HESI + EAQ: Respiratory

Question 1

What is the underlying pathophysiology of pneumonia?

blood clots in the lung

collapse of the lung

degenerative changes in the lung

inflammation and/or infection of the lung

Answer 1

nflammation and/or infection of the lung

The pathophysiology of pneumonia involves excess fluid in the lungs associated with an acute inflammatory process that is usually a result of infection. Microorganisms (bacteria, viruses, fungi, parasites) gain entry into the respiratory tract either by inhalation (from airborne transmission with talking, sneezing, coughing) or aspiration (secretions from the oropharynx or nasopharynx). The organisms are not successfully cleared, and they become established.

Question 2

Which considerations are critical for the nurse to make when assigning a room to a client with community acquired pneumonia (CAP)?
Select all that apply

Mr. Hannigan’s confusion

Infection control

The high anxiety level of Mr. Hannigan’s family members

Mr. Hannigan’s gray skin color

Answer 2

Mr. Hannigan’s confusion
Mr. Hannigan’s confusion is an important consideration for room assignment. The fact that Mr. Hannigan is confused places him at risk for injury. An initial assessment found Mr. Hannigan to be disoriented to time, place, and person. Bed placement as close to the nurses’ station as possible is important.

Infection control
Infection control is an important consideration for room assignment. Mr. Hannigan has pneumonia, although the specific organism responsible for infection is not known at this time. The means of transmission is not yet known. To decrease risk for hospital-acquired pneumonia or other nosocomial infections in other clients, Mr. Hannigan was assigned to a private

Question 3

Standard precautions, droplet precautions, and contact precautions apply for Mr. Hannigan. Besides a private room, which of the following infection control requirements are indicated?
Select all that apply

Wear a mask with close contact

Wear a gown when assisting Mr. Hannigan with bathing

Keep the door of Mr. Hannigan’s room closed

Have Mr. Hannigan wear a mask if he leaves his room

Wear gloves when handling tissues containing sputum

Answer 3

Wear a mask with close contact

Wear a gown when assisting Mr. Hannigan with bathing

Wear gloves when handling tissues containing sputum

Question 4

The nurse monitors the pulse oximetry to assess for which value?

arterial oxygen saturation

arterial oxygen content

partial pressure of oxygen

fraction of inspired oxygen

Answer 4

arterial oxygen saturation
Pulse oximetry measures arterial oxygen saturation, the amount of hemoglobin that is saturated with oxygen. Oxyhemoglobin releases oxygen to tissues. Arterial oxygen saturation is an indicator of tissue oxygenation. Arterial oxygen saturation readings are obtained invasively through analysis of arterial blood obtained by arterial line or arterial puncture (SaO2) OR noninvasively with the use of pulse oximetry (SpO2).

Question 5

The HCP prescribes oxygen therapy. As you implement the prescription for oxygen, the therapeutic effect of the nasal oxygen will be enhanced if Mr. Hannigan:

also does rigorous coughing

is positioned in the Fowler’s position

uses pursed lip breathing

is medicated for pain

Answer 5

is positioned in the Fowler’s position
The Fowler’s position (head of bed 45 degrees or higher) promotes full lung expansion and decreases the work of breathing. It can enhance the effectiveness of oxygen therapy and help increase oxygenation. Resting his arms on an overbed table may increase Mr. Hannigan’s tolerance for this position.

Question 6

Which risk factors for community acquired pneumonia does Mr. Hannigan have in his medical history?

Cigarette smoking 20 years ago

Splenectomy 10 years ago

Drinks beer each evening (one can)

Asymptomatic mitral valve prolapse

Answer 6

Splenectomy 10 years ago
The spleen normally serves important immunologic functions, keeping the blood free of unwanted substances and infecting organisms. Individuals without a spleen are at increased risk of bacterial infection, especially those caused by Streptococcus pneumoniae, Haemophilus influenzae, and others. Mr. Hannigan received the pneumococcal vaccine (which helps prevent infection due to the bacteria Streptococcus pneumoniae) about 10 years ago, when his spleen was removed. To maintain immunity, a one-time repeat vaccination is recommended. However, Mr. Hannigan was never revaccinated.

Question 7

You are conducting a physical assessment of Mr. Hannigan. Which findings would the nurse expect?
Select all that apply

lung crackles

tachypnea

hoarseness

nasal flaring

clubbing of fingers

Answer 7

lung crackles

tachypnea

nasal flaring

Question 8

You’ve noticed that Mr. Hannigan is restless, confused, and picks at his sheets. What cause would be suspected for these behaviors?

discomfort

hypoxia

tachycardia

Answer 8

hypoxia
Mr. Hannigan’s confusion is probably due to hypoxia. Restlessness and confusion are often early signs of hypoxemia, and reflect cerebral hypoxia.

Question 9

On admission, Mr. Hannigan was breathing rapidly. His increased respiratory rate was an effort to compensate for hypoxemia and take in more oxygen. An increase in the rate of breathing causes a decrease in arterial carbon dioxide levels. This can lead to:

Answer 9

respiratory alkalosis.

Question 10

Mr. Hannigan is receiving the broad-spectrum antiinfective drug levofloxacin. Levofloxacin is active against Strep pneumonia. Based on your knowledge of the potential complications of this drug, you will be alert for which adverse effects? (Select all that apply.)
Select all that apply

Tachycardia

Peripheral edema

Loose, watery stools

Tendon Rupture

Photosensitivity

Answer 10

Loose, watery stools

Tendon Rupture

Photosensitivity

Question 11

Mr. Hannigan is now breathing much easier and he is no longer confused. SpO2 on nasal oxygen at 2 liters per minute is now 95%.

However, he is complaining of chest discomfort, especially with coughing. His coughing has increased, and mucous is present.

How can the nurse best alleviate Mr. Hannigan’s discomfort?

Suggest that a narcotic analgesic be prescribed for Mr. Hannigan

Apply a chest binder to act as a splint for Mr. Hannigan’s thoracic cavity

Suggest that acetaminophen be prescribed to alleviate chest discomfort

Suggest that a sedative be prescribed for Mr. Hannigan

Answer 11

Suggest that acetaminophen be prescribed to alleviate chest discomfort
An analgesic such as acetaminophen should reduce Mr. Hannigan’s chest discomfort without suppressing his cough and gag reflexes. Cough and gag reflexes are needed to expectorate secretions and avoid aspiration. Sedatives and narcotic analgesics suppress these reflexes. Restriction of chest movement with a chest binder would limit airflow and increase hypoxia, predisposing Mr. Hannigan to more serious respiratory complications. Mr. Hannigan needs full lung expansion to insure maximum lung inflation and optimal gas exchange.

Question 12

Despite being given an NSAID, acetaminophen for pain, Mr. Hannigan continues to complain of chest soreness when coughing. What action by Mr. Hannigan would you suggest to him to decrease his discomfort?

hold a pillow across his chest when coughing

try to consciously suppress his cough

turn his head away when coughing

pull on the side rails when coughing

Answer 12

hold a pillow across his chest when coughing
Splinting sore chest muscles with a pillow during coughing should lessen musculoskeletal pain experienced when coughing, without interfering with chest expansion on an ongoing basis.

Question 13

When evaluating your plan of care for Mr. Hannigan with regard to the problem of impaired gas exchange, which criteria would indicate a successful outcome?

Mr. Hannigan has a heart rate below 100 per minute

Mr. Hannigan has a PaO2 (arterial oxygen) above 80 mm Hg

Mr. Hannigan has a PaCO2 (arterial carbon dioxide) above 45 mm Hg

Mr. Hannigan has a temperature below 37.2 degrees C (98.8 degrees F)

Answer 13

Mr. Hannigan has a PaO2 (arterial oxygen) above 80 mm Hg
A PaO2 (arterial oxygen) above 80 mm Hg is normal. It is a good indicator of adequate gas exchange at the alveoli level.

Question 14

Mr. Hannigan will be discharged very soon. Which discharge instructions are indicated?
Select all that apply

Take frequent rest periods as needed

Stop antibiotics when feeling better

Avoid carbonated drinks

Drink lots of fluid each day

Remain indoors while taking levofloxacin

Answer 14

Take frequent rest periods as needed

Drink lots of fluid each day

Question 15

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO 2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing?

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis

Respiratory alkalosis

Answer 15

Respiratory acidosis

The pH indicates acidosis; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

Question 16

When a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate?

Cordectomy

Tracheotomy

Total laryngectomy

Oropharyngeal resections

Answer 16

Cordectomy

A cordectomy is a surgical procedure performed in clients with laryngeal cancer; this surgery involves the removal of a vocal cord. A tracheotomy is a surgical incision in the trachea for the purpose of establishing an airway. A total laryngectomy is a surgical procedure in which the entire larynx, hyoid bone, strap muscles, and 1 or 2 tracheal rings are removed. A nodal neck dissection is also done in a total laryngectomy if the nodes are involved. An oropharyngeal resection is a surgical procedure performed to treat cancer of the oropharynx.

Question 17

A ___________ involves inserting a catheter into the pleural space to obtain specimens of pleural fluid or to remove a pleural effusion

Answer 17

thoracentesis

Question 18

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct.

Mold

Cold air

Pet dander

Air pollution

Cigarette smoke

Answer 18

All of the above

Question 19

Which parameter describes the maximum volume of air a client’s lungs may contain?

Vital capacity

Total lung capacity

Inspiratory capacity

Functional residual capacity

Answer 19

Total lung capacity

Question 20

Which statement describes a client’s tidal volume?

Tidal volume is the volume of air inhaled and exhaled with each breath.

Tidal volume is the amount of air remaining in the lungs after forced expiration.

Tidal volume is the additional air forcefully inhaled after normal inhalation.

Tidal volume is the additional air forcefully exhaled after normal exhalation.

Answer 20

Tidal volume is the volume of air inhaled and exhaled with each breath.

Question 21

______ volume is the volume of air inhaled and exhaled with each breath.

Answer 21

Tidal

Question 22

Which instructions would the nurse share with the client being discharged after rhinoplasty?

Avoid items that may trigger sneezing.

Consume fluids at a tepid temperature.

Brush the teeth thoroughly after each food intake.

Sleep on the back using one pillow under the head.

Answer 22

Avoid items that may trigger sneezing.

Question 23

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and would begin with which aspect of care?

The disease process and breathing exercises

How to control or prevent respiratory infections

Using aerosol therapy, especially nebulizers

Priorities when performing everyday activities

Answer 23

The disease process and breathing exercises

Question 24

Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site?

Sterile saline

Steroid cream

Oil-based lubricant

Mild soap and water

Answer 24

Mild soap and water

Question 25

At which interval are humidified oxygen systems replaced to prevent infection?

1 day

3 days

5 days

7 days

Answer 25

1 day

Question 26

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise?

Decreases chest pain

Conserves energy

Increases oxygen saturation

Promotes elimination of CO 2

Answer 26

Promotes elimination of CO 2

Question 27

Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? Select all that apply. One, some, or all responses may be correct.

Type of employment

Presence of ear pain

History of tobacco use

Oral hygiene practices

Amount of alcohol intake

Answer 27

all of the above

Question 27

Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. One, some, or all responses may be correct.

Facial edema

Septal deviation

Clear nasal drainage

Oxygen saturation 89%

Bilateral periorbital bruising

Answer 27

All of the above

Question 28

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax?

Emptying the drainage system when full

Keeping the drainage system at heart level

Notifying the health care provider of drainage greater than 50 mL/h

Marking the time on the drainage unit every shift

Answer 28

Marking the time on the drainage unit every shift

Question 29

After reviewing information about oxygenation for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy?

Partial pressure of oxygen (PaO 2) of 72; peripheral capillary oxygen saturation (SpO 2) of 96

PaO 2 of 60; SpO 2 of 90

PaO 2 of 55; SpO 2 of 88

PaO 2 of 70; SpO 2 of 92

Answer 29

PaO 2 of 55; SpO 2 of 88

A PaO 2 of 55 and SpO 2 of 88 indicate hypoxemia and that long-term oxygen therapy is needed. The values PaO 2 72 and SpO 2 96 indicate adequate oxygenation. The values PaO 2 60 and SpO 2 90 are adequate and the client would not require oxygen therapy. The values PaO 2 70 and SpO 2 92 are adequate and do not indicate a need for oxygen therapy.

Question 30

Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis?

Repositioning

Humidified air

Saline irrigation

Frequent suctioning

Answer 30

Saline irrigation

Saline irrigation of the nasal cavity facilitates drainage and decreases inflammation, allowing the client to breathe more comfortably. Repositioning a client does not specifically relieve the symptoms of sinusitis. Humidity prevents drying of the nasal passages. The nasal passages are not suctioned for a client with sinusitis.

Question 31

Which assessment finding is consistent with bronchospasm?

Wheezing

Rhonchi

Pleural friction rub

Low-pitched crackles

Answer 31

Wheezing

Question 32

When a client with a health care–acquired respiratory tract infection asks the nurse what this means, which response will the nurse give?

“You developed an infection that requires antibiotics.”

“This is a highly contagious infection requiring isolation.”

“An infection you had before beginning treatment has flared up.”

“Your infection occurred because of exposure to a health care facility. “

Answer 32

“Your infection occurred because of exposure to a health care facility. “

Question 33

When auscultating a client’s chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding?

Adventitious sounds

Fine crackling sounds

Vesicular breath sounds

Diminished breath sounds

Answer 33

Vesicular breath sounds

Question 34

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco 2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition?

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis

Respiratory alkalosis

Answer 34

Respiratory acidosis

The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO 2, and the acceptable range of arterial Pco 2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO 3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.

Question 35

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen?

To prevent dyspnea

To prevent cyanosis

To increase oxygen concentration to heart cells

To increase oxygen tension in the circulating blood

Answer 35

To increase oxygen concentration to heart cells

Question 36

How would the nurse position a client with epistaxis?

Supine

Side-lying

Upright leaning forward

Sitting with the head tipped backward

Answer 36

Upright leaning forward

A client with a nosebleed should be positioned upright leaning forward to prevent aspiration and decrease blood flow to the nose. The supine position increases the risk for aspiration or swallowing blood. The side-lying position will increase blood flow to the nose more than sitting upright and may increase aspiration risk. Having the head tipped backward increases the risk for aspiration or swallowing blood.

Question 37

How would the nurse position a client to practice supraglottic swallowing after tracheostomy?

In bed

Upright

Lying down

Position of comfort

Answer 37

Upright

Question 38

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. Which immediate action would the nurse implement?

Auscultate the lungs.

Obtain arterial blood gases.

Notify the health care provider.

Apply pressure to the abdomen.

Answer 38

Auscultate the lungs.

Question 39

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse?

Initiate oxygen via a nasal cannula

Administer the prescribed morphine

Prepare the client for endotracheal intubation

Place a nitroglycerin tablet under the client’s tongue

Answer 39

Initiate oxygen via a nasal cannula

Question 40

Which finding by the home health nurse who is visiting a client who has had laryngeal cancer surgery indicates a need for further intervention?

The client leans forward while coughing.

The client smokes 4 cigarettes per day.

The client avoids showering and swimming.

The client uses a water-based ointment to lubricate the stoma.

Answer 40

The client smokes 4 cigarettes per day.

Smoking can increase the risk for developing other cancers, such as lung cancer, and can decrease the rate of healing from laryngeal surgeries. Leaning forward while coughing promotes healing. Avoiding showering and swimming helps prevent water from entering the airways through the stoma. Using a non–oil-based ointment to lubricate the stoma may aid in quick healing.

Question 41

Which is the function of the water-seal chamber on a closed chest drainage system for a client with hemothorax?

Collects drainage from the pleural space

Prevents reflux of air back into the pleural space

Promotes drainage of blood from the pleural space

Controls level of suction applied to intrapleural space

Answer 41

Prevents reflux of air back into the pleural space

Water acts as a seal, preventing air from reentering the pleural space after is has been expelled during expiration. Blood or other drainage from the pleural space collects in the collection chamber of the chest drainage system. Blood from the hemothorax will drain into the collection chamber mainly under the effect of gravity. The level of suction applied to the intrapleural space is controlled by the fluid level in the suction control chamber.

Question 42

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning?

Preoxygenate the client before suctioning.

Employ gentle suctioning as the catheter is being inserted.

Loosen the client’s secretions before suctioning by instilling saline.

Ensure that the cuff of the tracheostomy is inflated during suctioning.

Answer 42

Preoxygenate the client before suctioning.

Administration of 100% oxygen for a few minutes before suctioning reduces the risk of hypoxia, the major complication of suctioning. Suction is applied as the catheter is withdrawn, not during insertion, to prevent hypoxia. Tracheostomy cuffs are indicated when the client is on mechanical ventilation. Although a saline solution may be instilled into a tracheostomy, this practice is not recommended.

Question 43

The nurse provides immediate postoperative care to a client. The client reports a sudden onset of shortness of breath and chest pain. Which action would the nurse take?

Provide supplemental oxygen

Administer intravenous morphine

Prepare for endotracheal intubation

Administer sublingual nitroglycerin

Answer 43

Provide supplemental oxygen

Question 44

A client has a closed chest drainage system in place. How would the nurse determine the amount of chest tube drainage?

Aspirate the drainage from the collection chamber.

Clamp the chest tube and empty the fluid from the collection chamber.

Refer to the date and time markings on the outside of the collection chamber.

Replace the existing system with a new one to access the drainage in the existing system.

Answer 44

Refer to the date and time markings on the outside of the collection chamber.

Question 45

When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?

“Tell me about your typical day before you were diagnosed with chronic lung disease.”

“Smoking and not doing the exercises will make your lung disease continue to get worse.”

“I can’t make you stop doing what you are doing, and it’s your choice to be sick or well.”

“Your shortness of breath is probably because of your smoking and not doing the exercises.”

Answer 45

“Tell me about your typical day before you were diagnosed with chronic lung disease.”

Question 46

In which position will the nurse place a client who has been transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection?

Left lateral recumbent

Lateral

High Fowler

Semi-Fowler

Answer 46

Semi-Fowler

The semi-Fowler position helps maintain the head and neck in functional alignment and facilitates respirations because the abdominal organs are not pressing against the diaphragm, which allows the thoracic cavity to expand without resistance. The left lateral recumbent position will place tension on the operative site because the head must be turned to the side. The lateral position inhibits respiratory excursion because the abdominal organs press against the diaphragm, and full expansion of the lung on the side on which the client is lying is inhibited. The high Fowler position may cause flexion of the neck, which may place tension on the suture line.

Question 47

Which action would the nurse take when a client with tuberculosis (TB) is admitted to the nursing unit?

Put on a gown when entering the room.

Place the client with another client who has TB.

Wear a particulate respirator when caring for the client.

Don a surgical mask with a face shield when entering the room.

Answer 47

Wear a particulate respirator when caring for the client.

Question 48

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety?

Respiratory acidosis

Respiratory alkalosis

Respiratory compensation

Respiratory decompensation

Answer 48

Respiratory alkalosis

Hyperventilation causes excess amounts of carbon dioxide (CO 2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess CO 2 retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD). Respiratory compensation and decompensation are terms not associated with this situation.

Question 49

Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?

Pleural effusion

Empyema

Pneumothorax

Atelectasis

Answer 49

Atelectasis

Atelectasis occurs after general anesthesia because of decreased respiratory depth and resulting collapse of alveoli. Pleural effusion is not a typical postoperative problem. Empyema would not be expected after surgery. Pneumothorax is not a common postoperative diagnosis.

Question 50

After the nurse teaches a client about self-management techniques for smoking cessation, which client statement indicates the need for further teaching?

“I should list the reasons why I should stop smoking.”

“I should visit all the places where I started smoking.”

“I should remove all ashtrays and lighters from my home.”

“I should try replacing tobacco with sugarless mints and gum.”

Answer 50

“I should visit all the places where I started smoking.”

Question 51

Which is the purpose of an occlusive dressing over a client’s sucking chest wound?

Protects the lung

Seals off major vessels

Prevents additional contamination of the wound

Maintains negative pressure within the chest cavity

Answer 51

Maintains negative pressure within the chest cavity

An occlusive dressing helps maintain negative intrathoracic pressure by preventing air from moving into the pleural space from the open wound. Without an occlusive dressing, this wound can result in an open pneumothorax and mediastinal shift. The dressing does not protect the lung. An occlusive dressing will not affect major blood vessels, which are not located at the periphery of the lung. Other types of dressings might be used to prevent contamination, but an occlusive dressing is used to seal the chest wall and maintain negative intrapleural pressure.

Question 52

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest?

Crackling

Wheezing

Decreased sounds

Vesicular sounds

Answer 52

Decreased sounds

Question 52

Which instruction would the nurse include when teaching a client how to perform diaphragmatic breathing?

Take rapid, deep breaths.

Breathe with hands on the hips.

Expand the abdomen on inhalation.

Lean forward from a sitting position.

Answer 52

Expand the abdomen on inhalation.

Question 52

Which instruction would the nurse teach the client concerned about dislodging a laryngectomy tube at a 3-week postoperative follow-up visit?

Reinsert another tube immediately.

Notify the health care provider at once.

Keep calm because this is not an immediate emergency.

Quickly take action to prevent the tracheal stoma from closing.

Answer 52

Keep calm because this is not an immediate emergency.

Clients’ concerns decrease if they understand the stoma will stay open long enough for easy insertion of another tube. A permanent opening into the trachea formed after 2 or 3 weeks and does not require prompt reinsertion of a tube. The client is in no immediate danger, and imperative notification of the health care provider is unnecessary.

Question 53

Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery?

Assist client to use the incentive spirometer.

Administer prescribed intravenous antibiotic.

Take client vital signs every 4 hours.

Auscultate breath sounds every 4 hours.

Answer 53

Assist client to use the incentive spirometer.

Question 54

Which color tag would the triage nurse working at a train accident use to label a client experiencing respiratory distress?

Red

Black

Green

Yellow

Answer 54

Red

A red tag (priority I) indicates a client with respiratory distress, trauma, or bleeding, or neurological deficits that need immediate treatment. Victims who are deceased are labeled with a black tag. A green tag (priority III) indicates a client who needs care that can wait for hours. A yellow tag (priority II) indicates injuries that need treatment within 2 hours.

Question 55

The community health nurse is educating a client who is interested in discontinuing cigarette smoking. Which would the teaching plan include?

Helping the client set a date to stop smoking

Referring the client to the American Red Cross (Canada: Canadian Red Cross)

Encouraging the client to eat when the desire to smoke occurs

Setting a follow-up phone call for several weeks after the preset target date

Answer 55

Helping the client set a date to stop smoking

Question 56

A client presenting with an acute asthma attack is being assessed in the emergency department. The client’s spouse reports that the client currently is undergoing treatment for an upper respiratory infection. The nurse would understand that the client most likely has which type of asthma?

Allergic

Emotional

Extrinsic

Intrinsic

Answer 56

Intrinsic

Intrinsic asthma is triggered by an internal factor such as a cold. Intrinsic asthma does not have an identifiable allergen. Asthma related to emotions is considered to be extrinsic asthma. Extrinsic asthma includes allergens such as pet dander, dust mites, mold, dust, and others.

Question 57

An orientee (newly hired nurse) provides postoperative care to a client after a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. How would the orientee’s preceptor evaluate the instructions given by the orientee?

Appropriate; oral intake after the procedure may result in aspiration

Appropriate; it is important to limit painful swallowing

Inappropriate; the client is too groggy after general anesthesia to comprehend information

Inappropriate; fluid replacement should begin immediately after the procedure

Answer 57

Appropriate; oral intake after the procedure may result in aspiration

Question 58

The nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. Which is the most important intervention for the nurse to include in this plan?

Ensuring sufficient rest

Changing lifestyle routines

Breathing clean outdoor air

Taking medications as prescribed

Answer 58

Taking medications as prescribed

Question 59

A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue?

Provide small, frequent meals.

Encourage pursed-lip breathing.

Schedule nursing activities to allow for rest.

Encourage bed rest until energy level improves.

Answer 59

Schedule nursing activities to allow for rest.

Question 60

The nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. The nurse would include which information in the education?

Purpose of bronchodilators

Importance of meticulous oral hygiene

Technique used in pursed-lip breathing

Methods used to maintain a dust-free environment

Answer 60

Importance of meticulous oral hygiene

Question 61

A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention?

Administer opioids frequently.

Assess for signs of pneumonia.

Give medication to suppress coughing.

Limit fluid intake to prevent pulmonary edema.

Answer 61

Assess for signs of pneumonia.

Clients with pleuritic disease are prone to developing pneumonia because of impaired lung expansion, air exchange, and drainage. Opioids are contraindicated because opioids depress respirations. Coughing should not be suppressed; it enhances lung expansion, air exchange, and lung drainage. Oral fluids should be encouraged; pulmonary edema does not develop unless the client has severe cardiovascular disease.

Question 62

Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?

Apply a thoracic binder for support.

Encourage coughing and deep breathing.

Defer pain medication the first day after injury.

Position the client face-down on a soft mattress.

Answer 62

Encourage coughing and deep breathing.

Question 63

The nurse is teaching Hands-Only Basic Life Support for adults in the community. After determining that the victim is not responding and the emergency medical system has been activated, which action would the rescuer take?

Identify the absence of pulse.

Give two rescue breaths with a CPR mask.

Perform the head tilt–chin lift maneuver.

Perform chest compressions at a rate of 100/min.

Answer 63

Perform chest compressions at a rate of 100/min.

Once the community rescuer verifies that the person is unresponsive and has activated the emergency medical response system, the rescuer should immediately begin chest compressions at a rate of 100/minute to a depth of 2 inches (5 cm), allowing full chest recoil between compressions. Performing the head tilt–chin lift maneuver, giving rescue breaths, and checking the pulse are not part of the Hands-Only Basic Life Support method of cardiopulmonary resuscitation (CPR). This method was designed to make it easier for community people to perform CPR. It quickly circulates the blood until trained assistance arrives.

Question 64

The nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange?

Supine

Orthopneic

Low-Fowler

Semi-Fowler

Answer 64

Orthopneic

The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange; it also enables the client to press the lower chest or abdomen against the overbed table, which increases pressure on the diaphragm to help with exhalation, reducing residual volume. The supine position does not permit the diaphragm to descend by gravity, and pressure of the abdominal organs against the diaphragm limits its movement. Low-Fowler and semi-Fowler positions do not maximize lung expansion to the same degree as the orthopneic position.

Question 65

The nurse provides teaching to a client who is being discharged after treatment for a pneumothorax. The nurse instructs the client to notify the health care provider immediately if experiencing which symptom of a recurring pneumothorax?

Substernal chest pain

Episodes of palpitation

Severe shortness of breath

Dizziness when standing up

Answer 65

Severe shortness of breath

Question 66

Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place?

“The restraints will be removed once the client is extubated.”

“We are required to restrain all clients with breathing tubes.”

“Restraints are a last resort to prevent accidental extubation.”

“It is routine procedure for us to restrain all intubated clients.”

Answer 66

“Restraints are a last resort to prevent accidental extubation.”

Question 67

After the nurse has finished teaching a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective?

“I will avoid crossing my legs.”

“Pillows placed under my knees will help avoid clots.”

“Staying on bed rest as long as possible is best for me.”

“Three times every day I will massage my lower legs to get blood moving.”

Answer 67

“I will avoid crossing my legs.”

Clients should avoid crossing the legs to prevent the constriction of blood flow in the lower leg, which can lead to deep vein thrombosis (DVT). When dislodged, DVT can become a pulmonary embolus. Pillows should not be placed under the knees because this constricts blood flow to and from the lower leg and increases risk for DVT. Activity, rather than staying immobile in bed, helps encourage blood flow. The lower legs should not be massaged because this action could dislodge a DVT that has formed.

Question 68

Which action will the nurse take to support safe oral intake after tracheostomy?

Include thin liquids.

Provide large meals.

Inflate the tracheostomy cuff fully.

Position client as upright as possible.

Answer 68

Position client as upright as possible.

After tracheostomy, positioning the client as upright as possible supports safe eating by preventing aspiration. Thin liquids are more difficult to swallow and increase the risk for aspiration. Large meals may cause overdistention of the stomach and lead to regurgitation and aspiration; meals should be small and frequent. The tracheostomy cuff should be deflated to decrease interference with swallowing.

Question 69

When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention?

Maintains a sterile field

Applies suction during insertion of the catheter

Preoxygenates with 100% oxygen for 1 minute

Tests suction pressure at 100 mm Hg before inserting catheter

Answer 69

Applies suction during insertion of the catheter

Suction should be applied during withdrawal, not insertion, of the catheter. A sterile field is required for tracheal suctioning, but not oral suctioning. Preoxygenation will be completed for 30 seconds to 3 minutes. Pressure must be tested before suctioning and be within the range of 80 to 120 mm Hg.

Question 70

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action?

Obtain vital signs.

Administer oxygen.

Notify the health care provider.

Auscultate the client’s lung sounds.

Answer 70

Administer oxygen.

Question 71

The nurse reviews the principles of oxygen administration. Which is the primary consideration when determining which method of oxygen delivery will be the most effective for a client?

Activity level

Facial anatomy

Mental capacity

Pathological condition

Answer 71

Pathological condition

Several modes are used for administration of oxygen; selection is based on the disease and the client’s status. Although the other factors such as activity level, facial anatomy, and mental capacity will be taken into consideration, the ultimate decision is based on the pathological condition and therapeutic needs.

Question 72

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which is appropriate to include?

They are indicative of pleural rubbing.

They are signs of bronchial constriction.

Crackles are located in the smaller air passages.

Crackles are heard during respiratory expiration.

Answer 72

Crackles are located in the smaller air passages.

Question 73

A client is admitted to the hospital with a diagnosis of emphysema. When teaching the client about breathing exercises, the nurse would include which instruction?

Spend more time inhaling than exhaling to blow off carbon dioxide.

Perform sit-ups to strengthen abdominal muscles to improve breathing.

Perform diaphragmatic exercises to improve contraction of the diaphragm.

Use abdominal exercises to limit the use of accessory muscles of respiration.

Answer 73

Perform diaphragmatic exercises to improve contraction of the diaphragm.

Question 74

A client is admitted to the emergency department after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. The nurse would monitor the client for which life-threatening response?

Ischemia

Lactic acidosis

Anaphylaxis

Increased blood pressure

Answer 74

Anaphylaxis

Question 75

Which nursing action will help a client obtain maximum benefits after postural drainage?

Administer oxygen.

Encourage coughing deeply.

Place the client in a sitting position.

Encourage the client to rest for 30 minutes.

Answer 75

Encourage coughing deeply.

Question 76

The nurse provides education about self-care management to a client who was recently diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement?

“I will try to avoid smoking.”

“I will maintain complete bed rest.”

“I’ll control the temperature in my home.”

“I’ll need to clean my mouth several times a day.”

Answer 76

“I will maintain complete bed rest.”

Although energy should be conserved, it is not necessary to restrict all activity; the client needs further teaching. Smoking should be avoided because it is a respiratory tract irritant and it interferes with gas exchange in the alveoli. Extremes in environmental temperature and humidity place stress on the respiratory system, interfering with gaseous exchange. Meticulous oral care is advisable because of the presence of excessive mucus; also, it reduces the amount of microorganisms that can enter the tracheobronchial tree, which can precipitate infection.