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1. A nurse is developing a teaching plan for a client about preventing acute
asthma attacks. Which of the following points should the nurse plan to discuss
first?: The client's perception of the disease process and what might have triggered
past attacks
The nurse should apply the nursing process priority-setting framework. The nurse
can use the nursing process to plan client care and prioritize nursing actions. Each
step of the nursing process builds on the previous step, beginning with assessment.
Before the nurse can formulate a plan of action, implement a nursing intervention,
or notify a provider of a change in the client's status, the nurse must first collect
adequate data from the client. Assessing the client will provide the nurse with
knowledge to make an appropriate decision. Therefore, the first step the nurse
should take is to assess the client's current knowledge.
2. A client is admitted to the emergency department following a motorcycle
crash. The nurse notes a crackling sensation upon palpation on the right side
of the client's chest. After notifying the provider, the nurse should document
this finding as which of the following?: Crepitus
Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation
that the nurse can feel when palpating the skin surface over the client's chest.
Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical
manifestation of a pneumothorax.
note:
-Crackles, which are sometimes called rales, are wet, popping sounds the nurse can
hear when auscultating the client's lungs.
3. A nurse is providing teaching to a client about pulmonary function tests.
Which of the following tests measures the volume of air the lungs can hold at
the end of maximum inhalation?: Total lung capacity
Pulmonary function tests are used to examine the effectiveness of the lungs and
identify lung problems. Total lung capacity measures the amount of air the lungs can
hold after maximum inhalation.
4. A nurse is caring for an older adult client who has chronic obstructive
pulmonary disease with pneumonia. The nurse should monitor the client for
which of the following acid-base imbalances?: Respiratory acidosis
Respiratory acidosis is a common complication of COPD. This complication occurs
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because clients who have COPD are unable to exhale carbon dioxide due to a loss
of elastic recoil in the lungs.
5. A nurse is caring for a client who has a tracheostomy with an inflated cuff in
place. Which of the following findings indicates that the nurse should suction
the client's airway secretions?: The nurse auscultates coarse crackles in the lung
fields.
The nurse should auscultate coarse crackles or rhonchi, identify a moist cough,
hear or see secretions in the tracheostomy tube, and then suction the client's airway
secretions.
6. A nurse in a provider's office is assessing a client who states he was
recently exposed to tuberculosis. Which of the following findings is a clinical
manifestation of pulmonary tuberculosis?: Night sweats
Night sweats and fevers are clinical manifestations of tuberculosis.
7. A nurse in the emergency department is assessing a client for a closed
pneumothorax and significant bruising of the left chest following a motor-ve-
hicle crash. The client reports severe left chest pain on inspiration. The nurse
should assess the client for which of the following manifestations of pneu-
mothorax?: Absence of breath sounds
A client who has pneumothorax experiences severely diminished or absent breath
sounds on the affected side.
8. A nurse in an urgent care clinical is collecting data from a client who reports
exposure to anthrax. Which of the following findings is an indication of the
prodromal stage of inhalation anthrax?: Dry cough
A dry cough is a clinical manifestation found in the prodromal stage of having
inhalation anthrax. During this stage, it is difficult to distinguish from influenza or
pneumonia because there is no sore throat or rhinitis.
9. A nurse is teaching about daily chest physiotherapy with a client who has
cystic fibrosis. The nurse should instruct the client that which of the following
is the purpose of the treatments?: To mobilize secretions in the airways
The purpose of chest physiotherapy is to loosen the client's secretions and promote
drainage of secretions from the lungs. Chest physiotherapy includes percussion,
vibration, and promotion of drainage by gravity.
10. A nurse on a medical unit is caring for a client who aspirated gastric
contents prior to admission. The nurse administers 100% oxygen by nonre-
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