Which of these clients will the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)?
Definition
Term
An RN and an LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which of these actions is best accomplished by the RN?
Definition
Plan client and family teaching regarding upcoming pulmonary function testing.
Term
A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which of these nursing tasks is best for the charge nurse to delegate to the experienced nursing assistant working in PACU?
Definition
Monitor blood pressure and pulse.
Term
The RN has received report about all of these clients. Which client needs the most immediate assessment?
Definition
Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
Term
The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients should be rescheduled for a visit on the following day. Which of these clients would be best to reschedule?
Definition
Client with emphysema who has been on home oxygen for a month and has SPO2 levels of 91% to 93%
Term
Which of these assessment findings will be of greatest concern when the nurse is assessing a client with emphysema?
Definition
Bronchial breath sounds heard at the bases
Term
People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilations? Select all that apply.
Definition
Term
Which nursing intervention is the priority in preparing the client for pulmonary function testing (PFT)?
Definition
Ensure no smoking 6 hours before the test.
Term
The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer?
Definition
Class II, can perform desk job
Term
A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention?
Definition
Pink frothy sputum
Term
A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest?
Definition
Adventitious breath sounds
Term
Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention?
Definition
Client with acute allergic reaction
Term
The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds?
Definition
Crackles
Term
In the older adult client, which respiratory change does not require further assessment by the nurse?
Definition
Increased anteroposterior (AP) diameter
Term
In assessing the client's respiratory status, blood gas test results reveal pH of 7.50, PaO2 of 99, PaCO2 of 29, and HCO[image] of 22. What action does the nurse need to take first?
Definition
Encourage the client to slow his breathing rate.
Term
The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first?
Definition
Implement NPO (nothing by mouth) status.
Term
Why are the turbinates important?
Definition
They increase the surface area of the nose for heating and filtering.
Term
A client is having surgery. He asks his nurse, "When they put that tube in my throat, where does it really go?" What is the name of the opening of the vocal cords?
Definition
Glottis
Term
Where does gas exchange occur?
Definition
Alveolus
Term
The client has a fever of 40° C. In which direction, if any, will this shift the oxyhemoglobin dissociation curve?
Definition
To the right
Term
Which of the components of a client's family history are of particular importance to the home health nurse who is assessing a new client with asthma?
Definition
Brother is allergic to peanuts.
Term
Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse?
Definition
Client with pain radiating to the shoulder
Term
The nurse is working in an urgent clinic. Which of these four clients needs to be evaluated first by the nurse?
Definition
Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry
Term
A client is admitted to the medical floor with a new diagnosis of lung cancer. How can the nurse assist the client initially with the anxiety associated with the new diagnosis?
Definition
Encourage client to ask questions and verbalize concerns.
Term
A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test will the nurse teach the client about to help confirm the diagnosis?
Definition
Computed tomography (CT) scan
Term
You are a charge nurse on a surgical floor. The LPN/LVN informs you that a new client who had an earlier bronchoscopy has the following vital signs: heart rate 132, respiratory rate 26, and blood pressure 98/50. The client is anxious and his skin is cyanotic. What will be your first action?
Definition
Administer oxygen.
Term
A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse?
Definition
Pneumothorax
Term
An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best?
Definition
The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula
Term
Which value indicates clinical hypoxemia and the need to increase oxygen delivery?
Definition
PaO2 of 65 mm Hg
Term
For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube?
Definition
Hyperoxygenate before and after suctioning.
Term
A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN?
Definition
Adjust the position of the oxygen tubing.
Term
The client with a new tracheostomy has a soiled dressing. What is the best nursing intervention?
Definition
Replace the dressing with sterile, folded 4 × 4 gauze.
Term
An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN?
Definition
Suction the tracheostomy using sterile technique.
Term
The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first?
Definition
Assess the client's respiratory status.
Term
A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first?
Definition
Listen to lung sounds.
Term
A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response?
Definition
"You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."
Term
The client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response?
Definition
"Do you have a pretty scarf or a large loose collar that you could place over it?"
Term
Which client has the most urgent need for frequent nursing assessment?
Definition
An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask
Term
The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period?
Definition
Picture board
Term
Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse?
Definition
Suctioning the client
Term
A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?
Definition
Face tent
Term
A "Do not resuscitate" (DNR) client has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first?
Definition
Ensures that the tubing is patent and that oxygen flow is high
Term
A client with a tracheostomy is at increased risk for aspiration. Which nursing intervention(s) will reduce this risk? Select all that apply.
Definition
Term
A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first?
Definition
Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask.
Term
The client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care?
Definition
"I can only take baths, no showers."
Term
The client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention?
Definition
Decreasing respiratory rate
Term
The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned?
Definition
Lung sounds may indicate absorption atelectasis.
Term
A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress?
Definition
The client is receiving oxygen at 4 L/min.
Term
The nursing assistant has taken vital signs of the ventilated postoperative client who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for?
Definition
Bright red blood rapidly seeping through the dressing
Term
The nurse answers the client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action?
Definition
Determines the cause of obstruction
Term
Which two factors in combination are the greatest risk factors for head and neck cancer?
Definition
Alcohol and tobacco use
Term
The nurse is planning care for the non-English-speaking client who is on complete voice rest. What alternative method of communication does the nurse implement?
Definition
Picture board
Term
Which clinical manifestation requires immediate action by the nurse for the client with laryngeal trauma?
Definition
Tachypnea
Term
Which finding in the postoperative client after nasoseptoplasty requires immediate intervention by the nurse?
Definition
Excessive swallowing
Term
The client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question?
Definition
"Give ibuprofen 800 mg every 8 hours as needed for pain."
Term
Which clinical manifestation in the client with facial trauma is the nurse's first priority?
Definition
Stridor
Term
The client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response?
Definition
"Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe."
Term
Which statement by the client with a laryngectomy indicates the need for further discharge teaching?
Definition
"I can't put anything over my stoma to cover it."
Term
When suctioning a client with an endotracheal tube for the first time, what does the nurse do first?
Definition
Briefly explains the procedure
Term
The client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure?
Definition
"I really will miss the taste of my favorite food."
Term
A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse?
Definition
Client with epistaxis with profuse bleeding on warfarin (Coumadin)
Term
The nurse manager at a long-term care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant?
Definition
Washing the skin with soap and water
Term
A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which of these preoperative interventions can be accomplished by an LPN/LVN working on the unit?
Definition
Administering preoperative antibiotics and anxiolytics
Term
A client who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. All of these physician requests are received. Which action will the nurse take first?
Definition
Immobilize the neck with a cervical collar.
Term
The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery?
Definition
Establish a means for communication during the immediate postoperative period, such as a Magic Slate or an alphabet board.
Term
A client's mother asks what is the most important thing she will need to know to care for her son who is having an inner maxillary fixation (IMF) completed as an outpatient. What does the RN tell her?
Definition
"Make sure he always has wire cutters with him."
Term
A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first?
Definition
Ask the client whether CPAP has been used consistently at night.
Term
Your client has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client had been very anxious about his surgery. Which of the following medications would you expect to find on his home medication list?
Definition
Lorazepam (Ativan)
Term
The client is 1 day postoperative from a total laryngectomy for cancer. He has indicated to you that he is experiencing pain. Pain management for him is best achieved with which medication?
Definition
IV morphine sulfate (Morphine)
Term
A client who has had a recent laryngectomy continues to report pain. Which of the following medications would be best used as an adjunct to a narcotic once he can take oral nutrition?
Definition
Liquid NSAIDs
Term
Your client is the football coach at a local high school. His chief problem is hoarseness. Which of the following is the best recommendation the nurse can make regarding his care?
Definition
Complete voice rest
Term
What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth?
Definition
Prevent radiation scatter when the beam hits metal in the mouth
Term
A new client arrives in the medical-surgical unit with a flap. The flap appears dusky in color. What is the nurse's first action?
Definition
Use a Doppler to assess flow to the area.
Term
of these clients are being cared for on the intensive care step-down unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit?
Definition
Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask.
Term
The RN and the nursing assistant are working together to provide care for a group of clients. Which of these nursing activities could the RN delegate to the nursing assistant?
Definition
Reinforce the use of slow expiration through pursed lips to maximize gas exchange for a client with sarcoidosis.
Term
A client has just been admitted to the intensive care unit (ICU) after having a left lower lobectomy with a video-assisted thoracoscopic surgery (VATS). Which of these requests will the nurse implement first?
Definition
Adjust oxygen flow rate to keep O2 saturation at 93% to 100%.
Term
The change-of-shift report has just been completed on the medical-surgical unit. Which of the following clients will the oncoming nurse plan to assess first?
Definition
Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38.
Term
A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first?
Definition
Albuterol (Proventil) 2 inhalations
Term
Your client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client?
Definition
Mucolytics thin secretions, making them easier to expectorate.
Term
The client has asthma that only gets worse during the summer. She tells the nurse she will be taking a medicine every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client?
Definition
Montelukast (Singulair)
Term
The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler?
Definition
Short-acting beta agonists
Term
A client has been diagnosed with asthma. Which statement below indicates that he correctly understands how to use an inhaler with a spacer correctly?
Definition
"If the spacer makes a whistling sound, I am breathing in too rapidly."
Term
What does the nurse do first when setting up a safe environment for the new client on oxygen?
Definition
Ensures that no combustion hazards are present in the room
Term
For relief of hypoxemia in the newly admitted client with chronic obstructive pulmonary disease (COPD), what does the client most likely need?
Definition
Oxygen flow rate of 1 to 2 L/min via nasal cannula
Term
Because clients with cystic fibrosis (CF) are at increased risk for infection, what does the nurse advise the client with CF to do?
(This is weird. It doesn't say the person IS infected.)
Term
While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do?
Definition
Calmly continues talking
Term
An environmental assessment of a factory is conducted, and inhalation exposure with a high level of particulate matter is found. What does the factory nurse do to generate the quickest compliance?
Definition
Teaches workers how to use a mask
Term
After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates understanding of the nurse's instructions?
Definition
"I must have my emergency inhaler with me at all times."
Term
The client says, "I hate this stupid COPD." What is the best response by the nurse?
Definition
"What is bothering you?"
Term
Which statement by the client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction?
Definition
"I don't need to get the flu shot."
Term
A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders?
Definition
The client is symptom free between exacerbations.
Term
In a presentation to middle school students, what does the nurse teach as the major risk factor for lung cancer?
Definition
Cigarette smoking
Term
The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success?
Definition
SpO2 level of 92% after ambulating 50 feet
Term
A newly diagnosed client with asthma says that his peak flow meter is reading 82% of his personal best. What does the nurse do?
Definition
Repeats the peak flow test
Term
The nurse is teaching the client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques?
Definition
Increased risk for sunburn
Term
After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first?
Definition
Assesses airway, breathing, and circulation
Term
The nurse observes a student nurse suction the right bronchus of a patient via the tracheostomy. The nurse determines care is appropriate if the student nurse places the patient's head in which position
the patient's head turned to the left
the patient's head turned to the right
the patint's head tilted forward toward the chest
the patient' head tilted backwards even with the shoulders
Definition
the patient's head turned to the left
Term
a patient diagnosed with COPD is drowsy and unable to expectorate secretions. the nurse should take which of the following actions
force fluids
administer high-flow oxygen mask
perform nasotracheal suction
perform postural drainage
Definition
perform nasotracheal suction
Term
the nurse teaches pursed lip breathing to the patient diagnosed with COPD. the nurse understands which of the following BEST describes the underlying purpose of this type of breathing
prevent air trapping
strengthen oral musculature
promot deep relaxation
enhance inspiratory capacity
Definition
prevent air trapping
Term
the nurse case for a patient receiving aminophyilline via continuous IV drip. the nurse understands that aminophylline is
an antimircobial
a mucolytic
a bronchodilator
an expectorant
Definition
a bronchodilator
Term
a patient is scheduled for rhoinoplasty. postoperative it is most important for the nurse to place the patient in which of the following positions
supine
left sims
modified trendelenburg
semi-fowlers
Definition
semi-fowlers
Term
the nurse cares for a patient diagnosed with active tuberculosis. which of the insrtuctions should the nurse give the patient about follow-up care after discharge from the hospital
we would like you to come to the clinic monthly to recheck your tine test and look for changes in your chest xray
we would like you to return to the clinic if you experience any side effects from the mediation
we would like you to come to the clinic weekly for your inh injections
we would like you to come to the clinic monthly to check the effects of the medication you are taking
Definition
we would like you to come to the clinic monthly to check the effects of the medication you are taking
Term
the nurse should lubricate catheter used to suction a patient's tracheostomy with which of the following
sterile water
mineral oil
hydrogen peroxide
k y jelly
Definition
sterile water
Term
the nurse expects which of the following modes of mechanical ventilation to be ordred for a patient with severe guillain barre syndrome
controlled ventilation
assist-control ventilation
syncrhonized intermittent mandatory ventilation
continuous positive airway pressure
Definition
controlled ventilation
Term
a patient is started on rifampin and isoniazid. which of the following explanations concerning these medications is ost appropriate for the nurse to give
you will have to take these medicines for the rest of your life
you must isolate yourself from your family while on this medicine
you will have to take this medicine about a year
you will need to take this medicine only when you have symptoms
Definition
you will have to take this medicine about a year
Term
the nurse performs nutritional couseling for a patient who is diagnosed with COPD. it is most important for the nurse to advise the patient to avoid consuming which nutrient in high amounts
carbohydrates
calories
protein
fats
Definition
carbohydrates
Term
the nurse prepares to suction the endotracheal tube of a patient on a mechanical ventilator. which of the following ventilator settings should be adjusted by the nurse before and after this procedure
tidal volume
respiratory rate
fraction of inspired oxygen (FiO2)
flow
Definition
fraction of inspired oxygen (FiO2)
Term
the nurse in the community health center identifies which of the following types of food is most likely to present problems for a client with respiratory difficulties
fruits
grains
dairy
fish
Definition
dairy
Term
the nurse preform teaching for a patient diagnosed with asthma. the nurse determines further teaching is necessary if the patient makes which of the following statements
i'm going to have to replace my wool rugs and feather pillows
i can no longer rake the leaves or garden like i used to
we are going to have to dust and vacuum more frequently
i'm going to have to establish a regular bedtime routine
Definition
i'm going to have to establish a regular bedtime routine
Term
the nurse obtains a history from a man admitted to the hospital with COPD. the nurse identifies which of the following factors is related to the patient developing COPD
the patient smoked for more than 30 years
the patient worked in an orchard for 20 years
the patient drinks four cans of beer a day
the patient had pancreatitis four times
Definition
the patient smoked for more than 30 years
Term
the nurse cares for patient on the med-surg unit. the nurse expects postural drainage to be ordered for which of the following patients
a patient diagnosed with cystic fibrosis
a patient diagnosed with ascities due to cirrhosis
a patient diagnosed with lymphedema
a patient diagnosed with a subdural hematoma
Definition
a patient diagnosed with cystic fibrosis
Term
the nurse understands which of the following is the cause of respiratory alkalosis
hyperglycemia
hyperventilation
fluid loss
airway compromise
Definition
hyperventilation
Term
a patient requires an emergency tracheostomy. when caring for the tracheostomy, the nurse should take which of the following actions
suction every hour
clean the inner cannula after suctioning
clean the site every four hours
hyperextend the patient's neck to maintain patency
Definition
clean the site every four hours
Term
a patient is admitted to the hospital after sustaining a severe electrical burn. a tracheostomy is performed, and the patient is unable to use either hand. it is most important for the nurse to take which of the following actions
obtain a closed circuit video monitor
pad the side rails of the bed
obtain a blow touch call bell
transfer the patient with a hoyer lift
Definition
obtain a blow touch call bell
Term
the clinic nurse instructs a client in the use of a metered dose inhaler. which statement by the client indicates the need for further teaching
i will breathe in deeply and slowly as i press down on the canister
i will hold the mouthpiece 2 inches in front of my mouth
i will count to 10 on my fingers after i breathe in
i will be careful not to shake the canister before I use it
Definition
i will be careful not to shake the canister before I use it
Term
the nurse cares for a patient receiving oxygen per nasal cannula. which of the following observations requires an immediate intervention by the nurse
a vistor arrives with a strong odor of cigarettes on the clothing
the electric plug for the suction machine has 3 prongs rather than 2
the patient complains of a dry mouth and has a cracked lip
a visitor is putting clear nail polish on the fingernails of the patient
Definition
a visitor is putting clear nail polish on the fingernails of the patient
Term
the nurse cares for a patient immediately after laryngoscopy. it is most important for the nurse to intervene if which of the following is observed
the patient is talking with the nurse
the patient coughs spontaneously
the patient is drinking from a straw
the patient is moving about in bed
Definition
the patient is drinking from a straw
Term
which of the following routes of administration should the nurse use when giving a mantoux test
intradermal injection
subcutaneous injection
local implantaiton
intramuscular injection
Definition
intradermal injection
Term
the pediatric nurse cares for a 3 year old child diagnosed with acute laryngotracheobronchitis in a croupette. the nurse is most concerned if which of the following is observed
the air inside the croupette is cool
the grandmother gives the child a teddy bear
the child has a cap on the head
the child appears frightened unless someone is nearby
Definition
the grandmother gives the child a teddy bear
Term
the nurse knows that it is essentiatl to have which of the following pieces of equipment at the bedside of the patient receiving mechanical ventilation
resuscitation bag
incentive spirometer
particulate respirator
patient controlled analgesia machine
Definition
resuscitation bag
Term
an adult is eating lunch and suddenly starts to choke, gasp for breath, and grab the throat. which of the following actions should the nurse take first
instruct the patient to administer back blows
offer the patient water to drink
ask the patient to speak
finger sweep the patient's mouth
Definition
ask the patient to speak
Term
the nurse reviews staff charting for a patient diagnosed with pleural effusion. the nurse expects to find which notations in the patient's chart
decreased breath sounds noted in left lower lobe
lungs clear with breath sounds heard in all areas
crackles heard in right thoracic area
rhonchi heard on expiration
Definition
decreased breath sounds noted in left lower lobe
Term
the nurse should instruct a patient undergoing nasal surgery not to blow the nose after surgery because
it increases intracranial pressure
it decreases the patient's oxygen supply
it encourages bruising and edema
it may cause a fracture
Definition
it encourages bruising and edema
Term
to facilitate communication with a patient who has a tracheostomy, which of these nursing approaches is best
tell the patient to nod his head to indicate yes and shake his head to indicate no
tell the patient to mouth words so that the nurse can lip-read
have someone who knows the patient to stay at the bedside to act as interpreter
ask the patient to anticipate needs and write them down
Definition
tell the patient to nod his head to indicate yes and shake his head to indicate no
Term
which of the following actions is essential for the nurse to take after arterial blood gases are drawn
apply pressure to puncture site
check and record vital signs
give 100% oxygen
assess for presnece of ulnar pulse
Definition
apply pressure to puncture site
Term
immediately following thoracentesis the nurse notices a progressive swelling on the right side of the patient's chest and neck. the nurse knows which of the following conditions is the most likely cuase of the swelling
pneumothorax post-thoracentesis
subcutaneous emphysema
lipoma
hematoma formation
Definition
subcutaneous emphysema
Term
the nurse monitors a patient receiving oxygen per face mask. the nurse is most concerned if which is observed
there is condensation in the tubing of the humidifier container
the pulse ox reading is 92%
the patient has a nonproductive cough
the skin under the elastic
Definition
the patient has a nonproductive cough
Term
abluterol (proventil) and beclomethasone (vanceril) by metered dose inhaler are ordered for a patient recently diagnosed with asthma. the patient asks the nurse, why do I have to be concerned about which medication i take first and waiting in between medication. which is the best response by the nurse
that is how your physician wrote the order
you do not have to be concerned. you can take them in whatevver way works best for you as long as you take them both
that is the standard way these medications areadministered
the proventil will open up the airway so the vanceril can be better absorbed. you wait to allow the proventil to have its full effect
Definition
the proventil will open up the airway so the vanceril can be better absorbed. you wait to allow the proventil to have its full effect
Term
the nurse care for a patient with a new tracheostomy immediately postop. it is most important for the nurse to take which action
place the patient supine until vital signs are stable
ask the patient which position makes the patien tmost comfortable
place the patient with head elevated and neck hyperextended
elevate the patient's head and turn to the head to one side until consciousness returns
Definition
elevate the patient's head and turn to the head to one side until consciousness returns
Term
the nurse undertands the primary mechanism of action of synchronized intermittent mandatory ventilation for a patient requiring respiratory support is which
the delivery of breaths is synchronized with the R wave of the patient
a set tidal volume is deliverd at a set rate regardless of the breathing efforts of the patient
positive pressure is intermittently exerted at the end of ventilator breaths
ventilator breaths are correlated with patient breathing and patient can breathe naturally inbetween
Definition
ventilator breaths are correlated with patient breathing and patient can breathe naturally in between
Term
a patient with a chest tube asks the nurse about the bubbling he sees in the water sela chamber of his drainage equipment. which response by the nurse is the most appropriate
it's supposed to do that
it shows your lung has not yet re-expanded
why don't you ask your doctor
what do you think it means
Definition
it shows your lung has not yet re-expanded
Term
a patient chokes on food and becomes cyanotic. which is the best action for the nurse to take
the nurse stands behind the patient, and with the palm of the hand delivers one quick blow to th middle of the back
the nurse stands behinds the patient, wraps arms around the patient's waist and with a fist makes a quick upward thrust into the abdomen
the nurse stands in front of the patient, puts the palm of the hand betwen the namal and rib cage, and pressess firmly upward several times
the nurse lays the patient on the floor and prepares to initiate cardiopulmonary resuscitation
Definition
the nurse stands behinds the patient, wraps arms around the patient's waist and with a fist makes a quick upward thrust into the abdomen
Term
a patient is admitted to the hospital with a diagnosis of acute right upper lobe pneumonia. the patient has a history of chronic brochitis and type 1 diabetes. which symtpom would the nurse expect to see
moist, cool skin
rust-colored sputum
bradycardia
decresed respiratory rate
Definition
rust-colored sputum
Term
the nurse performs discharge teaching for a patient diagnosed with COPD. the client asks if the oxygen concentration can be increased during periods of shortness of breath. on what is the nurse's response based
high flow oxygen interferes with breathing
low flow oxygen will not improve breathing
high flow oxygen will stimulate breathing
low flow oxygen is more comfortable
Definition
high flow oxygen interferes with breathing
Term
the nurse cares for the client needing a tracheostomy. the client's daughter asks the nurse, why does my father need a tracheostomy. the nurse understands that which is the primary reason for performing a tracheostomy
promotes pulmonary funciton
improves breathing capabilties
prevents respiratory infections
decreases respiratory tract secretions
Definition
improves breathing capabilties
Term
a patient arrives in the emergency room with an acute asthma attack. epinephrine is given subcutaneously. which observation by the nurse best indicates the treatment is effective
an increase in the patient's alertness
an increase in the patient's pulse rate
a decrease in the patient's blood pressure and pulse
a decrease in the patient's inspiratory difficulty
Definition
a decrease in the patient's inspiratory difficulty
Term
which sign or symptom, if observed by the nurse, is most important to determine if a patient is hypoxic
cool bluish skin
abnormal blood gases
elevated temperature
increased sputum production
Definition
abnormal blood gases
Term
the nurse cares for a client diagnosed with tuberculosis. the client asks, why do I have to take pyridoxine (vitain B6). what explanation does the nurse provide
promote the absorption of inh
prevent neuritis
alleviate gastrointestinal symptoms
prevent kidney damage
Definition
prevent neuritis
Term
the patient diagnosed with cholesystitis is blind. in preparation for surgery the nurse teaches the patient diaphragmatic breathing. which is the most effective teaching method for the nurse to use
the nurse demonstrates diaphragmatic breathing and then asks the patient to do a return demonstration
the nurse discusses te rationale behind postoperative abdominal breathing, outlines the steps, and answers questions
the nurse asks the patient to put both hands on the abdomen and breathe in and out while keeping the chest still
the nurse asks the patient to tighten and release muscles, progressing from the toes to the head
Definition
the nurse asks the patient to put both hands on the abdomen and breathe in and out while keeping the chest still
Term
the nurse identifies which patient is most at risk for developing pneumonia
a patient with a foley catheter
a patient with a nasogatric tube
a patient diagnosed with psoriasis
a patient diagnosed with paget's disease
Definition
a patient with a nasogatric tube
Term
the nurse on the neurologic unit knows that which is the primary reason for having a patient diagnosed with cardiovascular accident position the head flexed slightly forward while sitting upright to eat
it increase the ease of swallowing
to decrease the musculature effort of maintaining the head erect
to decrease anxiety from seeing feeing utensils coming directly at them
to prevent aspiration
Definition
to prevent aspiration
Term
a patient diagnosed with a tension pneumothorax resulting from the chest hitting the steering wheel in an automobile accident. the emergency department nurse knows that the highest priority is given to which
oxygenation
chest tube insertion
ABG determination
attaching a cardiac monitor
Definition
chest tube insertion
Term
the nurse prepares a patient for a thoracentesis. the nurse should position the patient in which position
semi fowlers
upright
on the affected side
prone
Definition
upright
Term
the nurse cares for a patient receiving aminophylline. the nurse identifies which is a common side effect of aminophylline
increased respiratory rate
increased pulse rate
decreased respiratory rate
decreased pulse rate
Definition
increased pulse rate
Term
the nurse identifies which is the characteristic sound of breathing in a patient experiencing an acute asthma attack
murmuring with lubb dub sounds
high pitched musical like squeaky sounds
igh pitched harsh loud blowing sounds
low pitched rubbing or grating sounds
Definition
high pitched musical like squeaky sounds
Term
the nurse identifies which group of equipment is essential to have at the bedside of a patient with a closed-chest chest tube drainage system in place
the nurse instructs a group of high school students how to perform the abdominal thrust maneuver. the nurse determines that teaching is successful if a student makes which comment
the abdominal thrust maneuver dislodges food or other foreign bodies from the airway
the abdominal thrust maneuver involves hitting the person on the back several times
the abdominal thrust maneuver should not be done if the person is unconscioius
the abdominal thruse maneuver should only be done by a well trained health care professional
Definition
the abdominal thrust maneuver dislodges food or other foreign bodies from the airway
Term
blood gas results on a patient with emphysema indicate severe hypoxia. oxygen therapy is ordered. which method of oxygen administration will most likely be used
face mask with reservoir
face mask without reservoir
nasal cannula
venturi mask
Definition
venturi mask
Term
the nurse preforms teaching for a patient diagnosed with tuberculosis. the nurse explains that tuberculosis is caused by which
a virus
poor sanitation
poor nutrition
a bacterium
Definition
a bacterium
Term
the outer cannula of a patient's tracheostomy tube is accidentaly expelled 36 hours after surgery. which action should the nurse take first
contact the physician immediately
cut the tracheostomy neck ties
insert the emergency outer tube that is taped to the head of the bed
ventilate the chest using a manual resuscitation bag
Definition
ventilate the chest using a manual resuscitation bag
Term
the nurse instructs a patient about how to use an incentive spirometer. the nurse determines that teaching is effective if the patient makes which statement
i should take a deep breath and blow into the mouthpiece
i'm glad that i only have to do this twice a day
i should ask for pain medication prior to using the spirometer
i should lie down to use the incentive spirometer
Definition
i should ask for pain medication prior to using the spirometer
Term
the nurse cares for a patient afer rhinoplasty and observes bright red blood on the external dressing. which action should the nurse take first
return the patient to the operating room
contact the physician
examine the patient's throat
perform nasopharyngeal suctioning
Definition
examine the patient's throat
Term
the nurse identifies it is most important to observe for hyperventilation in a patient receiving which mode of mechanical ventilation
control ventilation
assist-control ventilation
syncronous intermittent mandatory ventilation
continuous positive airway pressure
Definition
assist-control ventilation
Term
the nurse assess a patient receiving isoniazid. it is most important for the nurse to observe for which
hepatitis
glomerulonephritis
photosensitivity
deafness
Definition
hepatitis
Term
an adult is in a motorcycle accident and sustains three fractured ribs and a pneumothorax. a chest tube is inserted. the nurse should take which of the following actions
montior the fluctuation in the tube
pin the tubes to the sheets
clamp the tubes when transferring the patient to bed
empty the bottles every eight hours
Definition
montior the fluctuation in the tube
Term
the home care nurse visit a client diagnosed with chronic bronchitis. the nurse notes the client is weak and congested. it is most important for the nurse to make which statement
cough as much as you can. the secretions have to come out
if you hold a pillow against your abdomen, the coughing would be easier
take 3 or 4 deep breaths and as you exhale the last breath cough 3 times
it does not matter when you cough. just do it
Definition
take 3 or 4 deep breaths and as you exhale the last breath cough 3 times
