Respiratory NCLEX Q and A

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NCLEXQA RespiratoryThe nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from therecovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Selectall that apply.1.Excessive bubbling in th e wate r seal chamber2.Vigorous bubbling in the suction control chamber3.Drainage system maintained below the client's chest4.50 mLof drainageinthe drainage collection chamber5.Occlusive dressing in place over the chest tube insertion site6.Fluctuation of water in the tube in the water seal chamber during inhalation andexhalationThe nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the clientto take which action?1.Stay very still.2.Exhale very quickly.3.Inhale and exhale quickly.4.Perform the Valsalva maneuver.The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentlebubblinginthe water seal chamber. What action is mostappropriate?1.Do nothing, because this is an expected finding.2.Check for an air leak, because the bubbling should be intermittent3.Increase the suction pressure so th at the bubbling becom es vigorous.4.Clamp the chest tube and notify the health care provider immediately.The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide bloodreport reveals a level of 1296. Based on this level, the nurse would anticipate noting which sign in the client?1.Coma2.Flushing3.Dizziness4.TachycardiaRationale:Carbon monoxide levels between 11% and 2096 resultinflushing, headache, decreased visual activity, decreasedcerebral functioning, and slight breathlessness: levels of 21% to 40% resultinnausea, vomiting, dizziness, tinnitus,vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia: levels of 4196 to 6096 result in seizureand coma: and levels higher than 6096 result indeath.The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Whichfinding indicates the presence of a pneumothorax in this client?

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1.A low respiratory rate2.Diminished breath sounds3.The presence of a barrel chest4.A sucking sound at the site of injuryRationale:This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness ofbreath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, andsubcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site ofinjury would be noted with an open chest injury.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? Selectallthat apply.1.A low arterial PCo2level2.A hyperinflated chest noted on the chest x-ray3.Decreased oxygen saturation with mild exercise4.A widened diaphragm noted on the chest x-ray5.Pulmonary function tests that demonstrate increased vital capacityThe nurse instructsaclienttousethepursed-lip method of breathing and evaluates the teaching by asking theclient about the purpose of this type of breathing.. The nurse determines that the client understands if the clientstates that the primarypurpose of pursed-lip breathing istopromotewhichoutcome?1.Promote oxygen intake.2.Strengthen the diaphragm.3.Strengthen the intercostal muscles.4.Promote carbon dioxide elimination.The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated fortuberculosis. Which instructions should the nurse include on the list?Select allthat apply.1.Activities should be resumed gradually.2.Avoid contact with other individuals, except family members, for at least 6 months.3.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 beenexposed.5.Cover the mouth and nose when coughing or sneezing and put used tissues in plasticbags.6.When 1 sputum culture is negative, the client is no longer considered infectious andusuaIly can retu rn to former employm ent.

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The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should bereported immediately to the health care provider?1.Dry cough2.Hematuria3.Bronchospasm4.Blood-streaked sputumRationale:If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frankblood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs ofcomplications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension,tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioningtime to a maximum of which time period?1.5 seconds2.10 seconds3.30 seconds4.60 secondsThe nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on themonitor that the heart rate is decreasing. Which nursing intervention is appropriate?1.Continue to suction.2.Notify the health care provider immediately.3.Stop the procedure and reoxygenate the client.4.Ensure that the suction is limited to 15 seconds.The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect tonote which finding?1.Slow, deep respirations2.Rapid, deep respirations3.Paradoxical respirations4.Pain, especially with inspirationA client with a chest injury has suffered flail chest. The nurse assesses the client for whichmost distinctive sign offlail chest?1.Cyanosis2.Hypotension3.Paradoxical chest movement4.Dyspnea, especially on exhalation

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The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distresssyndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?1.Bilateral wheezing2.Inspiratory crackles3.Intercostal retractions4.Increased respiratory rateThe nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receivingmedication for 2 weeks. The nurse determines that the client has understood the information if the client makeswhich statement?1."I need to continue medication therapy for 1 month."2." l e a n t shop at th e malI for the next 6 mont hs."3."I can return to work if a sputum culture comes back negative."4."I should not be contagious afte r 2 to 3 weeks of medication the rapy."Aclient has experienced pulmonary embolism. The nurse should assess for which symptom, whichis most commonly reported?1.Hot, flushed feeling2.Sudden chills and fever3.Chest pain that occurs suddenly4.Dyspnea when deep breaths are takenAclient who is human immunodeficiency virus (HIVJ-positive has had a tuberculin skin test (TST). The nurse notes a7-mm area of induration at the site of the skin test and interprets the result as which finding?1.Positive2.Negative3.Inconclusive4.Need for repeat testingA client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the clientfor which expected finding?1.Dyspnea2.Headache3.Weightgain4.HypothermiaRationale:Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as arespiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever,dyspnea, cough, and weight loss. Enlargeme nt of the die nt's lymph nodes, liver, and spleen may occur as well.

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The nurse is giving discharge instructionsto aclient with pulmonary sarcoidosis. The nurse concludes that theclient understands the information if the client indicates to report whichearlysign of exacerbation?1.Fever2.Fatigue3.Weight loss4.Shortness of breathRationale:Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations includenight sweats. fever, weight loss, and skin nodules.The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whetherthe client wears which item during periods of exposure to silica particles?1.Mask2.Gown3.Gloves4.Eye protectionAn oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a preciseoxygen concentration. Which oxygen delivery system would the nurse prepare for the client?1.Face tent2.Venturi mask3.Aerosol mask4.Tracheostomy collarThe nurse is instructinga hospitalized client with a diagnosis of emphysema about measures that will enhance theeffectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume?1.Sitting up in bed2.Side-lying in bed3.Sitting in a recliner chair4.Sittingup andleaning on an overbed tableThe community health nurse is conducting an educational session with community members regarding the signsand symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as adiagnosis if which signs and symptoms are present? Select all that applly.1.Dyspnea2.Headache3.Night sweats4.A bloody, productive cough5.A cough with the expecto ration of mucoid sputu m

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The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should checkthe results of which diagnostic test that will confirm this diagnosis?1.Chest x-ray2.Bronchoscopy3.Sputum culture4.Tuberculin skin testThe nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. Thenurse instructs the client that which positions alleviate dyspnea? Selectallthatapply.1.Sitting up and leaning on a table2.Standing and leaning against a wall3.Lying supine with the feet elevated4.Sitting up with the elbows resting on knees5.Lying on the back in a low Fowler's positionA client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hourspostoperatively. what type of drainage should the nurse expect?1.Serous2.Bloody3.Serosanguineous4.Bloody, with frequent small clotsThe nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse isplanning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursingaction is required before plugging the tube?1.Deflate the cuff on the tu be.2.Place the inner cannula into the tube.3.Ensure that the client is able to speak.4.Ensure that the client is able to swallow.The nurse is caring for a client wrho is on strict bed rest and creates a plan of care with goals related to theprevention of deep vein thrombosis and pulmonary emboli. Which nursing action ismosthelpful in preventingthese disorders from developing?1.Restricting flu ids2.Placingapillow under the knees3.Encouraging active range-of-motion exercises4.Applying a heating pad to the lower extremities

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