RESPIRATORY
1- A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (SATA)
-Assign th...
1- A charge nurse receives notification of the admission of a client who is coughing
frequently and whose sputum is pink, frothy, and copious. The client has history of
night sweats, anorexia, and weight loss. Which of the following actions should the
nurse take? (SATA)
-Assign the client to a private room with negative-pressure airflow
-Wear an N95 respirator when entering the client’s room.
2- A nurse is assisting a provider with a comprehensive physical examination of a client.
When the provider uses transillumination, the nurse should explain to the client that this
technique help evaluate which of the following structures?
-Maxillary sinuses
3- A nurse is caring for a client who smokes cigarettes and has a new diagnosis of
emphysema. How should the nurse assist the client with smoking cessation?
-Discuss ways the client can reduce the number of cigarettes smoked per day.
4- A nurse is planning care for a client who has chronic obstructive pulmonary disease
(COPD) and is malnourished. Which of the following recommendations to promote
nutritional intake should the nurse include in the plan?
-Eat high-calorie food first.
Rational: client who has COPD experience early satiety. Client should eat calorie-dense
food first.
5- A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The
nurse should identify that which of the following findings is an adverse effect of this
medication?
-Tinnitus.
Rational: An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.
6- A nurse in a medical-surgical unit is assessing a client. The nurse should identify that
which of the following findings is a manifestation of a pulmonary embolism?
-Stabbing chest pain
Rational: sudden chest pain that is sharp and stabbing is a manifestation of pulmonary
, embolism. Other manifestations include dyspnea, coughing, hemoptysis (coughing up
blood), tachypnea, tachycardia, diaphoresis, and feeling of impending doom.
7- A nurse in the PACU is assessing a newly admitted client and observes intercostal
retractions and a high-pitched inspiratory sound (stridor). The nurse should identify
theses findings as manifestations of which of the following complications?
-Respiratory obstruction
8- A nurse is reviewing the laboratory results of a client who has metabolic alkalosis.
Which of the following laboratory values should the nurse expect?
-ph 7.49,HCO3-32mEq/L, PaCO2 40mmHg
Rational: Metabolic alkalosis: pH and bicarbonate values are greater than the expected
references range, and the PaCO2 is within the expected reference range.
9- A nurse is providing teaching to a client who has a chronic cough and is scheduled
for a bronchoscopy. Which of the following client statements indicates an
understanding of the teaching?
-“A tissue sample might be obtained during the procedure”
10- A nurse is preparing a client for a bronchoscopy. Which of the following actions should
the nurse take? (SATA)
-Explain that the client will receive sedation and will not remember the procedure.
-Verify that the client understands the purpose and nature of the procedure.
11- A nurse is preparing a client for discharge following a bronchoscopy. Which of the
following assessment is the nurse’s monitoring priority?
-Confirming the gag reflex
Rational: The greater risk to the client’s safety is aspiration resulting from a depressed
gag reflex. 12- A nurse is caring for a client who is postoperative following a thoracic
lobectomy. The client has 2
chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest
wall. When a family member asks why the client has 2 chest tubes, which of the following
responses should the nurse make?
-“The lower tube will drain blood, and the higher tube will remove air.”
, 13- A nurse is providing teaching to a client who will undergo a total laryngectomy.
Which of the following statements indicate that the client understands the impact of
the surgery?
- “I understands that I will have a permanent tracheostomy after the surgery.”
Rational: With a partial laryngectomy, the tracheostomy is temporary. With the total
laryngectomy the tracheostomy will be permanent.
14- A nurse is providing discharge instructions to a client who has a new laryngectomy.
The nurse tells the client to be careful while bathing to prevent which of the following
complications?
-Aspiration of water.
Rational: This is a client with a tracheostomy, so he will need to use a shower shield over
the stoma when bathing or showering to keep water out of the airway.
15- A nurse is caring for a client who is extremely anxious and is hyperventilating. The
client’s ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3-25 mEq/L. The nurse
should identify that the client has which of the following acid-base imbalances?
-Respiratory alkalosis.
16- A nurse is planning postoperative education for a client who will undergo a radical
neck dissection for cancer of the larynx. The nurse should include which of the
following topics? (SATA)
-NPO status
-Alternative methods of communication
- Changes in body image
-Swallowing exercises.
17- A nurse in a clinic is providing teaching for a client who is scheduled to have a
tuberculin skin test. Which of the following pieces of information should the nurse
include?
- “You must return to the clinic to have the test read in 2 or 3 days.”
18- A nurse is providing discharge teaching to a client who is postoperative following a
rhinoplasty/ Which of the following instructions should the nurse include?
“Lie on your back with your head elevated 30º when resting.”
, 19- A nurse is preparing to assist provider with an arterial blood withdrawal from a
client’s radial artery for ABG measurements. Which of the following actions the nurse
plan to take?
-Perform an Allen’s test prior to obtaining the specimen.
Rational: the nurse should ensure that the circulation of the hands 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.
20- A nurse is providing teaching to a client about pulmonary function testing. Which of
the following tests measures the volume of air the lungs can holds at the end of
maximum inhalation?
-Total lung capacity
21- A nurse is providing preoperative teaching to a client who is to undergo a
pneumonectomy. The client states, “I am afraid coughing will hurt after surgery.”
Which of the following statements by the nurse is appropriate?
-“I will show you how to splint your incision while coughing.”
22- A nurse is caring for a client who has a tracheostomy and is receiving mechanical
ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of
the following to the nurse?
-A leak within the ventilator’s circuitry.
23- A nurse is caring for a client who is postoperative following a rhinoplasty. Which of
the following findings should the nurse report to the surgeon?
-Frequent swallowing
Rational: this indicates posterior nasal bleeding and possibly hemorrhage.
24- A nurse is caring for a client immediately following extubation. Which of the
following manifestations indicates that the nurse should call the rapid response
team?
-Stridor
Rational: the nurse should identify that stridor (high-pitched crowing sound heard
during inspiration) is caused by laryngeal edema and can indicate impending airway
obstruction.
25- A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube
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