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Adult Health - Respiratory - Silvestri Exam Questions And Correct Answers
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Adult Health - Respiratory - Silvestri Exam QuestionsAnd Correct Answers
The nurse is assessing the functioning of a chest tube drainage system for a client who
has just arrived from the recovery room following a thoracotomy with wedge resection.
Which are the expected assessment findings? Select all that apply. - ANSWER Drainage
system maintained below the client's chest
4.
50 mL of drainage in the drainage collection chamber
5.
Occlusive dressing in place over the chest tube insertion site
6.
Fluctuation of water in the tube in the water seal chamber during inspiration and
expiration
During removal of a chest tube, the nurse is assisting a health care provider. The nurse
should instruct the client to take which action? - ANSWER Perform the Valsalva
maneuver.
The nurse caring for a client with a pneumothorax and who has had a chest tube
inserted notes continuous gentle bubbling in the water seal chamber. What action is
most appropriate? - ANSWER Check for an air leak, because the bubbling should be
intermittent.
The nurse is caring for a client who had an inhalation injury from a wood stove. The
carbon monoxide blood report is 12%. Based on this level the nurse would expect to
observe which symptom in the client? - ANSWER Flushing
,The emergency department nurse is assessing the client who sustained a blunt trauma
to the chest wall. What would be the confirmation of a pneumothorax in this client? -
ANSWER Decreased breath sounds
The nurse is caring for a client hospitalized with acute exacerbation of chronic
obstructive pulmonary disease. Which findings would the nurse expect to note on
assessment of this client? Select all that apply. - ANSWER A hyperinflated chest noted
on the chest x-ray
3.
Decreased oxygen saturation with mild exercise
The nurse teaches a client to use the pursed-lip method of breathing and assesses the
teaching by asking the client for the purpose for this type of breathing. The nurse
recognizes that the client understands when the client states the primary purpose of
pursed-lip breathing is to promote which outcome? - ANSWER Promote carbon dioxide
elimination.
The nurse is preparing a list of home care instructions for a client who has been
hospitalized and treated for tuberculosis. Which instructions should the nurse include
on the list? Select all that apply. - ANSWER Activities should be resumed gradually.
A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
4.
Respiratory isolation is not necessary because family members already have been
exposed.
5.
Avoid contacting others in order to prevent infection. While coughing or sneezing, the
mouth and nose should be covered and tissues used should be placed in plastic bags.
, The nurse is caring for a client who has just undergone a bronchoscopy and biopsy.
Which of the following findings, if present in the client, would the nurse need to report
immediately to the health care provider? ANSWER Bronchospasm
The nurse is about to perform suctioning on the client through a tracheostomy tube. The
nurse should include in the plan suctioning time limitation to a maximum of which of the
following time periods? - ANSWER 10 seconds
The nurse is suctioning a client through an endotracheal tube. While performing the
suction, the heart rate is noted to be bradycardic on the monitor. Which nursing action
is indicated? - ANSWER The procedure should be stopped and the client reoxygenated.
The nurse is assessing the respiratory status of a client who has sustained a fractured
rib. The nurse should expect to find the presence of which condition? - ANSWER Pain,
especially with inspiration
A client with a chest injury has sustained flail chest. The nurse examines the client for
what most characteristic sign of flail chest? - ANWER Paradoxical chest movement
The nurse is caring for a client with multiple trauma who is considered to be at risk for
developing acute respiratory distress syndrome. The nurse would look for what earliest
indicator of acute respiratory distress syndrome? - ANWER Increased respiratory rate
A client was admitted with tuberculosis and has been receiving medication for 2 weeks.
The nurse has provided discharge teaching to the client. Which of the following
statements by the client indicates to the nurse that the client has understood the
teaching? - ANSWER "I should not be contagious after 2 to 3 weeks of medication
therapy."
A client has experienced a pulmonary embolism. The nurse should assess for what
symptom, which is most commonly reported? - ANWER Sudden onset chest pain
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