Ch26:Respiratory Assessment, ATI- 17-25
Terms in this set (52)
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests.
When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
a. Supine with the head of the bed elevated 30 degrees
b. In a high-Fowler's position with the left arm extended
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as "99." After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.
A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate?
a. Elevate the head of the bed to 80 to 90 degrees.
b. Keep the patient NPO until the gag reflex returns.
c. Place on bed rest for at least 4 hours after bronchoscopy.
d. Notify the health care provider about blood-tinged mucus.
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler's position.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration heard on inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
a. Notify the health care provider.
b. Document the response to exercise.
c. Administer the PRN supplemental O2.
d. Encourage the patient to pace activity.
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.
The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective?
a. "I will use my inhaler right before the test."
b. "I won't eat or drink anything 8 hours before the test."
c. "I should inhale deeply and blow out as hard as I can during the test."
d. "My blood pressure and pulse will be checked every 15 minutes after the test."
For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.
The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills?
a. The student starts at the apices of the lungs and moves to the bases.
b. The student compares breath sounds from side to side avoiding bony areas.
c. The student places the stethoscope over the posterior chest and listens during inspiration.
d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.
Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
a. Start giving the patient discharge teaching on the day of admission.
b. Have the patient repeat the instructions immediately after teaching.
c. Accomplish the patient teaching just before the scheduled discharge.
d. Arrange for the patient's caregiver to be present during the teaching.
Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.
A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
a. Start an IV so contrast media may be given.
b. Ensure that the patient has been NPO for at least 6 hours.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to undress to the waist and remove any metal objects.
Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used.
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?
a. "I have not had any acute asthma attacks during the last year."
b. "I became short of breath an hour before coming to the hospital."
c. "I've been taking Tylenol 650 mg every 6 hours for chest-wall pain."
d. "I've been using my albuterol inhaler more frequently over the last 4 days."
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?
a. Allergy to shellfish
b. Apical pulse of 104
c. Respiratory rate of 30
d. Oxygen saturation of 90%
Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.
The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?
a. The bicarbonate level (HCO3-) is 31 mEq/L.
b. The arterial oxygen saturation (SaO2) is 92%.
c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.
When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?
a. Weak cough effort
b. Barrel-shaped chest
c. Dry mucous membranes
d. Bilateral crackles at lung bases
Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.
A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next?
a. Administer bicarbonate.
b. Complete a head-to-toe assessment.
c. Place the patient on high-flow oxygen.
d. Obtain repeat arterial blood gases (ABGs).
Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given. Bicarbonate would worsen the patient's condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen.
After the nurse has received change-of-shift report, which patient should the nurse assess first?
a. A patient with pneumonia who has crackles in the right lung base
b. A patient with possible lung cancer who has just returned after bronchoscopy
c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider?
a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider?
a. Respirations are 36 breaths/minute.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present.
The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
a. Listen to a patient's lung sounds for wheezes or rhonchi.
b. Label specimens obtained during percutaneous lung biopsy.
c. Instruct a patient about how to use home spirometry testing.
d. Measure induration at the site of a patient's intradermal skin test.
Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.
A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)?
a. Patient is claustrophobic.
b. Patient is allergic to shellfish.
c. Patient recently used a bronchodilator inhaler.
d. Patient is not able to remove a wedding band.
e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.
ANS: B, E
Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).
While listening to the posterior chest of a patient who is experiencing acute shortness of breath, the nurse hears these sounds. How should the nurse document the lung sounds?
Click here to listen to the audio clip : http://static.us.elsevierhealth.com/lewis_9e/wheezing.mp3
a. Pleural friction rub
b. Low-pitched crackles
c. High-pitched wheezes
d. Bronchial breath sounds
Wheezes are continuous high-pitched or musical sounds heard initially with expiration. The other responses are typical of other adventitious breath sounds.
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?
A. Position the client in an upright position, leaning over the bedside table.
B. Explain the procedure to the client.
C. Obtain ABGs from the client.
D. Administer benzocaine spray to the client.
A. Correct: Positioning the client in an upright position and bent over the bedside table widens the
pleural space for the provider to access the pleural fluid.
B. Incorrect: It is not the role of the nurse to explain the procedure to the client. This is the
responsibility of the provider.
C. Incorrect: It is not indicated that the client needs ABGs drawn.
D. Incorrect: Benzocaine spray is not administered with a thoracentesis. It is used for
A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the
following can cause a low pulse oximetry reading? (Select all that apply.)
A. Nail polish
B. Inadequate peripheral circulation
D. Increased Hgb level
A. Correct: Nail polish can affect the accuracy of pulse oximetry and result in an incorrect pulse
B. Correct: Inadequate peripheral circulation can result in a low reading while obtaining a client's
pulse oximetry level.
C. Incorrect: Hypothermia can result in a low reading while obtaining a client's pulse
D. Incorrect: A decreased Hgb level can result in a low reading while obtaining a client's pulse
E. Correct: Edema can result in a low reading while obtaining a client's pulse oximetry level.
A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse
report to the provider?
A. Blood-tinged sputum
B. Dry, nonproductive cough
C. Sore throat
A. Incorrect: Blood-tinged sputum is an expecting finding following a bronchoscopy.
B. Incorrect: A dry, nonproductive cough is an expected finding following a bronchoscopy.
C. Incorrect: A sore throat is an expected finding following a bronchoscopy.
D. Correct: Bronchospams can indicate the client is having difficulty maintaining a patent airway.
The nurse should notify the provider immediately.
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies
should the nurse ensure is in the client's room? (Select all that apply.)
A. Oxygen equipment
B. Incentive spirometer
C. Pulse oximeter
D. Sterile dressing
E. Suture removal kit
A. correct: Oxygen equipment is necessary to have in the client's room if the client becomes short
of breath following the procedure.
B. Incorrect: An incentive spirometer is indicated for a client following thoracic surgery to
promote improved oxygenation and pulmonary function.
C. Correct: Pulse oximetry is necessary to monitor the client's oxygen saturation level during
D. Correct: A sterile dressing is necessary to apply to the puncture site following the procedure.
E. Incorrect: A suture removal kit is needed to remove sutures following surgery.
A nurse is caring for a client following a thoracentesis. Which of the following clinical manifestations
should the nurse recognize as risks for complications? (Select all that apply.)
B. Localized bloody drainage on the dressing
E. Report of pain at the puncture site
A. Correct: Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should
notify the provider immediately.
B. Incorrect: Localized bloody drainage contained on a dressing is an expected finding following
C. Correct: Fever can indicate an infection. The nurse should notify the provider immediately.
D. Correct: Hypotension can indicate intrathoracic bleeding. The nurse should notify the
E. Incorrect: The client's report of pain at the puncture site is an expected finding following
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.)
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing
A. Correct: Oxygen should be readily available in case the client develops respiratory distress
following chest tube placement. The nurse should monitor the client's respiration, oxygen
saturation, and lung sounds.
B. Correct: If the chest tubing becomes disconnected, the end of the tubing should be placed in
sterile water to restore the water seal.
C. Correct: Hemostat clamps should be available for the nurse to use to check for air leaks.
D. Incorrect: An indwelling urinary catheter is not indicated for a client who has a chest tube.
E. Correct: If the chest tubing becomes disconnected, the nurse should immediately place an
occlusive dressing over the chest tube insertion site. This allows air to escape and reduces the risk
for development of a tension pneumothorax.
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that
the client's chest tube was accidentally removed. Which of the following actions should the nurse take first?
A. Place the tubing in sterile water to restore the water seal.
B. Apply sterile gauze to the insertion site.
C. Place tape around the insertion site.
D. Assess the client's respiratory status.
A. Incorrect: Placing the tubing in sterile water to restore the water seal is an appropriate action,
but it is not the first action.
B. Correct: Using the airway, breathing, and circulation (ABC) priority-setting framework, the
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.
C. Incorrect: Placing tape around the insertion site ensures that the sterile gauze remains intact
and is an appropriate action, but it is not the first action.
D. Incorrect: Assessing the client's respiratory status is an appropriate action, but it is not the
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.)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level
A. Incorrect: Continuous bubbling in the water seal chamber indicates an air leak.
B. Correct: Gentle bubbling in the suction control chamber is an expected finding as air is
C. Correct: 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.
D. Incorrect: The nurse should cover the sutures at the insertion site with an airtight dressing.
E. Incorrect: The drainage system should be maintained in an upright position below the level of
the client's chest.
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?
A. Lie on his left side.
B. Use the incentive spirometer.
C. Cough at regular intervals.
D. Perform the Valsalva maneuver.
A. Incorrect: Incorrect: The position the client should assume during removal of a chest tube will
depend upon the location of the insertion site.
B. Incorrect: The use of an incentive spirometer is not indicated during chest tube removal.
C. Incorrect: The client is instructed to breathe normally and remain calm during the procedure.
D. Correct: The client should be instructed to take a deep breath, exhale, and bear down (Valsalva
maneuver) as the chest tube is being removed. This increases intrathoracic pressure and reduces
the risk of an air embolism.
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.)
A. Encourage the client to cough every 2 hr.
B. Check for continuous bubbling in the suction chamber.
C. Strip the drainage tubing every 4 hr.
D. Clamp the tube once a day.
E. Obtain a chest x-ray.
A. Correct: The nurse should instruct the client to cough every 2 hr. This promotes oxygenation
and lung reexpansion.
B. Correct: The nurse should check for continuous bubbling in the suction chamber to verify that
suction is being maintained at an appropriate level.
C. Incorrect: The nurse should not milk or strip the drainage tubing to check for kinks. This action
is only to be done when prescribed by the provider. Stripping creates negative high pressure and
can damage the client's lung tissue.
D. Incorrect: The nurse should not clamp the tubing unless indicated by the provider. This is
done to verify for the presence of an air leak or if the tubing accidentally has been disconnected.
Clamping may cause a tension pneumothorax.
E. Correct: A chest x-ray is obtained following the procedure to verify chest tube placement.
A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early
clinical manifestations of hypoxemia? (Select all that apply.)
B. Pale skin
E. Elevated blood pressure
A. INCORRECT: Confusion is a late clinical manifestation of hypoxemia.
B. CORRECT: Pale skin is an early clinical manifestation of hypoxemia.
C. INCORRECT: Bradycardia is a late clinical manifestation of hypoxemia.
D. INCORRECT: Hypotension is a late clinical manifestation of hypoxemia.
E. CORRECT: Elevated blood pressure is an early clinical manifestation of hypoxemia.
A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the
following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask
A. INCORRECT: A nonrebreather mask delivers an approximated amount of oxygen to the client.
B. CORRECT: A venturi mask incorporates an adapter that allows a precise amount of oxygen to be
delivered to the client.
C. INCORRECT: A nasal cannula delivers an approximated amount of oxygen to the client.
D. INCORRECT: A simple face mask delivers an approximated amount of oxygen to the client.
A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The 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 is the priority
A. Obtain baseline vital signs and oxygen saturation.
B. Obtain a sputum culture.
C. Obtain a complete history from the client.
D. Provide a pneumococcal vaccination.
A. CORRECT: Assessment is the first step of the nursing process and is essential in planning
B. INCORRECT: Obtaining a sputum culture is an appropriate action by the nurse, but it is not the
C. INCORRECT: Obtaining a complete history from the client is an appropriate action by the nurse,
but it is not the priority action.
D. INCORRECT: Providing for a
A nurse is caring for a client who has pneumonia. Assessment findings include temperature
37.8° C (100° F), respirations 30/min, BP 130/76, heart rate 100/min, and SaO2 91% on room air. Using a
scale of 1 to 4, with 1 being the highest priority, prioritize the following nursing interventions.
A. Administer antibiotics as prescribed.
B. Administer oxygen therapy.
C. Perform a sputum culture.
D. Administer an antipyretic medication to promote client comfort.
B. The client's respiratory and heart rates are elevated, and her oxygen saturation is 91% on room air.
Using the ABC priority framework, providing oxygen is the first intervention.
C. Obtaining a sputum culture is the second nursing intervention. It should be done prior to
administering oral medications to obtain an appropriate and adequate specimen.
A. Administration of antibiotics is the third action the nurse should take. The sputum culture should
be obtained prior to antibiotic administration.
D. Administering an antipyretic medication is the fourth nursing intervention.
A nurse in a clinic is caring for a client who has sinusitis. Which of the following techniques should the
nurse use to identify clinical manifestations of this disorder?
A. Percussion of posterior lobes of lungs
B. Auscultation of the trachea
C. Inspection of the conjunctiva
D. Palpation of the orbital areas
A. INCORRECT: Lung percussion is not an appropriate technique to identify clinical manifestations of
sinusitis; it is appropriate for a client who has pneumonia.
B. INCORRECT: Auscultation of the trachea is not an appropriate technique to identify clinical
manifestations of sinusitis; it is appropriate for a client who has bronchitis.
C. INCORRECT: Inspection of the conjunctiva is not an appropriate technique to identify clinical
manifestations of sinusitis; it is appropriate for a client who has anemia.
D. CORRECT: Palpation of the orbital, frontal, and facial areas will elicit a report of tenderness, which
is a clinical manifestation in a client who has sinusitis.
A nurse in the emergency department is caring for a client who was admitted with an acute asthma
attack. Which of the following indicates the client's respiratory status is declining? (Select all that apply.)
A. SaO2 95%
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVCs)
A. INCORRECT: An oxygen saturation of 95% is an expected finding within the respiratory system
and exhibits no signs of distress.
B. CORRECT: Wheezing is a clinical manifestation indicating that the client's respiratory status
C. CORRECT: Retraction of sternal muscles is a clinical manifestation that the client's respiratory
status is declining.
D. INCORRECT: Pink mucous membranes is an expected finding within the respiratory system and
exhibits no signs of distress.
E. CORRECT: Premature ventricular complexes (PVCs) are a clinical manifestation that the client's
respiratory status is declining.
A nurse working on a medical-surgical unit admits a client. Two hours after admission, the client's SaO2
is 91% and he is exhibiting audible wheezes and use of his accessory muscles. Which of the following
medications should the nurse expect to administer?
D. Beta2 agonist
A. INCORRECT: An antibiotic is not indicated for these symptoms. An antibiotic typically is given for a
B. INCORRECT: A beta-blocker is not indicated for these symptoms. A beta blocker typically is given for
dysrhythmias, heart disease, or hypertension.
C. INCORRECT: An antiviral is not indicated for these symptoms. An antiviral typically is given for a virus.
D. CORRECT: A beta2 agonist should be given to relief the client's symptoms.
A nurse is completing discharge teaching with a client who has a new prescription for prednisone
(Deltasone) for asthma. Which of the following client statements indicates a need for further teaching?
A. "I will drink plenty of fluids while taking this medication."
B. "I will tell the doctor if I have black, tarry stools."
C. "I will take my medication on an empty stomach."
D. "I will monitor my mouth for canker sores."
A. INCORRECT: The client should drink plenty of fluids while taking this prednisone. This medication can
cause the client to have a dry mouth or to become thirsty.
B. INCORRECT: The client should inform the provider if the client experiences black, tarry stools. This
medication can increase the client's bleeding tendency. Black stools can be an indication of blood in
C. CORRECT: This statement by the client indicates a need for further teaching. The client should take
this medication with food. Taking prednisone on an empty stomach can cause gastrointestinal distress.
D. INCORRECT: The client should monitor their mouth for canker sores. This medication can cause
bleeding of the gums and soreness in the mouth. It also decreases the client's immunity function.
A nurse is assessing a client with asthma. Which of the following is a risk factor associated with this disease?
B. Environmental allergies
C. Alcohol use
A. INCORRECT: Gender is not a risk factor associated with asthma.
B. CORRECT: Environmental allergies are a risk factor associated with asthma. A client with
environmental allergies typically has other allergic problems such as rhinitis or a skin rash.
C. INCORRECT: Alcohol use is not a risk factor associated with asthma.
D. INCORRECT: Race is not a risk factor associate with asthma.
A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the
following statements by the client indicates the teaching was effective?
A. "This medication can decrease my immune response."
B. "I take this medication to prevent asthma attacks."
C. "I need to take this medication with food."
D. "This medication has a slow onset to treat my symptoms."
A. INCORRECT: A bronchodilator does not decrease the body's immune response. An
anti‑inflammatory medication can cause this effect.
B. CORRECT: A bronchodilator prevents asthma attacks from occurring.
C. INCORRECT: A bronchodilator does not need to be given with food. An anti-inflammatory
medication can cause gastrointestinal distress and needs to be to be given with food.
D. INCORRECT: A bronchodilator has a fast onset to relieve asthma attack symptoms.
A nurse is providing discharge teaching to a client who has COPD and has a new prescription for
albuterol (Proventil). Which of the following statements made by the client indicates an understanding of
A. "This medication can increase my blood sugar levels."
B. "This medication can decrease my immune response."
C. "I can have an increase in my heart rate while taking this medication."
D. "I can have mouth sores while taking this medication."
A. INCORRECT: Anti-inflammatory agents such as corticosteroids can cause hyperglycemia.
B. INCORRECT: Anti-inflammatory agents such as corticosteroids can decrease the immune response.
C. CORRECT: Bronchodilators such as albuterol can cause tachycardia.
D. INCORRECT: Anti-inflammatory agents such as corticosteroids can cause mouth sores.
A nurse is preparing to administer a new prescription prednisone (Deltasone) to a client who has COPD.
Which of the following should the nurse monitor for? (Select all that apply.)
A. Monitor the client or hypokalemia.
B. Monitor the client for tachycardia.
C. Observe the client for fluid retention.
D. Monitor the client for nausea.
E. Advise the client to report black, tarry stools.
A. CORRECT: The nurse should observe the client for a hypokalemia. This is a adverse effect while
B. INCORRECT: Tachycardia is an adverse effect of a bronchodilator.
C. CORRECT: The nurse should observe the client for fluid retention. This is an adverse effect while
D. INCORRECT: Nausea is an adverse effect of a bronchodilator.
E. CORRECT: The nurse should monitor the client for black, tarry stools. This is an adverse effect
while taking prednisone.
A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements
made by the client indicates an understanding of the teaching?
A. "I will place the adapter on my finger to read my blood oxygen saturation level."
B. "I will lie on my back with my knees bent."
C. "I will rest my hand over my abdomen to create resistance."
D. "I will take in a deep breath and hold it before exhaling."
A. INCORRECT: The client should place an adapter on her finger to read the level of blood oxygen
saturation while performing a pulse oximetry reading.
B. INCORRECT: The client should lie on her back with knees bent while practicing diaphragmatic or
C. INCORRECT: The client should rest her hand over her abdomen while practicing diaphragmatic or
D. CORRECT: The client should take in a deep breath and hold it for 3 to 5 seconds before exhaling.
As the client exhales, the needle of the spirometer rises. This promotes lung expansion.
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?
A. "There are portable oxygen delivery systems that you can take with you."
B. "When you go out, you can remove the oxygen and then reapply it when you get home."
C. "You probably will not be able to go out as much as you used to."
D. "Home health services will come to you so you will not need to get out."
A. CORRECT: The client should be informed that there are portable oxygen systems that he can use to
leave the house. This should alleviate his anxiety.
B. INCORRECT: This is not an appropriate statement for the nurse to make. The client should be on
oxygen at all times.
C. INCORRECT: This is not an appropriate statement for the nurse to make. The client should be
encouraged to return to his daily routine.
D. INCORRECT: This is not an appropriate statement for the nurse to make. The client should
be encouraged to return to his daily routine. Home health services are to promote a client's
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?
A. Take quick breaths upon inhalation.
B. Place your hand over your stomach.
C. Take a deep breath in through your nose.
D. Puff your checks upon exhalation.
A. INCORRECT: The client should take a slow deep breath upon inhalation. This improves the client's
breathing and allows oxygen into lungs.
B. INCORRECT: The client should place her hand on her stomach while performing diaphragmatic or
abdominal breathing. This allows resistance to be met and serves as a guide to the client that she is
inhaling and exhaling correctly.
C. CORRECT: The client should take a deep breath in through her nose while performing pursed-lip
breathing. This controls the client's breathing.
D. INCORRECT: The client should not puff her cheeks upon
A nurse is assessing a client who has experienced a gunshot wound. Findings include blood pressure
108/55 mm Hg, heart rate 124/min, respiratory rate 36/min, temperature 38.6° C (101.4° F), and SaO2 95%
on oxygen 15 L/min via nonrebreather mask. The client reports dyspnea and pain. The nurse reassesses the
client 30 min later. Which of the following should the nurse report to the provider? (Select all that apply.)
A. Distended neck veins
B. Tracheal deviation
E. Heart rate 154/min
A. CORRECT: Distended neck veins indicate that the client's condition is worsening and should
be reported to the provider. Distended neck veins are due to impaired gas exchange, which
compresses the blood vessels and limits blood return.
B. CORRECT: Tracheal deviation indicates that the client's condition is worsening and should be
reported to the provider. Tracheal deviation is due to altered intrathoracic pressure, which moves
the trachea toward the unaffected side.
C. INCORRECT: Headache is not indicated with this client's condition and does not need to be
reported to the provider.
D. INCORRECT: Nausea is not indicated with this client's condition and does not need to be reported
to the provider.
E. CORRECT: A heart rate of 154/min indicates that the client's condition is worsening and should be
reported to the provider. An increased heart rate is due to impaired cardiac output as a result of trauma.
A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following
actions should the nurse perform first?
A. Assess the client's pain.
B. Obtain a large-bore IV needle for decompression.
C. Administer lorazepam (Ativan).
D. Prepare for chest tube insertion.
A. INCORRECT: Assessing the client's pain is important, but this is not the priority action at this time.
B. CORRECT: According to the airway, breathing, circulation (ABC) priority-setting framework,
establishing and maintaining the client's respiratory function is the priority. Therefore, obtaining a
large-bore IV needle for decompression is the priority action by the nurse.
C. INCORRECT: The client will likely be anxious, and a benzodiazepine medication can be
administered, but this is not the priority action at this time.
D. INCORRECT: The nurse should gather supplies to prepare for chest tube insertion, but this is not
the priority action at this time.
NCLEX® Connection: Pharmacological
A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the
following should be included in the teaching?
A. "Notify your provider if you experience weakness."
B. "You should be able to return to work in 1 week."
C. "You need to wear a mask when in crowded areas."
D. "Notify your provider if you experience a cough."
A. INCORRECT: The client does not need to report weakness. This is an expected finding following
recovery from a pneumothorax.
B. INCORRECT: The client should not expect to return to work in 1 week. The client should expect a
lengthy recovery following a pneumothorax.
C. INCORRECT: The client does not need to wear a mask following a pneumothorax. A mask is
required for clients who are immunosuppressed.
D. CORRECT: The client should notify the provider of a cough. This may indicate that the client has a
respiratory infection and should be treated.
NCLEX® Connection: Physiological Adaptations,
A nurse in the emergency department is assessing a client with a suspected flail chest. Which of the
following clinical findings confirm this diagnosis? (Select all that apply.)
E. Paradoxic chest movement
A. INCORRECT: Tachycardia is a clinical manifestation indicative of flail chest due to inadequate
B. CORRECT: Cyanosis is a clinical manifestation indicative of flail chest due to inadequate
C. CORRECT: Hypotension is a clinical manifestation indicative of flail chest.
D. CORRECT: Dyspnea is a clinical manifestation indicative of flail chest. This is due to injury and the
client's inability to effectively inhale and exhale.
E. CORRECT: Paradoxic chest movement is a clinical manifestation indicative of flail chest. This is
due to injury to the chest and the inability to inhale and exhale.
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