Science Medicine Pulmonology
Respiratory - Saunders NCLEX-PN
Examination 6th Edition
Save
Students also studied
Flashcard sets Study guides Practice tests
Respiratory test I & M I: Pulse Oximetry Respiratory Worksheet 321 oxy
34 terms 152 terms 10 terms 19 terms
Kyleseger2004 Preview IshaPatel1012 Preview a_appleton3 Preview kate
Discourage smoking
Use a room humidifier
Use lozenges that contain a topical anesthetic agents
The nurse is caring for a client with
laryngitis. Which interventions should the (Rationale)
nurse implement? Select all that apply.
Smoking irritates the throat so the client is discouraged from smoking. A humidifier
will prevent a dry nose and throat. Lozenges with a topical anesthetic agent will
decrease throat discomfort. Voice rest means not talking at all, even whispering.
There should be a sign on the intercom indicating voice rest and going to the client's
room.
Negative
The nurse is reading the results of a
Mantoux tuberculin skin test on a client (Rationale)
with no documented health problems. The
site has no induration and a 1-mm area of A positive Mantoux tuberculin skin test reading has an induration measuring 10 mm or
ecchymosis. Which interpretation should more in diameter and indicates exposure to tuberculosis. A small area of ecchymosis
the nurse make of these results? is insignificant and is probably related to injection technique. Therefore, the
remaining options are incorrect.
See an expert-written answer!
, It would not increase the actual suction in the system but would cause more air to be
pulled through the air vent and suction chamber to the suction source.
A client has a chest tube that is attached to Rationale:
a chest drainage system. The client asks the The amount of suction in the chest drainage system is controlled by the amount of
nurse, "Can the tube come out faster if you sterile water that is poured into the suction control chamber. In a dry suction system,
turn the wall suction up higher?" The nurse's this is accomplished by regulating the suction dial on the chest drainage device.
response is based on which fact with Increasing the wall suction will only cause vigorous bubbling in the suction chamber,
regard to turning up the wall suction? as more air is pulled through the air vent and suction control chamber to the suction
source. The only effect this would have is to increase the rate of water evaporation
from the suction control chamber, so sterile water would have to be added to the
system more frequently.
Wheezes
Rationale:
The nurse is listening to the client's breath Wheezes are musical noises heard on inspiration, expiration, or both. They are the
sounds and hears musical whistling noises result of narrowed air passages. Crackles have the sound that is heard when a few
on inspiration and expiration scattered strands of hair are rubbed together near the ear, and indicate fluid in the alveoli.
throughout the right lung fields. How Rhonchi are usually heard on expiration when there is excessive production of
should the nurse interpret these noises? mucus, which accumulates in the air passages. A pleural friction rub is characterized
by sounds that are described as creaking, groaning, or grating in quality. The sounds
are localized over an area of inflammation of the pleura and may be heard in both
the inspiratory and expiratory phases of the respiratory cycle.
Enables the client to speak
The nurse is told that an assigned client will
have a fenestrated tracheostomy tube
Rationale:
inserted. The nurse should provide the
A fenestrated tube has a small opening in the outer cannula that allows some air to
client with which information about this
escape through the larynx; this type of tube enables the client to speak. Options 2, 3,
type of tube?
and 4 are incorrect with regard to this type of tube.
"I will need surgery to drain my sinuses."
Rationale:
The nurse provides instructions to the client regarding measures to promote sinus
Which statement by the client indicates a
drainage, comfort, and resolution of the infection. The nurse instructs the client to
need for further teaching regarding the
apply heat in the form of hot wet packs over the affected sinuses to promote
reinforced home care instructions for acute
comfort and help resolve the infection. Large amounts of fluids are important to help
sinusitis?
liquefy secretions. Sleeping with the head of the bed elevated to a 45-degree angle
will assist in promoting drainage. Surgery may be performed to improve drainage in
chronic conditions if other measures are not helpful, but it is not usually a treatment
measure for acute sinusitis.
See an expert-written answer!
, 50 mL of drainage in the drainage-collection chamber
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation and
exhalation
The nurse is assisting with monitoring the
(Rationale)
functioning of a chest-tube drainage
The bubbling of water in the water-seal chamber indicates air drainage from the
system in a client who just returned from
client. This is usually seen when intrathoracic pressure is greater than atmospheric
the recovery room after a thoracotomy
pressure, and it may occur during exhalation, coughing, or sneezing. Excessive
with wedge resection. Which findings
bubbling in the water-seal chamber may indicate an air leak, which is an unexpected
should the nurse expect to note? Select all
finding. The fluctuation of water in the tube in the water-seal chamber during
that apply.
inhalation and exhalation is expected. An absence of fluctuation may indicate that
the chest tube is obstructed, the lung has re-expanded, or no more air is leaking into
the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-
control chamber. A total of 50 mL of drainage is not excessive in a client returning to
the nursing unit from the recovery room; however, drainage of more than 70 to 100
mL/hr is considered excessive and requires health care provider notification. The
chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air
from entering the pleural space. Positioning the drainage system below the client's
chest allows gravity to drain the pleural space.
A clinic nurse is assisting in caring for a Get plenty of rest.
client whose chief complaint is the
presence of flulike symptoms. Which Take antipyretics for fever.
recommendation by the nurse is
therapeutic? Select all that apply. Increase intake of liquids.
The nurse is caring for a client who is Cough
suspected of having lung cancer. The nurse
monitors the client for which most frequent
early sign of lung cancer?
Cough
A client arrives in the emergency Place the client in high-Fowler's position.
department with an episode of status
asthmaticus. What is the nurse's priority
action?
The nurse instructs a client on pursed-lip The client breathes out slowly through the mouth.
breathing and asks the client to
demonstrate the breathing technique.
Which observation by the nurse indicates
that the client is performing the technique
correctly?
A client had thoracic surgery 2 days ago There is a leak in the system, which requires immediate investigation and correction.
and has a chest tube in place connected to
a closed chest tube system. The nurse
notes continuous bubbling in the water seal
chamber. The nurse determines which?
Respiratory - Saunders NCLEX-PN
Examination 6th Edition
Save
Students also studied
Flashcard sets Study guides Practice tests
Respiratory test I & M I: Pulse Oximetry Respiratory Worksheet 321 oxy
34 terms 152 terms 10 terms 19 terms
Kyleseger2004 Preview IshaPatel1012 Preview a_appleton3 Preview kate
Discourage smoking
Use a room humidifier
Use lozenges that contain a topical anesthetic agents
The nurse is caring for a client with
laryngitis. Which interventions should the (Rationale)
nurse implement? Select all that apply.
Smoking irritates the throat so the client is discouraged from smoking. A humidifier
will prevent a dry nose and throat. Lozenges with a topical anesthetic agent will
decrease throat discomfort. Voice rest means not talking at all, even whispering.
There should be a sign on the intercom indicating voice rest and going to the client's
room.
Negative
The nurse is reading the results of a
Mantoux tuberculin skin test on a client (Rationale)
with no documented health problems. The
site has no induration and a 1-mm area of A positive Mantoux tuberculin skin test reading has an induration measuring 10 mm or
ecchymosis. Which interpretation should more in diameter and indicates exposure to tuberculosis. A small area of ecchymosis
the nurse make of these results? is insignificant and is probably related to injection technique. Therefore, the
remaining options are incorrect.
See an expert-written answer!
, It would not increase the actual suction in the system but would cause more air to be
pulled through the air vent and suction chamber to the suction source.
A client has a chest tube that is attached to Rationale:
a chest drainage system. The client asks the The amount of suction in the chest drainage system is controlled by the amount of
nurse, "Can the tube come out faster if you sterile water that is poured into the suction control chamber. In a dry suction system,
turn the wall suction up higher?" The nurse's this is accomplished by regulating the suction dial on the chest drainage device.
response is based on which fact with Increasing the wall suction will only cause vigorous bubbling in the suction chamber,
regard to turning up the wall suction? as more air is pulled through the air vent and suction control chamber to the suction
source. The only effect this would have is to increase the rate of water evaporation
from the suction control chamber, so sterile water would have to be added to the
system more frequently.
Wheezes
Rationale:
The nurse is listening to the client's breath Wheezes are musical noises heard on inspiration, expiration, or both. They are the
sounds and hears musical whistling noises result of narrowed air passages. Crackles have the sound that is heard when a few
on inspiration and expiration scattered strands of hair are rubbed together near the ear, and indicate fluid in the alveoli.
throughout the right lung fields. How Rhonchi are usually heard on expiration when there is excessive production of
should the nurse interpret these noises? mucus, which accumulates in the air passages. A pleural friction rub is characterized
by sounds that are described as creaking, groaning, or grating in quality. The sounds
are localized over an area of inflammation of the pleura and may be heard in both
the inspiratory and expiratory phases of the respiratory cycle.
Enables the client to speak
The nurse is told that an assigned client will
have a fenestrated tracheostomy tube
Rationale:
inserted. The nurse should provide the
A fenestrated tube has a small opening in the outer cannula that allows some air to
client with which information about this
escape through the larynx; this type of tube enables the client to speak. Options 2, 3,
type of tube?
and 4 are incorrect with regard to this type of tube.
"I will need surgery to drain my sinuses."
Rationale:
The nurse provides instructions to the client regarding measures to promote sinus
Which statement by the client indicates a
drainage, comfort, and resolution of the infection. The nurse instructs the client to
need for further teaching regarding the
apply heat in the form of hot wet packs over the affected sinuses to promote
reinforced home care instructions for acute
comfort and help resolve the infection. Large amounts of fluids are important to help
sinusitis?
liquefy secretions. Sleeping with the head of the bed elevated to a 45-degree angle
will assist in promoting drainage. Surgery may be performed to improve drainage in
chronic conditions if other measures are not helpful, but it is not usually a treatment
measure for acute sinusitis.
See an expert-written answer!
, 50 mL of drainage in the drainage-collection chamber
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation and
exhalation
The nurse is assisting with monitoring the
(Rationale)
functioning of a chest-tube drainage
The bubbling of water in the water-seal chamber indicates air drainage from the
system in a client who just returned from
client. This is usually seen when intrathoracic pressure is greater than atmospheric
the recovery room after a thoracotomy
pressure, and it may occur during exhalation, coughing, or sneezing. Excessive
with wedge resection. Which findings
bubbling in the water-seal chamber may indicate an air leak, which is an unexpected
should the nurse expect to note? Select all
finding. The fluctuation of water in the tube in the water-seal chamber during
that apply.
inhalation and exhalation is expected. An absence of fluctuation may indicate that
the chest tube is obstructed, the lung has re-expanded, or no more air is leaking into
the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-
control chamber. A total of 50 mL of drainage is not excessive in a client returning to
the nursing unit from the recovery room; however, drainage of more than 70 to 100
mL/hr is considered excessive and requires health care provider notification. The
chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air
from entering the pleural space. Positioning the drainage system below the client's
chest allows gravity to drain the pleural space.
A clinic nurse is assisting in caring for a Get plenty of rest.
client whose chief complaint is the
presence of flulike symptoms. Which Take antipyretics for fever.
recommendation by the nurse is
therapeutic? Select all that apply. Increase intake of liquids.
The nurse is caring for a client who is Cough
suspected of having lung cancer. The nurse
monitors the client for which most frequent
early sign of lung cancer?
Cough
A client arrives in the emergency Place the client in high-Fowler's position.
department with an episode of status
asthmaticus. What is the nurse's priority
action?
The nurse instructs a client on pursed-lip The client breathes out slowly through the mouth.
breathing and asks the client to
demonstrate the breathing technique.
Which observation by the nurse indicates
that the client is performing the technique
correctly?
A client had thoracic surgery 2 days ago There is a leak in the system, which requires immediate investigation and correction.
and has a chest tube in place connected to
a closed chest tube system. The nurse
notes continuous bubbling in the water seal
chamber. The nurse determines which?
