A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?
Position the client in an upright position, leaning over the bedside table.
Explain the procedure.
Obtain ABGs.
Administer benzocaine spray.
A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.40, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid‑base imbalances?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider?
Blood‑tinged sputum
Dry, nonproductive cough
Sore throat
Bronchospasms
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client’s room? (Select all that apply.)
Oxygen equipment
Incentive spirometer
Pulse oximeter
Sterile dressing
Suture removal kit
A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.)
Dyspnea
Localized bloody drainage on the dressing
Fever
Hypotension
Report of pain at the puncture site
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client’s room? (Select all that apply.)
Oxygen
Sterile water
Enclosed hemostat clamps
Indwelling urinary catheter
Occlusive dressing
A nurse is caring for a client 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?
Obtain a chest x‑ray.
Apply sterile gauze to the insertion site.
Place tape around the insertion site.
Assess respiratory status.
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.)
Continuous bubbling in the water seal chamber
Gentle constant bubbling in the suction control chamber
Rise and fall in the level of water in the water seal chamber with inspiration and expiration
Exposed sutures without dressing
Drainage system upright at chest level
A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do?
Lie on his left side.
Use the incentive spirometer.
Cough at regular intervals.
Perform the Valsalva maneuver.
A nurse is planning care for a client 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.)
Encourage the client to cough every 2 hr.
Check for continuous bubbling in the suction chamber.
Strip the drainage tubing every 4 hr.
Clamp the tube once a day.
A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV?
“It keeps the alveoli open and prevents atelectasis.”
“It allows preset pressure delivered during spontaneous ventilation.”
“It guarantees minimal minute ventilator.”
“It delivers a preset ventilatory rate and tidal volume to the client.”
A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.)
Confusion
Pale skin
Bradycardia
Elevated blood pressure
A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
Apply a vest restraint if self‑extubation is attempted.
Monitor ventilator settings every 8 hr.
Document tube placement in centimeters at the angle of jaw.
Assess breath sounds every 1 to 2 hr.
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
Nonrebreather mask
Venturi mask
Nasal cannula
Simple face mask
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client’s respiratory muscles should the nurse include in the plan of care? (Select all that apply.)
Assist‑control
Synchronized intermittent mandatory ventilation
Continuous positive airway pressure
Pressure support ventilation
Independent lung ventilation
A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.)
Client who has dysphagia
Client who has AIDS
Client who was vaccinated for pneumococcus and influenza 6 months ago
Client who is postoperative and has received local anesthesia
Client who has a closed head injury and is receiving ventilation
Client who has myasthenia gravis
A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?
Obtain baseline vital signs and oxygen saturation.
Obtain a sputum culture.
Obtain a complete history from the client.
Provide a pneumococcal vaccine.
A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder?
Percussion of posterior lobes of lungs
Auscultation of the trachea
Inspection of the conjunctiva
Palpation of the orbital areas
A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching?
“I should wash my hands after blowing my nose to prevent spreading the virus.”
“I need to avoid drinking fluids if I develop symptoms.”
“I need a flu shot every 2 years because of the different flu strains.”
“I should cover my mouth with my hand when I sneeze.”
A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.)
SaO2 95%
Wheezing
Retraction of sternal muscles
Pink mucous membranes
Premature ventricular complexes (PVCs)
A nurse is caring for a client 2 hr after admission. The client 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?
Antibiotic
Beta‑blocker
Antiviral
Beta2 agonist
A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding of the teaching?
“I will decrease my fluid intake while taking this medication.”
“I will expect to have black, tarry stools.”
“I will take my medication with meals.”
“I will monitor for weight loss while on this medication.”
A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma?
Gender
Environmental allergies
Alcohol use
Race
A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching?
“This medication can decrease my immune response.”
“I take this medication to prevent asthma attacks.”
“I need to take this medication with food.”
“This medication has a slow onset to treat my symptoms.”
A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching?
“This medication can increase my blood sugar levels.”
“I can have an increase in my heart rate while taking this medication.”
“I can have mouth sores while taking this medication.”
A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.)
Hypokalemia
Tachycardia
Fluid retention
Nausea
Black, tarry stools
A nurse is discharging a client who has COPD. Upon discharge, the client 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?
“There are portable oxygen delivery systems that you can take with you.”
“When you go out, you can remove the oxygen and then reapply it when you get home.”
“you probably will not be able to go out as much as you used to.”
“Home health services will come to you so you will not need to get out.”
A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
“I will place the adapter on my finger to read my blood oxygen saturation level.”
“I will lie on my back with my knees bent.”
“I will rest my hand over my abdomen to create resistance.”
“I will take in a deep breath and hold it before exhaling.”
A nurse is planning to instruct a client on how to perform pursed‑lip breathing. Which of the following should the nurse include in the plan of care?
Take quick breaths upon inhalation.
Place your hand over your stomach.
Take a deep breath in through your nose.
Puff your checks upon exhalation.
A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: 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 client statements indicate the client understands the teaching? (Select all that apply.)
“I can substitute one medication for another if I run out because they all fight infection.”
“I will wash my hands each time I cough.”
“I will wear a mask when I am in a public area.”
“I am glad I don’t have to have any more sputum specimens.”
“I don’t need to worry where I go once I start taking my medications.”
A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching?
“You will need to continue to take the multimedication regimen for 4 months.”
“You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.”
“You will need to remain hospitalized for treatment.”
“You will need to wear a mask at all times.”
A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to ethambutol?
“your urine can turn a dark orange.”
“Watch for a change in the sclera of your eyes.”
“Watch for any changes in vision.”
“Take vitamin B6 daily.”
A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?
“you might notice yellowing of your skin.”
“you might experience pain in your joints.”
“you might notice tingling of your hands.”
“you might experience a loss of appetite.”
A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
Persistent cough
Weight gain
Fatigue
Night sweats
Purulent sputum
A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (Select all that apply.)
A client who has a BMI of 30
A female client who is postmenopausal
A client who has a fractured femur
A client who is a marathon runner
A client who has chronic atrial fibrillation
A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect to find? (Select all that apply.)
Bradypnea
Pleural friction rub
Hypertension
Petechiae
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 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority?
Notify the provider.
Administer heparin via IV infusion.
Administer oxygen therapy.
Obtain a spiral CT scan.
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?
“I am allergic to morphine.”
“I take antacids several times a day.”
“I had a blood clot in my leg several years ago.”
“It hurts to take a deep breath.”
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?
Hip arthroplasty 2 weeks ago
Elevated sedimentation rate
Incident of exercise‑induced asthma 1 week ago
Elevated platelet count
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.)
Tachypnea
Deviation of the trachea
Decreased use of accessory muscles
Pleuritic pain
A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first?
Assess the client’s pain.
Obtain a large‑bore IV needle for decompression.
Administer lorazepam.
Prepare for chest tube insertion.
A nurse is reviewing instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client?
“Notify your provider if you experience weakness.”
“You should be able to return to work in 1 week.”
“You need to wear a mask when in crowded areas.”
“Notify your provider if you experience a productive cough.”
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.)
Cyanosis
Paradoxic chest movement
A nurse in the emergency department is assessing a client who was in a motor vehicle crash. 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 38.6° C (101.4° F), and SaO2 92% on room air. Which of the following actions should the nurse take first?
Administer oxygen via a high‑flow mask.
Initiate IV access.
A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
“This medication is given to treat infection.”
“This medication is given to facilitate ventilation.”
“This medication is given to decrease inflammation.”
“This medication is given to reduce anxiety.”
A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.)
A client who experienced a near‑drowning incident
A client following coronary artery bypass graft surgery
A client who has a hemoglobin of 15.1 mg/dL
A client who has dysphagia
A client who experienced a drug overdose
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.)
Administer antibiotics.
Provide supplemental oxygen.
Administer antiviral medications.
Administer of bronchodilators.
Maintain ventilatory support.
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.)
Fentanyl
Furosemide
Midazolam
Famotidine
Dexamethasone
