NURS 122 ATI RESPIRATORY

A nurse is caring for a client who is taking albuterol. For which of the following adverse effects should the nurse monitor the client?
1. Hyperkalemia
2. Dyspnea
3. Tachycardia
4. Candidiasis
Tachycadia

A nurse is assessing a client who has emphysema. The nurse should report which of the following assessment findings?
1. Digital clubbing
2. Elevated temperature
3. Barrel-shaped chest
4. Diminished breath sounds
Elevated temperature

Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections. A nurse should report an elevated temperature to the provider, as this indicates a possible respiratory infection.

A nurse is caring for a client following the insertion of a chest tube. The nurse should plan to have which of the following items in the client’s room?
1. extra drainage system
2. suture removal set
3. container of sterile water
4. nonadherent pads
container of sterile water

The nurse should plan to place the open end of the tubing if it becomes disconnected into the sterile water to prevent a pneumothorax. The tubing and sterile water are then placed below the client’s chest.

A nurse is assessing a client who has a chest tube in place following thoracic surgery. Which of the following findings indicated a need for intervention?
1. Fluctuation of drainage in the tubing with inspiration
2. continuous bubbling in the water seal chamber
3. drainage of 75mL in the first hour after surgery
4. several small, dark-red blood clots in the tubing
Continuous bubbling in the water seal chamber

continuous bubbling in the water seal chamber suggests an air leak

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate (conscious) sedation. Which of the following assessments by the nurse is the priority?
1. gag reflex
2. pain level
3. dehydration
4. redness at the IV insertion site
gag reflex

the greatest risk to the client is aspiration due to the depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag relfex

A nurse receives prescriptions from the provider to perform nasopharyngeal suctioning for each of the following clients. The nurse should clarify the provider’s prescription for which of the following clients?
1. A client who has a closed-head injury and is lethargic
2. A client who has a fractured femur and reports severe pain
3. A client who has a ruptured appendix and a temperature of 39 C (102.2 F)
4. A client who has emphysema and respiration’s of 36/min
A client who has a closed-head injury and is lethargic

A recent head injury is a contraindication for nasopharyngeal suctioning because suctioning can increase intracranial pressure.

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the priority for the nurse to use to evaluate the effectiveness of the mechanical ventilation?
1. blood pressure
2. capillary refill
3. arterial blood gases
4. heart rate
Arterial blood gases

when using the airway, breathing, circulation approach the client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

A nurse is caring for a client who has acute respiratory distress syndrome. Which of the following assessment findings indicates a decline in the client’s condition?
1. increase in respiratory rate
2. increase in oxygen saturation
3. decrease in carbon dioxide retention
4. decrease in intercostal retractions
increase in respiratory rate

an increase in respiratory rate indicates increased work of breathing and the need for improvement in oxygen delivery.

A nurse is caring for a client who is 1hr postoperative following a thoracentesis. Which of the following is the priority assessment finding?
1. pallor
2. insertion site pain
3. tracheal deviation to the unaffected side
4. temperature 37.3C (99.1F)
tracheal deviation to the unaffected side

when using the airway, breathing, circulation approach to client care, the nurse should identify tracheal deviation as the priority assessment because this indicates a tension pneumothorax, which is a medical emergency

A nurse is providing instruction to a client on how to use montelukast to treat chronic asthma. Which of the following statements indicates the clients understands the teaching?
1. “I will take this medication with each meal.”
2. “I will take this medication during my asthma attacks.”
3. “I will take this medication up to three times per day when I begin to wheeze.”
4. “I will take this medication every evening, even when I do not have symptoms.”
“I will take this medication every evening, even when I do not have symptoms.”

Montelukast is used for prophylaxis of asthma exacerbation and is taken on a daily basis in the evening. The client should take montelukast every day as maintenance therapy for asthma.

A nurse is caring for a client who has bacterial pneumonia. The nurse should expect which of the following assessment findings?
1. decreased fremitus
2. SaO2 95% on room air
3. temperature 38.8C (101.8F)
4. bradypnea
temperature 38.8C (101.8F)

An elevated temperature is an expected finding for a client who has bacterial pneumonia.

A nurse is caring for a client who has COPD. Which of the following findings should the nurse report to the provider?
1. oxygen saturation 89%
2. productive cough with green sputum
3. clubbing of fingers
4. pursed-lip breathing with exertion
productive cough with green sputum

A nurse should report a productive cough with green sputum to the provider as this indicates an infection.

A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with rifampin. The nurse should plan to include which of the following in the client’s discharge teaching plan?
1. ringing in the ears is expected
2. purified protein derivative (PPD) skin test results will improve in 4 months
3. urine and other secretions will be orange.
4. take the medication with meals.
urine and other secretions will be orange

rifampin will turn urine and other secretions orange.

A nurse is caring for a client who is in respiratory distress. Which of the following devices should the nurse use to provide the highest level of oxygen via a low-flow system?
1. Nasal cannula
2. Nonrebreather mask
3. Simple face mask
4. partial rebreather mask
nonrebreather mask

a nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This delivers greater than 90% FIO2, which provides the highest level of oxygen.

A nurse working in the emergency department is caring for a client following a chest trauma. Which of the following finders indicates a tension pneumothorax?
1. collapsed neck veins on the affected side
2. collapsed neck veins on the unaffected side
3. tracheal deviation to the affected side
4. tracheal deviation to the unaffected side
tracheal deviation to the unaffected side

a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is caring for a client who is postoperative and develops an acute onset of severe chest pain and worsens upon inspiration. The client is anxious and tachypneic. Which of the following actions should the nurse take first?
1. Apply supplemental oxygen
2. increase the rate of IV fluids
3. administer pain medication
4. initiate heparin therapy
apply supplemental oxygen

when using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the firest action the nurse should take is to apply supplemental oxygen.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack?
1. cromolyn sodium
2. prednisone
3. fluticasone and salmeterol
4. albuterol
albuterol

the nurse should administer albuterol, a short-acting beta 2-adrenergic agonist, as it acts quickly to produce bronchodilation during an acute asthma attack.

A nurse is planning care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?
1. schedule respiratory treatments following meals
2. have the client sit in a chair for 2-hr periods three times per day
3. provide a diet that is high in calories and protein
4. combine activities to allow for longer periods between activities
provide a diet that is high in calories and protein

the nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

A nurse is caring for a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement?
1. airborne
2. neutropenic
3. contact
4. droplet
airborne

the nurse should initiate airborne precautions for the client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air

A nurse is caring for a client receiving mechanical ventilation. The low pressure alarm sounds. Which of the following should the nurse recognize as a cause of the alarm?
1. excess secretions
2. kinks in the tubing
3. artificial airway cuff leak
4. biting on the endotracheal tube
artificial airway cuff leak

An artificial airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound.

A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the priority?
1. provide a quiet environment
2. encourage use of incentive spirometry every 1 to 2 hr
3. initiate continuous cardiac monitoring
4. administer heparin via continuous IV infusion
administer heparin via continuous IV infusion

Using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

A nurse is caring for a client who has lung cancer. Which of the following assessment findings should the nurse expect?
1. blood-tinged sputum
2. decreased tactile fremitus
3. resonance with percussion
4. peripheral edema
blood-tinged sputum

the nurse should expect blood-tinged sputum secondary to bleeding from the tumor

A nurse is caring for a client who is 4 hr postoperative following a total laryngectomy for laryngeal cancer. Which of the following assessments is the priority?
1. bleeding at the surgical site
2. oxygen saturation
3. urinary retention
4. level of consiousness
oxygen saturation

Using the airway, breathing, circulation approach to client care, the nurse should identify the client’s oxygen saturation is the priority assessment. A client who is postoperative following a total laryngectomy is at risk for hypoxia due to airway obstruction and decreased oxygen saturation is an indication of obstructed airway

A nurse is positioning a client who has emphysema to promote effective breathing. The nurse should place the client in which of the following positions?
1. lateral position with a pillow over the chest to support the arm
2. high-fowler’s position with arms supported on the overbed table
3. semi-fowler’s position with pillows supporting both arms
4. supine position with the head of the bed elevated 15 degrees
high fowlers position with arms supported on the overbed table

the nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms on the overbed table

A nurse is caring for a client who is postoperative and is hypoventilating secondary to general anesthesia effects and incisional pain. Which of the following ABG values support the nurse’s suspicion of respiratory acidosis?
1. pH 7.50, PO2 95mm Hg, PaCO2 25 mm Hg, HCO3- 22mEq/l
2. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/l
3. pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/l
4. pH 7.30, PO2 80 mmHg, PaCO2 55 mm Hg, HCO3- 22 mEq/l
pH 7.30, PO2 80 mmHg, PaCO2 55 mm Hg, HCO3- 22 mEq/l

these ABG values indicate respiratory acidosis. The pH is less than 7.35 and the paCO2 is greater than 45 mmHG, which indicates respiratory acidosis

A nurse is assisting with a thoracentesis. Which of the following actions is appropriate for the nurse to take when
assisting with this procedure? (select all that apply)
1. wear goggles and make during the procedure
2. cleanse the area with an antiseptic solution
3. instruct the client to take deep breaths during insertion of the needle
4. position the client laterally on the affected side
5. apply pressure to the site after the needle is withdrawn
wear goggles and make during the procedure—-the nurse and provider should wear these PPE items to reduce the risk of exposure to pleural fluid

cleanse the area with an antiseptic solution–the use of antiseptic solution decreases the risk of infection, which is increased due to the invasive procedure

apply pressure to the site after the needle is withdrawn–the application of pressure decreases the risk of bleeding at needle insertion site.

A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take?
1. use clean technique to suction the client’s endotracheal tube
2. use a rotating motion to remove the suction catheter
3. suction the oropharngeal cavity prior to suctioning the endotracheal tube
4. suction the client’s endotracheal tube every 2 hr
use a rotating motion to remove the suction catheter

the nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue trauma

A nurse is caring for a client who has acute respiratory failure. Which of the following laboratory findings should the nurse expect?
1. arterial pH 7.50
2. paCO2 25 mm Hg
3. SaO2 92%
4. PaO2 58 mm Hg
PaO2 58 mm Hg

the nurse should expect the client who has acute respiratory failure to have a lower partial pressures of oxygen

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism?
1. a client who is 12 hr postoperative following a total hip arthroplasty
2. a client who is 8 hr postoperative following an open surgical appendectomy
3. a client who is 2 hr postoperative following an open reduction external fixation of the right radius
4. a client who is 4 hr postoperative following a laparscopic cholecystectomy
a client who is 12 hr postoperative following a total hip arthroplasty

the nurse should identify the client who has undergone a total hip replacement surgery is a greatest risk for a pulmonary embolus due to decreased mobility of the affected extremity. Therefore, this is the priority finding.

A nurse is providing discharge instruction of a client following a tracheostomy. Which of the following statements by the client indicates a need for further instruction?
1. “I need to inspect the stoma for signs of infection or skin irritation.”
2. “I will clean the cannula with half-strength peroxide and rinse with saline.”
3. “I can remove the old twill ties once the new ties are place.”
4. “I should apply suction while inserting the catheter into my tracheostomy.”
“I should apply suction while inserting the catheter into my tracheostomy.”

the client should apply suction only when withdrawing the catheter to prevent tracheal tissue trauma

A nurse is caring for a client who has lung cancer. which of the following assessment findings should the nurse expect? Blood-tinged sputum A nurse is caring for a client who is 4 hr postoperative following a total laryngectomy for …

A nurse working in the emergency department is caring for a client following a chest trauma. What findings indicates a tension pneumothorax? Tracheal deviation to the unaffected side. Rat.: a tension pneumothorax results from free air filling the chest cavity, …

A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? A. Lateral position with a pillow at the back and over the chest …

The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client’s international normalized ratio (INR) is 2.0. What is the nurse’s best action? Discontinue the heparin. The nurse is caring for a postoperative …

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: A) Alcoholism and hypertension B) Obesity …

To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? Arterial blood gas (ABG) analysis rationale: ABG analysis is most useful in this setting because ventilatory failure …

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