Question 1

When using sterile technique to perform tracheostomy care of a new tracheostomy,which action is correct?&#10;A) Apply sterile gloves.&#10;B) Place the patient in semi-Fowler's position,if possible.&#10;C) Clean the stoma under the faceplate with hydrogen peroxide.&#10;D) Cut a slit in sterile 4 $\times$ 4 gauze halfway through to make a dressing.&#10;

Accepted Answer

Place the patient in semi-Fowler's position,if possible.&#10;

Question 2

The nurse is caring for a patient who is experiencing dyspnea.Which position would be most effective if incorporated into the patient's care?&#10;A) Supine&#10;B) Head of bed elevated 80&#176;&#10;C) Head of bed elevated 30&#176;&#10;D) Lying on left side&#10;

Accepted Answer

Elevating the head of the bed to 80° can help to relieve dyspnea by allowing for improved lung expansion and oxygenation. The supine position may exacerbate dyspnea, lying on the left side may not be beneficial, and elevating the head of the bed to only 30° may not be enough to alleviate dyspnea.

Question 3

Chest percussion and postural drainage would be an appropriate intervention for which condition?&#10;A) Congestive heart failure&#10;B) Pulmonary edema&#10;C) Pneumonia&#10;D) Pulmonary embolus&#10;

Accepted Answer

Chest percussion and postural drainage are commonly used interventions for patients with pneumonia to help mobilize secretions and improve lung function. They may not be as effective or appropriate for congestive heart failure, pulmonary edema, or pulmonary embolus.

Question 4

A client with a tracheostomy being mechanically ventilated has a pulse oximetry reading of 85%,heart rate of 113 beats/min,and respiratory rate of 30 breaths/min.The client is restless,and crackles and rhonchi are auscultated over both lungs.Which action should the nurse take?

A) Call the respiratory therapist to check the ventilator settings.
B) Provide endotracheal suctioning.
C) Provide tracheostomy care.
D) Notify the physician of the patient's signs of fluid overload.

Accepted Answer

The client's low pulse oximetry reading, high heart rate, and high respiratory rate combined with restlessness and adventitious lung sounds suggest that the client may have excessive secretions in the tracheostomy tube or in the airways. Endotracheal suctioning can help remove the mucus from the airways, improve oxygenation, decrease work of breathing, and reduce the risk of complications such as infection and atelectasis. The other options may also be appropriate depending on the client's condition, but they do not directly address the current priority of managing the airway and improving gas exchange.

Question 5

While a patient is receiving hygiene care,the chest tube becomes disconnected from the water-seal chest drainage system (CDU).Which action should the nurse take immediately?&#10;A) Clamp the chest tube close to the insertion site.&#10;B) Set up a new drainage system and connect it to the chest tube.&#10;C) Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU.&#10;D) Place the disconnected end nearest the patient into a bottle of sterile water.&#10;

Accepted Answer

Placing the disconnected end of the chest tube nearest the patient into a bottle of sterile water is the immediate action to take. This prevents air from entering the pleural space through the disconnected tube, maintaining the water seal and preventing a potential pneumothorax until the system can be properly reconnected.

Question 6

The nurse administers intravenous morphine sulfate to a patient for pain control.For which adverse effect should the nurse monitor this patient?&#10;A) Decreased heart rate&#10;B) Muscle weakness&#10;C) Decreased urine output&#10;D) Respiratory depression&#10;

Accepted Answer

Respiratory depression is the most significant adverse effect of morphine sulfate administration. Morphine can suppress the breathing center in the brainstem, leading to respiratory depression, and in severe cases, respiratory arrest. The nurse should monitor the patient's respiratory rate, depth, and effort frequently and assess oxygen saturation levels. If respiratory depression occurs, the nurse should immediately stop the infusion and administer naloxone, a narcotic antagonist, as ordered. Option A is incorrect because morphine sulfate can cause an initial increase in heart rate followed by bradycardia. Option B is incorrect as muscle weakness is not a frequent adverse effect of morphine sulfate. Option C is incorrect as morphine sulfate does not have a direct effect on urine output.

Question 7

A client with a closed head injury has a respiratory pattern that progressively increases and then decreases in depth,followed by a period of apnea.What is this client's breathing pattern?&#10;A) Biot's breathing&#10;B) Kussmaul's respirations&#10;C) Sleep apnea&#10;D) Cheyne-Stokes respirations&#10;

Accepted Answer

The described respiratory pattern is characteristic of Cheyne-Stokes respirations, which are commonly seen in patients with closed head injuries. Cheyne-Stokes respirations are characterized by alternating periods of deep breathing followed by decreased breathing, and sometimes apnea, and are caused by dysfunction in the brainstem's respiratory center.

Question 8

A patient with chronic obstructive pulmonary disease (COPD)is prescribed O₂at 24% FIO₂.What is the most appropriate oxygen delivery method for this patient? A) Nonrebreather mask B) Nasal cannula C) Partial rebreather mask D) Venturi mask

Accepted Answer

The Venturi mask is the most appropriate oxygen delivery method for the patient with COPD because it delivers precise oxygen concentrations while minimizing the risk of CO2 retention, which can occur with other delivery methods. The 24% FIO2 setting on the O₂ device matches the flow rate of the Venturi mask, which makes it the ideal choice for this patient. Nasal cannula and nonrebreather masks should be avoided because they do not reduce the risk of CO2 retention, and a partial rebreather mask may not deliver precise oxygen concentrations.

Question 9

The nurse examines the site of a client's tuberculin skin test as being 5 mm induration and documents that the test is positive.Which information in the client's history did the nurse use to make this clinical determination?

A) HIV positive
B) Type 2 diabetes mellitus
C) Lives in a skilled nursing facility
D) Recent immigrant to the United States

Accepted Answer

A positive tuberculin skin test in a client with 5 mm of induration is considered significant if the client is HIV-positive. Other individuals who are considered high-risk and may have a positive test at this level include recent immigrants, healthcare workers, and individuals living in crowded settings, such as skilled nursing facilities. Type 2 diabetes mellitus is not directly associated with an increased risk of tuberculosis infection or a positive tuberculin skin test.

Question 10

The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis.Which response indicates to the nurse that the medication is effective?&#10;A) The amount of sputum decreases with each dose administered.&#10;B) Cough is completely suppressed,and the patient is able to sleep through the night.&#10;C) Dry,unproductive cough is reduced,but voluntary coughing is more productive.&#10;D) Involuntary coughing produces large amounts of thick yellow sputum.&#10;

Accepted Answer

An antitussive/expectorant medication helps to reduce coughing and make it more productive, meaning the patient is able to cough up and expel mucus. Choice A is incorrect as decreasing sputum production is not a desired effect with expectorant use. Choice B is incorrect as complete suppression of the cough is not desirable for patients with bronchitis because it can lead to retained secretions and increased risk for infection. Choice D is incorrect as thick yellow sputum may indicate an infection, which would require further treatment.

Question 11

The nurse notes that a client has a prescription for a peak expiratory flow meter.For which health problem should the nurse prepare teaching for this client?&#10;A) Asthma&#10;B) Pneumonia&#10;C) Emphysema&#10;D) Pulmonary edema&#10;

Accepted Answer

The answer of The nurse notes that a client has...

Question 12

What is the rationale for wrapping petroleum gauze around a chest tube insertion site?&#10;A) Prevents air from leaking around the site&#10;B) Prevents infection at the insertion site&#10;C) Absorbs drainage from the insertion site&#10;D) Protects the tube from becoming dislodged&#10;

Accepted Answer

The answer of What is the rationale for wrapping petroleum...

Question 13

A client with pulmonary hypertension and right-sided heart failure has conversational dyspnea and shortness of breath.What is the first action the nurse should take?&#10;A) Review and implement the primary care provider's prescriptions for treatments.&#10;B) Perform a quick physical examination of breathing,circulation,and oxygenation.&#10;C) Gather a thorough medical history,including current symptoms,from the family.&#10;D) Administer oxygen to the patient through a nasal cannula.&#10;

Accepted Answer

The answer of A client with pulmonary hypertension and right-sided...

Question 14

Which information provides the most reliable data about the effectiveness of airway suctioning?&#10;A) The amount,color,consistency,and odor of secretions&#10;B) The patient's tolerance for the procedure&#10;C) Breath sounds,vital signs,and pulse oximetry before and after suctioning&#10;D) The number of suctioning passes required to clear secretions&#10;

Accepted Answer

The answer of Which information provides the most reliable data...

Question 15

A patient has just had a chest tube inserted to dry-seal suction drainage.Which is a correct nursing intervention for maintenance?&#10;A) Keep the head of the bed flat for 6 hours.&#10;B) Immobilize the patient's arm on the affected side.&#10;C) Keep the drainage system lower than the insertion site.&#10;D) Drain condensation into the humidifier when it collects in the tubing.&#10;

Accepted Answer

The answer of A patient has just had a chest...

Question 16

A client's pulse oximetry reading is 90%.What action should the nurse take first?&#10;A) Raise the head of the bed.&#10;B) Prepare to administer oxygen.&#10;C) Notify the healthcare provider.&#10;D) Move the sensor to another area.&#10;

Accepted Answer

The answer of A client's pulse oximetry reading is 90%.What...

Question 17

A 62-year-old man with emphysema does not understand the need to stop smoking at this age because lung problems already exist.Which would be the best response to his statement?&#10;A) &#34;You should quit so your family does not get sick from exposure to secondhand smoke.&#34;&#10;B) &#34;You will need to use oxygen,but remember it is a fire hazard to smoke with oxygen in your home.&#34;&#10;C) &#34;Once you stop smoking,your body will begin to repair some of the damage to your lungs.&#34;&#10;D) &#34;You should ask your primary care provider for a prescription for a nicotine patch to help you quit.&#34;&#10;

Accepted Answer

The answer of A 62-year-old man with emphysema does not...

Question 18

Which blood level normally provides the primary stimulus for breathing?&#10;A) pH&#10;B) Oxygen&#10;C) Bicarbonate&#10;D) Carbon dioxide&#10;

Accepted Answer

The answer of Which blood level normally provides the primary...

Question 19

A client in labor after 32 weeks' gestation is eager to deliver.Which client statement indicates that teaching provided about fetal development was effective?&#10;A) &#34;The baby's lungs are well developed now,but he will be at increased risk for SIDS if I deliver early.&#34;&#10;B) &#34;We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early.&#34;&#10;C) &#34;If I deliver this early my baby is at risk for respiratory distress syndrome,a condition that can be life threatening.&#34;&#10;D) &#34;Thanks for reassuring me; I was pretty sure there isn't much risk to the baby this far along in my pregnancy.&#34;&#10;

Accepted Answer

The answer of A client in labor after 32 weeks'...

Question 20

A client is coughing and has bilateral rhonchi throughout the lung fields.Which nursing diagnosis is most appropriate for these assessment findings?&#10;A) Impaired Gas Exchange&#10;B) Ineffective Airway Clearance&#10;C) Ineffective Breathing Pattern&#10;D) Impaired Spontaneous Ventilation&#10;

Accepted Answer

The answer of A client is coughing and has bilateral...

Question 21

The nurse is counseling a 17-year-old girl on smoking cessation.What should the nurse include when teaching this client? Select all that apply.&#10;A) &#34;Keep healthy snacks or gum available to chew instead of smoking a cigarette.&#34;&#10;B) &#34;Don't tell your friends and family you are trying to quit,until you feel confident that you'll be successful.&#34;&#10;C) &#34;Plan a time to quit when you will not have many other demands or stressors in your life.&#34;&#10;D) &#34;Reward yourself with an activity you enjoy when you quit smoking.&#34;&#10;E) &#34;Spend time with friends who do not smoke.&#34;&#10;

Accepted Answer

The answer of The nurse is counseling a 17-year-old girl...

Question 22

A client has a chest drainage system.What should the nurse include when teaching the client about this system? Select all that apply.&#10;A) Perform frequent coughing and deep-breathing exercises.&#10;B) Sit up in a chair but do not walk while the drainage system is in place.&#10;C) Get out of bed without assistance as much as possible.&#10;D) Immediately notify the nurse if experiencing increased shortness of breath.&#10;E) Make sure the collection device is above the level of the chest tube insertion site.&#10;

Accepted Answer

The answer of A client has a chest drainage system.What...

Question 23

A patient with COPD has a pulse oximetry reading of 97%.What other finding would indicate adequate tissue and organ oxygenation? Select all that apply.&#10;A) Normal urine output&#10;B) Strong peripheral pulses&#10;C) Clear breath sounds bilaterally&#10;D) Normal muscle strength&#10;E) Orientation&#10;

Accepted Answer

The answer of A patient with COPD has a pulse...

Question 24

For which condition is obesity associated with a higher risk of conditions that affect the pulmonary and cardiovascular systems? Select all that apply.&#10;A) Reduced alveolar-capillary gas exchange&#10;B) Lower respiratory tract infections&#10;C) Sleep apnea&#10;D) Hypertension&#10;E) Dyspnea on exertion&#10;

Accepted Answer

The answer of For which condition is obesity associated with...

Question 25

Which statement is accurate about nasotracheal suctioning? Select all that apply.&#10;A) Apply suction for no longer than 10 to 15 seconds during a single pass.&#10;B) Apply suction while inserting and removing the catheter.&#10;C) Reapply oxygen between suctioning passes for ventilator patients.&#10;D) Gently rotate the suction catheter as you remove it.&#10;E) Allow intervals of at least 30 seconds between suctioning.&#10;

Accepted Answer

The answer of Which statement is accurate about nasotracheal suctioning?...

Question 26

The nurse instructs the mother of a toddler on safety.What information about the toddler's developmental stage and factors that influence oxygenation should the nurse include? Select all that apply.&#10;A) Frequent,serious respiratory infections&#10;B) Airway obstruction from aspiration of small objects&#10;C) Drowning in small amounts of water around the home&#10;D) Development of asthma&#10;E) Develop shortness of breath with extreme activity&#10;

Accepted Answer

The answer of The nurse instructs the mother of a...

Question 27

A client recovering from a respiratory infection is concerned about a new onset of diarrhea.What should the nurse assess in this client?&#10;A) Last use of steroids&#10;B) Amount of vitamin C ingested&#10;C) Frequency of decongestant use&#10;D) Use of over-the-counter antitussives&#10;

Accepted Answer

The answer of A client recovering from a respiratory infection...

Question 28

Which intervention is likely to reduce the risk of postoperative atelectasis? Select all that apply.&#10;A) Administer bronchodilators.&#10;B) Apply low-flow oxygen.&#10;C) Encourage coughing and deep breathing and coughing.&#10;D) Administer pain medication.&#10;E) Assist to move and reposition in bed.&#10;

Accepted Answer

The answer of Which intervention is likely to reduce the...

Question 29

Which factor influences normal lung volumes and capacities? Select all that apply.&#10;A) Age&#10;B) Race&#10;C) Body size&#10;D) Activity level&#10;E) Gender&#10;

Accepted Answer

The answer of Which factor influences normal lung volumes and...

Question 30

A client has a nursing diagnosis of Ineffective Breathing Pattern identified on the care plan.What should the nurse expect when assessing this client?&#10;A) Coughing&#10;B) Cold extremities&#10;C) Adventitious breath sounds&#10;D) Respiratory rate of 8 breaths/min&#10;

Accepted Answer

The answer of A client has a nursing diagnosis of...

Deck 37: Oxygenation