the nurse should immediately place a gauze dressing of the site. An occlusive dressing can also be necessary to prevent the redevelopment of a pneumothrorax.
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A nurse is caring for a patient who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? 1. Obtain chest x-ray 2. Apply sterile gauze to the insertion site 3. Place tape around the insertion site 4. Assess respiratory status
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2. Apply sterile gauze to the insertion site Using ABC, application of a sterile gauze to the site should be the first action for the nurse to take. This allows air to escape and reduces the risk for development of a tension pneumothorax.
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A nurse is assessing a patient who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply) 1. Continuous bubbling in the water seal chamber 2. Gentle constant bubbling in the suction control chamber 3. Rise and fall in the level of water in the water seal chamber with inspiration and expiration 4. Exposed sutures without dressing 5. Drainage system upright at chest level
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2. Gentle constant bubbling in the suction control chamber Gentle bubbling in the suction control chamber is an expected finding as air is being removed. 3. Rise and fall in the level of water in the water seal chamber with inspiration and expiration A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicates that the drainage system is functioning properly.
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A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the patient to do? 1. Lie on his left side 2. Use the incentive spirometer 3. Cough at regular intervals 4. Perform the Valsalva maneuver
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4. Perform the Valsalva maneuver The patient should be instructed to take a deep breath, exhale, and bear down as the chest tube is being removed. This increases intrathroacic pressure and reduces the risk of an air embolism.
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A nurse is planning care for a patient following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply) 1. Encourage the patient to cough every 2 hours 2. Check for continuous bubbling in the suction chamber 3. Strip the drainage tubing every 4 hours 4. Clamp the tube once a day 5. Obtain a chest x-ray
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1. Encourage the patient to cough every 2 hours The nurse should instruct the patient to cough every 2 hours. This promotes oxygenation and lung reexpansion. 2. Check for continuous bubbling in the suction chamber The nurse should check for continuous bubbling in the suction chamber to verify that suction is being maintained at the appropriate level. 5. Obtain a chest x-ray A chest x-ray is obtained following the procedure to verify chest tube placement.
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A nurse is discharging a patient who has pulmonary TB and is to start therapy with rifampin. The nurse should plan to include which of the following in the patient's teaching plan: 1. Ringing in the ears is expected. 2. Purified protein derivative skin test results will improve in 4 months. 3. Urine and other secretions will be orange. 4. Take the medication with meals.
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3. Urine and other secretions will be orange. Rifampin will turn urine and other secretions orange.
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A nurse is caring for a patient who has bacterial pneumonia. The nurse should expect which of the following assessment findings: 1. Decreased fremitus 2. SaO2 95% on room air 3. Temperature 38.8 C ( 101.8 F) 4. Bradypnea
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3. Temperature 38.8 C ( 101.8 F) An elevated temperature is an expected finding for a patient who has bacterial pneumonia.
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A nurse is caring for a patient receiving mechanical ventilation. The low pressure alarm sounds. Which of the following should the nurse recognize as a cause for the alarm: 1. Excess secretions 2. Kinks in the tubing 3. Artificial airway cuff leak 4. Biting on the endotracheal tube
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3. Artificial airway cuff leak An artificial airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound.
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A nurse is caring for a patient who has acute respiratory distress syndrome. Which of the following assessment findings indicates a decline in the patient's condition: 1. Increase in respiratory rate 2. Increase in oxygen saturation 3. Decrease in carbon dioxide retention 4. Decrease in intercostal retractions
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1. Increase in respiratory rate An increase is respiratory rate indicates increased work of breathing and the need for improvement in oxygen delivery.
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A nurse is caring for a patient with a PE. Which of the following interventions is the priority: 1. Provide a quiet environment 2. Encourage use of incentive spirometry ever 1 to 2 hours 3. Initiate continuous cardiac monitoring 4. Administer heparin via continuous IV fusion
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4. Administer heparin via continuous IV fusion Using the ABC approach, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation.
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A nurse is planning care for a patient who has COPD. Which of the following interventions should the nurse include in the plan of care: 1. Schedule respiratory treatments after meals 2. Have the patient sit in a chair for 2-hour periods 3x a day 3. Provide a diet high in calories and protein 4. Combine activities to allow for longer rest periods between activities
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3. Provide a diet high in calories and protein The nurse should provide a patient who has COPD with a diet that is high in protein and low on carbs
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A nurse is caring for a patient who has COPD. Which of the following findings should the nurse report to the provider: 1. Oxygen saturation 89% 2. Productive cough with green sputum 3. Clubbing of fingers 4. Pursed lipped breathing with exertion
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2. Productive cough with green sputum A nurse should report a productive cough with green sputum to the provider as it indicates an infection
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A nurse is caring for a patient who has acute respiratory failure. Which of the following laboratory findings should the nurse expect: 1. Arterial pH 7.50 2. PaCO2 25 mm Hg 3. SaO2 92% 4. PaO2 58 mm Hg
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4. PaO2 58 mm Hg The nurse should expect a patient who has acute respiratory failure to have lower partial pressures of oxygen.
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A nurse is caring for a patient who is postoperative and is hypoventilating secondary to general anesthesia effects and incisional pain. Which of the following ABG values support the nurse's suspicion of respiratory acidosis: 1. pH 7.50, PO2 99 mm Hg, PaCO2 25 mm Hg, HCO3 22 mEq/L 2. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3 30 mEq/L 3. pH 3.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3 20 mEq/L 4. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L
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4. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.
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A nurse is assisting with a thoracentesis. Which of the following actions is appropriate for the nurse to take when assisting with this procedure: (Select all that apply) 1. Wear goggles and mask during the procedure 2. Cleanse the area with an antiseptic solution 3. Instruct the patient to take deep breaths during insertion of the needle 4. Position the patient laterally on the affected side 5. Apply pressure to the site after the needle is withdrawn
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1. Wear goggles and mask during the procedure 2. Cleanse the area with an antiseptic solution 5. Apply pressure to the site after the needle is withdrawn
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A nurse is caring for a patient who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take: 1. Use clean technique to suction the patient's endotracheal tube 2. Use a rotating motion to remove the suction catheter 3. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube 4. Suction the patient's endotracheal tube every 2 hours
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2. Use a rotating motion to remove the suction catheter The nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue trauma.
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A nurse is caring for a patient following the insertion of a chest tube. The nurse should plan to have which of the following items in the patient's room: 1. Extra drainage system 2. Suture removal set 3. Container of sterile water 4. Nonadherant pads
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3. Container of sterile water The nurse should plan to place the open end of tubing if it becomes disconnected into the sterile water to prevent a pneumothorax.
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A nurse is assessing a patient who has emphysema. The nurse should report which of the following assessment findings: 1. Digital clubbing 2. Elevated temperature 3. Barrel-shaped chest 4. Diminished breath sounds
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2. Elevated temperature Patients who have emphysema are at risk for development of pneumonia and other respiratory infections. A nurse should report an elevated temperature to the provider.
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A nurse in the emergency department is caring for a patient who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply) 1. SaO2 95% 2. Wheezing 3. Retraction of sternal muscles 4. Pink mucous membranes 5. Premature ventricular complexes (PVCs)
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2. Wheezing Wheezing is a manifestation indicating the patient's respiratory status is declining. 3. Retraction of sternal muscles Retraction of sternal muscles is a manifestation that the patient's respiratory status is declining. 5. Premature ventricular complexes (PVCs) PVCs are a manifestation that the patient's respiratory status is declining.
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A nurse is caring for a patient 2 hours after admission. The patient has an SaO2 of 91% exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? 1. Antibiotic 2. Beta-blocker 3. Antiviral 4. Beta 2 agonist
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4. Beta 2 agonist The nurse should administer a beta2 agonist, which causes dilation of the bronchioles to relieve symptoms.
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A nurse is providing discharge teaching to a patient who has a new prescription for prednisone for asthma. Which of the following patient statements indicates an understanding of the teaching: 1. "I will decrease my fluid intake while taking this medication." 2. "I will expect to have black, tarry stools." 3. "I will take my medication with meals." 4. "I will monitor for weight loss while on this medication."
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3. "I will take my medication with meals." The patient should take this medication with food. Taking prednisone on an empty stomach can cause gastrointestinal distress.
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A nurse is assessing a patient who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? 1. Gender 2. Environmental allergies 3. Alcohol use 4. Race
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2. Environmental allergies Environmental allergies are a risk factor associated with asthma. A patient who has environmental allergies typically has other allergic problems, such as rhinitis or a skin rash.
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A nurse is reinforcing teaching with a patient on the purpose of taking a bronchodilator. Which of the following patient statements indicates an understanding of the teaching? 1. "This medication can decrease my immune response." 2. "I take this medication to prevent asthma attacks." 3. "I need to take this medication with food." 4. "This medication has a slow onset to treat my symptoms."
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2. "I take this medication to prevent asthma attacks." A bronchodilator can prevent asthma attacks from occurring.
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A nurse is providing discharge teaching to a patient who has COPD and a new prescription for albuterol. Which of the following statements by the patient indicates an understanding of the teaching? 1. "This medication can increase my blood sugar levels." 2. "This medication can decrease my immune response." 3. "I can have an increase in my heart rate while taking this medication. 4. "I can have mouth sores while taking this medication."
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3. "I can have an increase in my heart rate while taking this medication. Bronchodilators, such as albuterol, can cause tachycardia.
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A nurse is preparing to administer a dose of a new prescription of prednisone to a patient who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply) 1. Hypokalemia 2. Tachycardia 3. Fluid retention 4. Nausea 5. Black, tarry stools
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3. Fluid retention The nurse should observe for fluid retention. This is an adverse effect of prednisone. 5. Black, tarry stools The nurse should monitor for black, tarry stools.
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A nurse is discharging a patient who has COPD. Upon discharge, the patient is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? 1. "There are portable oxygen delivery systems that you can take with you." 2. "When you go out, you can remove the oxygen and then reapply it when you get home." 3. "You probably will not be able to go out as much as you used to." 4. "Home health services will come to you so you will not need to get out."
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1. "There are portable oxygen delivery systems that you can take with you." The nurse should inform the patient that there are portable oxygen systems that he can use to leave the house. This should alleviate the patient's anxiety.
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A nurse is instructing a patient on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching." 1. "I will place the adapter on my finger to read my blood oxygen saturation level." 2. "I will lie on my back with my knees bent." 3. "I will rest my hand over my abdomen to create resistance. 4. "I will take in a deep breath and hold it before exhaling."
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4. "I will take in a deep breath and hold it before exhaling." The patient who is using the spirometer should take in a deep breath and hold it for 3 to 5 seconds before exhaling. As the patient exhales, the needle of the spirometer rises. This promotes lung expansion.
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A nurse is planning to instruct a patient on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? 1. Take quick breaths upon inhalation. 2. Place your hand over you stomach. 3. Take a deep breath in through your nose. 4. Puff your cheeks upon exhalation.
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3. Take a deep breath in through your nose. The patient should take a deep breath is through her nose while performing pursed-lip breathing. This controls the patient's breathing.
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A home health nurse is teaching a patient who has active TB. The provider has prescribed the following medication regiment: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following patient statements indicate the client understands the teaching? (Select all that apply) 1. "I can substitute one medication for another if I run out because they all fight infection." 2. "I will wash my hands each time I cough." 3. "I will wear a mask when I am in a public area." 4. "I am glad I don't have to have any more sputum specimens." 5. "I don't need to worry where I go once I start taking my medications."
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2. "I will wash my hands each time I cough." The client should wash her hands each time she coughs to prevent spreading the infection. 3. "I will wear a mask when I am in a public area." The patient should wear a mask while in public areas to prevent spreading the infection. The client has active TB, which is transmitted through the airborne route.
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A nurse is teaching a patient who has TB. Which of the following statements should the nurse include in the teaching? 1. "You will need to continue to take the multimedication regimen for 4 months." 2. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." 3. "You will need to remain hospitalized for treatment." 4. "You will need to wear a mask at all times."
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2. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." The client who has tuberculosis needs to provide sputum samples every 2 to 4 weeks to monitor the effectiveness of the medication.
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A nurse is caring for a patient who has a new diagnosis of TB and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the patient related to ethambutol? 1. "Your urine can turn a dark orange." 2. "Watch for a change in the sclera of your eyes." 3. "Watch for any changes in vision." 4. "Take vitamin B6 daily."
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3. "Watch for any changes in vision." The client who is receiving ethambutol will need to watch for visual changes due to optic neuritis, which can result from taking this medication.
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A nurse is preparing to administer a new prescription for isoniazid to a patient who has TB. The nurse should instruct the patient to report which of the following findings as an adverse effect of the medication? 1. "You might notice yellowing of your skin." 2. "You might experience pain in your joints." 3. "You might notice tingling of your hands." 4. "You might experience a loss of appetite."
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3. "You might notice tingling of your hands." Tingling of the hands is an adverse effect of isoniazid.
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A nurse is providing information about TB to a group of patients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply) 1. Persistent cough 2. Weight gain 3. Fatigue 4. Night sweats 5. Purulent sputum
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1. Persistent cough 3. Fatigue 4. Night sweats 5. Purulent sputum
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A nurse is caring for a group of clients. Which of the following clients are at risk for a PE? (Select all that apply) 1. A client who has a BMI of 30 2. A female client who is postmenopausal. 3. A client who has a fractured femur. 4. A client who is a marathon runner. 5. A client who has chronic atrial fibrillation
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1. A client who has a BMI of 30 3. A client who has a fractured femur. 5. A client who has chronic atrial fibrillation
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A nurse is assessing a client who has a PE. Which of the following manifestations should the nurse expect to find? (Select all that apply) 1. Bradypnea 2. Pleural friction rub 3. Hypertension 4. Petechiae 5. Tachycardia
answer
2. Pleural friction rub 4. Petechiae 5. Tachycardia
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A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are heart rate 117/min, respirations 38/min, temperature 101.2 F, and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? 1. Notify the provider. 2. Administer haparin via IV infusion. 3. Administer oxygen therapy. 4. Obtain a spiral CT scan.
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3. Administer oxygen therapy. When using the ABC approach to care, the nurse determines that the priority finding is related to the respiratory status. Meeting oxygenation needs by administering oxygen therapy is the priority action.
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A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? 1. "I am allergic to morphine." 2. "I take antacids several time a day." 3. "I had a blood clot in my leg several years ago." 4. It hurts to take a deep breath."
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2. "I take antacids several time a day." The greatest risk to the client is the possibility of bleeding from a peptic ulcer. The priority intervention is to notify the provider of the finding.
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A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? 1. Hip arthroplasty 2 weeks ago 2. Elevated sedimentation rate 3. Incident of exercise-induced asthma 1 week ago 4. Elevated platelet count
answer
1. Hip arthroplasty 2 weeks ago The client who has undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site.
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A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply) 1. Tachypnea 2. Deviation of the trachea 3. Bradycardia 4. Decreased use of accessory muscles 5. Pleuritic pain
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1. Tachypnea 2. Deviation of the trachea 5. Pleuritic pain
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A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? 1. Assess the client's pain. 2. Obtain a large-bore IV needle for decompression. 3. Administer lorazepam. 4. Prepare for chest tube insertion.
answer
2. Obtain a large-bore IV needle for decompression. The priority action the nurse should take when using the ABC approach to client care is to establish and maintain the client's respiratory function. Obtaining a large-bore IV needle for decompression is the priority action by the nurse.
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A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client? 1. "Notify your provider if you experience weakness." 2. "You should be able to return to work in 1 week." 3. You need to wear a mask when in crowded areas." 4. "Notify your provider if you experience a productive cough."
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4. "Notify your provider if you experience a productive cough." The client should notify the provider of a productive or persistent cough. This can indicate that the client might need treatment of a respiratory infection.
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A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply) 1. Bradycardia 2. Cyanosis 3. Hypotension 4. Dyspnea 5. Paradoxic chest movement
answer
2. Cyanosis 3. Hypotension 4. Dyspnea 5. Paradoxic chest movement
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A nurse in the emergency department is assessing a client who was in a MVA. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 101.4 F, and SaO2 92% on room air. Which of the following actions should the nurse take first? 1. Obtain chest x-ray. 2. Prepare for chest tube insertion. 3. Administer oxygen via a high-flow mask. 4. Initiate IV access.
answer
3. Administer oxygen via a high-flow mask. According to the ABC process, the nurse should place the priority on administering oxygen via high-flow mask to provide the client oxygen to restore optimal breathing.
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A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has ARDS. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? 1. "This medication is given to treat infection." 2. "This medication is given to facilitate ventilation." 3. "This medication is given to decrease inflammation." 4. "This medication is given to reduce anxiety."
answer
2. "This medication is given to facilitate ventilation." Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption.
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A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing respiratory distress syndrome? (Select all that apply) 1. A client who experienced a near-drowning incident. 2. A client following coronary artery bypass graft surgery. 3. A client who has a hemoglobin of 15.1 mg/dL 4. A client who has dyphagia. 5. A client who experienced a drug overdose.
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1. A client who experienced a near-drowning incident. 2. A client following coronary artery bypass graft surgery. 4. A client who has dyphagia. 5. A client who experienced a drug overdose.
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A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply) 1. Administer antibiotics. 2. Provide supplemental oxygen 3. Administer antiviral medication 4. Administer of bronchodilators 5. Maintain ventilatory support
answer
2. Provide supplemental oxygen 4. Administer of bronchodilators 5. Maintain ventilatory support
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A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply) 1. Fentanyl 2. Furosemide 3. Midazolam 4. Famotidine 5. Dexamethasone
answer
1. Fentanyl 3. Midazolam
