2220 exam 2 with correct answers |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A nurse assesses a client's respiratory status. Which information is of highest priority for the
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nurse to obtain? |||\\\ |||\\\
a. Average daily fluid intake
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b. Neck circumference
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c. Height and weight
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d. Occupation and hobbies - correct answer✔✔ANS: D
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Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a client's occupation and hobbies. Although it will be important for the nurse to assess the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
client's fluid intake, height, and weight, these will not be as important as determining his
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
occupation and hobbies. Determining the client's neck circumference will not be an important |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
part of a respiratory assessment.
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A nurse is caring for an older adult client who has a pulmonary infection. Which action should
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the nurse take first?
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a. Encourage the client to increase fluid intake.
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b. Assess the client's level of consciousness.
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c. Raise the head of the bed to at least 45 degrees.
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d. Provide the client with humidified oxygen. - correct answer✔✔ANS: B
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Assessing the client's level of consciousness will be most important because it will show how
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the client is responding to the presence of the infection. Although it will be important for the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the bed; increase oral fluid intake; and humidify the oxygen administered, none of these
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
actions will be as important as assessing the level of consciousness. Also, the client who has a
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pulmonary infection may not be able to cough effectively if an area of abscess is present. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
correctly matched to the nurse's primary intervention? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,a. Hollow sounds are heard over the trachea. - The nurse increases the oxygen flowrate.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
b. Crackles are heard in bases. - The nurse encourages the client to cough forcefully.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. Wheezes are heard in central areas. - The nurse administers an inhaledbronchodilator.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
d. Vesicular sounds are heard over the periphery. - The nurse has the client breathe deeply -
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
correct answer✔✔ANS: C |||\\\ |||\\\ |||\\\
Wheezes are indicative of narrowed airways, and bronchodilators help to open the air |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
process, and coughing forcefully will not help the client expectorate secretions. Vesicular
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sounds heard in the periphery are normal and require no intervention.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral
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chest diameter. Which question should the nurse ask the client in response to this finding?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. "Are you taking any medications or herbal supplements?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
b. "Do you have any chronic breathing problems?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. "How often do you perform aerobic exercise?"
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d. "What is your occupation and what are your hobbies?" - correct answer✔✔ANS: B
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The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
be seen in people who have lived at a high altitude for many years. Therefore, an AP chest
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diameter that is the same as the lateral chest diameter should be rechecked but is not as |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Although occupation and hobbies may expose a client to irritants that can cause chronic lung
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
disorders and barrel chest, asking about chronic breathing problems is more direct and should
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
be asked first. |||\\\ |||\\\
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
water. Which action should the nurse take next? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Call the physician and request a prescription for food and water.
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,b. Provide the client with ice chips instead of a drink of water.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. Assess the client's gag reflex before giving any food or water.
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d. Let the client have a small sip to see whether he or she can swallow. - correct
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answer✔✔ANS: C |||\\\
The topical anesthetic used during the procedure will have affected the client's gag reflex.
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Before allowing the client anything to eat or drink, the nurse must check for the return of this
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reflex.
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy.
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The client presents with continuous cyanosis even with oxygen therapy. Which action should
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the nurse take next? |||\\\ |||\\\ |||\\\
a. Administer an albuterol treatment.
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b. Notify the Rapid Response Team.
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c. Assess the client's peripheral pulses.
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d. Obtain blood and sputum cultures. - correct answer✔✔ANS: B
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Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is
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an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and
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cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing
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care. An albuterol treatment would not address the client's oxygenation problem. Assessment
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
of pulses and cultures will not provide data necessary to treat this client.
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A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
should the nurse take first? |||\\\ |||\\\ |||\\\ |||\\\
a. Document the findings.
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b. Administer oxygen therapy.
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c. Position the client in high-Fowler's position.
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d. Administer prescribed albuterol. - correct answer✔✔ANS: A
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Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal
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finding over the trachea and larynx. The nurse should document this finding. There is no need
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
, to implement oxygen therapy, administer albuterol, or change the client's position because the
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finding is normal. |||\\\ |||\\\
A nurse plans care for a client who is at high risk for a pulmonary infection. Which
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interventions should the nurse include in this client's plan of care? (Select all that apply.) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Encourage deep breathing and coughing.
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b. Implement an air mattress overlay.
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c. Ambulate the client three times each day.
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d. Provide a diet high in protein and vitamins.
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e. Administer acetaminophen (Tylenol) twice daily. - correct answer✔✔ANS: A, C, D
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Regular pulmonary hygiene and activities to maintain health and fitness help to maximize
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functioning of the respiratory system and prevent infection. A client at high risk for a |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pulmonary infection may need a specialty bed to help with postural drainage or percussion; |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol
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would not decrease the risk of a pulmonary infection.
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A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs)
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for a client. Which statements should the nurse include in communications with the respiratory
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
therapist prior to the tests? (Select all that apply.)
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a. "I held the client's morning bronchodilator medication."
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b. "The client is ready to go down to radiology for this examination."
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c. "Physical therapy states the client can run on a treadmill."
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d. "I advised the client not to smoke for 6 hours prior to the test."
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e. "The client is alert and can follow your commands." - correct answer✔✔ANS: A, D, E
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
to the test, and the client can follow basic commands, including different breathing maneuvers.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Which statements about shock are true? SATA |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A nurse assesses a client's respiratory status. Which information is of highest priority for the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
nurse to obtain? |||\\\ |||\\\
a. Average daily fluid intake
|||\\\ |||\\\ |||\\\ |||\\\
b. Neck circumference
|||\\\ |||\\\
c. Height and weight
|||\\\ |||\\\ |||\\\
d. Occupation and hobbies - correct answer✔✔ANS: D
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a client's occupation and hobbies. Although it will be important for the nurse to assess the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
client's fluid intake, height, and weight, these will not be as important as determining his
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
occupation and hobbies. Determining the client's neck circumference will not be an important |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
part of a respiratory assessment.
|||\\\ |||\\\ |||\\\ |||\\\
A nurse is caring for an older adult client who has a pulmonary infection. Which action should
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the nurse take first?
|||\\\ |||\\\ |||\\\
a. Encourage the client to increase fluid intake.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
b. Assess the client's level of consciousness.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. Raise the head of the bed to at least 45 degrees.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
d. Provide the client with humidified oxygen. - correct answer✔✔ANS: B
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Assessing the client's level of consciousness will be most important because it will show how
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the client is responding to the presence of the infection. Although it will be important for the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the bed; increase oral fluid intake; and humidify the oxygen administered, none of these
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
actions will be as important as assessing the level of consciousness. Also, the client who has a
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pulmonary infection may not be able to cough effectively if an area of abscess is present. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
correctly matched to the nurse's primary intervention? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,a. Hollow sounds are heard over the trachea. - The nurse increases the oxygen flowrate.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
b. Crackles are heard in bases. - The nurse encourages the client to cough forcefully.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. Wheezes are heard in central areas. - The nurse administers an inhaledbronchodilator.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
d. Vesicular sounds are heard over the periphery. - The nurse has the client breathe deeply -
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
correct answer✔✔ANS: C |||\\\ |||\\\ |||\\\
Wheezes are indicative of narrowed airways, and bronchodilators help to open the air |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
process, and coughing forcefully will not help the client expectorate secretions. Vesicular
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sounds heard in the periphery are normal and require no intervention.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
chest diameter. Which question should the nurse ask the client in response to this finding?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. "Are you taking any medications or herbal supplements?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
b. "Do you have any chronic breathing problems?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
c. "How often do you perform aerobic exercise?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
d. "What is your occupation and what are your hobbies?" - correct answer✔✔ANS: B
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest.
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Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation
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problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also
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be seen in people who have lived at a high altitude for many years. Therefore, an AP chest
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diameter that is the same as the lateral chest diameter should be rechecked but is not as |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Although occupation and hobbies may expose a client to irritants that can cause chronic lung
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disorders and barrel chest, asking about chronic breathing problems is more direct and should
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be asked first. |||\\\ |||\\\
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of
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water. Which action should the nurse take next? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Call the physician and request a prescription for food and water.
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,b. Provide the client with ice chips instead of a drink of water.
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c. Assess the client's gag reflex before giving any food or water.
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d. Let the client have a small sip to see whether he or she can swallow. - correct
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answer✔✔ANS: C |||\\\
The topical anesthetic used during the procedure will have affected the client's gag reflex.
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Before allowing the client anything to eat or drink, the nurse must check for the return of this
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reflex.
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy.
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The client presents with continuous cyanosis even with oxygen therapy. Which action should
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the nurse take next? |||\\\ |||\\\ |||\\\
a. Administer an albuterol treatment.
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b. Notify the Rapid Response Team.
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c. Assess the client's peripheral pulses.
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d. Obtain blood and sputum cultures. - correct answer✔✔ANS: B
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Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is
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an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and
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cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing
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care. An albuterol treatment would not address the client's oxygenation problem. Assessment
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of pulses and cultures will not provide data necessary to treat this client.
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A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action
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should the nurse take first? |||\\\ |||\\\ |||\\\ |||\\\
a. Document the findings.
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b. Administer oxygen therapy.
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c. Position the client in high-Fowler's position.
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d. Administer prescribed albuterol. - correct answer✔✔ANS: A
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Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal
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finding over the trachea and larynx. The nurse should document this finding. There is no need
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, to implement oxygen therapy, administer albuterol, or change the client's position because the
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finding is normal. |||\\\ |||\\\
A nurse plans care for a client who is at high risk for a pulmonary infection. Which
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interventions should the nurse include in this client's plan of care? (Select all that apply.) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
a. Encourage deep breathing and coughing.
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b. Implement an air mattress overlay.
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c. Ambulate the client three times each day.
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d. Provide a diet high in protein and vitamins.
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e. Administer acetaminophen (Tylenol) twice daily. - correct answer✔✔ANS: A, C, D
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Regular pulmonary hygiene and activities to maintain health and fitness help to maximize
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functioning of the respiratory system and prevent infection. A client at high risk for a |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pulmonary infection may need a specialty bed to help with postural drainage or percussion; |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol
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would not decrease the risk of a pulmonary infection.
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A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs)
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for a client. Which statements should the nurse include in communications with the respiratory
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therapist prior to the tests? (Select all that apply.)
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a. "I held the client's morning bronchodilator medication."
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b. "The client is ready to go down to radiology for this examination."
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c. "Physical therapy states the client can run on a treadmill."
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d. "I advised the client not to smoke for 6 hours prior to the test."
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e. "The client is alert and can follow your commands." - correct answer✔✔ANS: A, D, E
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To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have
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been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior
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to the test, and the client can follow basic commands, including different breathing maneuvers.
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The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.
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Which statements about shock are true? SATA |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
