ADULT HEALTH RESPIRATORY - EXAMINATION COMPLETE
QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: The emergency department nurse is assessing a client
who has sustained a blunt injury to the chest wall. Which finding
indicates the presence of a pneumothorax in this client?
Answer:
Diminished breath sounds
Question 2: The nurse is caring for a client hospitalized with acute
exacerbation of chronic obstructive pulmonary disease. Which
findings would the nurse expect to note on assessment of this
client? Select all that apply.
Answer:
A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen
saturation with mild exercise
Question 3: The nurse instructs a client to use the pursed-lip
method of breathing and evaluates the teaching by asking the
client about the purpose of this type of breathing. The nurse
determines that the client understands if the client states that the
primary purpose of pursed-lip breathing is to promote which
outcome?
Answer:
Promote carbon dioxide elimination.
Question 4: The nurse is preparing a list of home care instructions
for a client who has been hospitalized and treated for tuberculosis.
Which instructions should the nurse include on the list? Select all
,that apply.
Answer:
Activities should be resumed gradually. A sputum culture is needed every 2 to
4 weeks once medication therapy is initiated. 4. Respiratory isolation is not
necessary because family members already have been exposed. 5. Cover the
mouth and nose when coughing or sneezing and put used tissues in plastic
bags.
Question 5: The nurse caring for a client with a pneumothorax and
who has had a chest tube inserted notes continuous gentle
bubbling in the water seal chamber. What action is most
appropriate?
Answer:
Check for an air leak, because the bubbling should be intermittent.
Question 6: The nurse is caring for a client who suffered an
inhalation injury from a wood stove. The carbon monoxide blood
report reveals a level of 12%. Based on this level, the nurse would
anticipate noting which sign in the client?
Answer:
Flushing
Question 7: The nurse is caring for a client after a bronchoscopy
and biopsy. Which finding, if noted in the client, should be reported
immediately to the health care provider?
Answer:
Bronchospasm
,Question 8: The nurse is preparing to suction a client via a
tracheostomy tube. The nurse should plan to limit the suctioning
time to a maximum of which time period?
Answer:
10 seconds The nurse is suctioning a client via an endotracheal tube. During
the suctioning procedure, the nurse notes on the monitor that the heart rate is
decreasing. Which nursing intervention is appropriate?
Question 9: The nurse is suctioning a client via an endotracheal
tube. During the suctioning procedure, the nurse notes on the
monitor that the heart rate is decreasing. Which nursing
intervention is appropriate?
Answer:
Stop the procedure and reoxygenate the client.
Question 10: The nurse is assessing the respiratory status of a
client who has suffered a fractured rib. The nurse should expect to
note which finding?
Answer:
Pain, especially with inspiration
Question 11: A client with a chest injury has suffered flail chest.
The nurse assesses the client for which most distinctive sign of
flail chest?
Answer:
Paradoxical chest movement
Question 12: The nurse is assessing a client with multiple trauma
who is at risk for developing acute respiratory distress syndrome.
, The nurse should assess for which earliest sign of acute
respiratory distress syndrome?
Answer:
Increased respiratory rate
Question 13: The nurse has conducted discharge teaching with a
client diagnosed with tuberculosis who has been receiving
medication for 2 weeks. The nurse determines that the client has
understood the information if the client makes which statement?
Answer:
"I should not be contagious after 2 to 3 weeks of medication therapy."
Question 14: The nurse is assessing the functioning of a chest tube
drainage system in a client who has just returned from the recovery
room following a thoracotomy with wedge resection. Which are the
expected assessment findings? Select all that apply.
Answer:
Drainage system maintained below the client's chest 4. 50 mL of drainage in
the drainage collection chamber 5. Occlusive dressing in place over the chest
tube insertion site 6. Fluctuation of water in the tube in the water seal chamber
during inhalation and exhalation
Question 15: Fluctuation of water in the tube in the water seal
chamber during inhalation and exhalation The nurse is assisting a
health care provider with the removal of a chest tube. The nurse
should instruct the client to take which action?
Answer:
Perform the Valsalva maneuver.
QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: The emergency department nurse is assessing a client
who has sustained a blunt injury to the chest wall. Which finding
indicates the presence of a pneumothorax in this client?
Answer:
Diminished breath sounds
Question 2: The nurse is caring for a client hospitalized with acute
exacerbation of chronic obstructive pulmonary disease. Which
findings would the nurse expect to note on assessment of this
client? Select all that apply.
Answer:
A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen
saturation with mild exercise
Question 3: The nurse instructs a client to use the pursed-lip
method of breathing and evaluates the teaching by asking the
client about the purpose of this type of breathing. The nurse
determines that the client understands if the client states that the
primary purpose of pursed-lip breathing is to promote which
outcome?
Answer:
Promote carbon dioxide elimination.
Question 4: The nurse is preparing a list of home care instructions
for a client who has been hospitalized and treated for tuberculosis.
Which instructions should the nurse include on the list? Select all
,that apply.
Answer:
Activities should be resumed gradually. A sputum culture is needed every 2 to
4 weeks once medication therapy is initiated. 4. Respiratory isolation is not
necessary because family members already have been exposed. 5. Cover the
mouth and nose when coughing or sneezing and put used tissues in plastic
bags.
Question 5: The nurse caring for a client with a pneumothorax and
who has had a chest tube inserted notes continuous gentle
bubbling in the water seal chamber. What action is most
appropriate?
Answer:
Check for an air leak, because the bubbling should be intermittent.
Question 6: The nurse is caring for a client who suffered an
inhalation injury from a wood stove. The carbon monoxide blood
report reveals a level of 12%. Based on this level, the nurse would
anticipate noting which sign in the client?
Answer:
Flushing
Question 7: The nurse is caring for a client after a bronchoscopy
and biopsy. Which finding, if noted in the client, should be reported
immediately to the health care provider?
Answer:
Bronchospasm
,Question 8: The nurse is preparing to suction a client via a
tracheostomy tube. The nurse should plan to limit the suctioning
time to a maximum of which time period?
Answer:
10 seconds The nurse is suctioning a client via an endotracheal tube. During
the suctioning procedure, the nurse notes on the monitor that the heart rate is
decreasing. Which nursing intervention is appropriate?
Question 9: The nurse is suctioning a client via an endotracheal
tube. During the suctioning procedure, the nurse notes on the
monitor that the heart rate is decreasing. Which nursing
intervention is appropriate?
Answer:
Stop the procedure and reoxygenate the client.
Question 10: The nurse is assessing the respiratory status of a
client who has suffered a fractured rib. The nurse should expect to
note which finding?
Answer:
Pain, especially with inspiration
Question 11: A client with a chest injury has suffered flail chest.
The nurse assesses the client for which most distinctive sign of
flail chest?
Answer:
Paradoxical chest movement
Question 12: The nurse is assessing a client with multiple trauma
who is at risk for developing acute respiratory distress syndrome.
, The nurse should assess for which earliest sign of acute
respiratory distress syndrome?
Answer:
Increased respiratory rate
Question 13: The nurse has conducted discharge teaching with a
client diagnosed with tuberculosis who has been receiving
medication for 2 weeks. The nurse determines that the client has
understood the information if the client makes which statement?
Answer:
"I should not be contagious after 2 to 3 weeks of medication therapy."
Question 14: The nurse is assessing the functioning of a chest tube
drainage system in a client who has just returned from the recovery
room following a thoracotomy with wedge resection. Which are the
expected assessment findings? Select all that apply.
Answer:
Drainage system maintained below the client's chest 4. 50 mL of drainage in
the drainage collection chamber 5. Occlusive dressing in place over the chest
tube insertion site 6. Fluctuation of water in the tube in the water seal chamber
during inhalation and exhalation
Question 15: Fluctuation of water in the tube in the water seal
chamber during inhalation and exhalation The nurse is assisting a
health care provider with the removal of a chest tube. The nurse
should instruct the client to take which action?
Answer:
Perform the Valsalva maneuver.
