NCLEX Practice Questions Saunders - Respiratory System

NCLEX Practice Questions Saunders - Respiratory System ScienceMedicinePulmonology erikakelsh Save Respiratory Disorders NCLEX questi...43 terms SetfiretoitPreview Respiratory NCLEX Questions 31 terms conzy2Preview Respiratory NCLEX Questions 131 terms rwillia2Preview Saunde 21 terms And The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client?

• A low respiratory rate
• Diminished breath sounds
• The presence of a barrel chest
• A sucking sound at the site of injury
• Diminished breath sounds

Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply.

• Hypocapnia
• A hyperinflated chest noted on the chest x-ray
• Decreased oxygen saturation with mild exercise
• A widened diaphragm noted on the chest x-ray
• Pulmonary function tests that demonstrate increased vital capacity
• A hyperinflated chest noted on the chest x-ray
• Decreased oxygen saturation with mild exercise

Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing.The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome?

• Promote oxygen intake
• Strengthen the diaphragm
• Strengthen the intercostal muscles
• Promote carbon dioxide elimination
• Promote carbon dioxide elimination

Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.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.

• Activities should be resumed gradually.
• Avoid contact with other individuals, except family members, for at least 6 months.
• A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
• Respiratory isolation is not necessary because family members already have been exposed.
• Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.
• When one sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.
• Activities should be resumed gradually.
• A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
• Respiratory isolation is not necessary because family members already have been exposed.
• Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand.Advise the client of the side effects of the medication and ways of minimizing them to ensure compliance. Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Inform the client that activities should be resumed gradually and about the need for adequate nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. Inform the client and family that respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing and to cover the mouth and nose when coughing or sneezing and to put used tissues into plastic bags. Inform the client that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.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?

• Dry cough
• Hematuria
• Bronchospasm
• Blood-streaked sputum
• Bronchospasm

Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs/symptoms of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

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?

• 1 minute
• 5 seconds
• 10 seconds
• 30 seconds
• 10 seconds

Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 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 most appropriate?

• Continue to suction.
• Notify the health care provider immediately.
• Stop the procedure and reoxygenate the client.
• Ensure that the suction is limited to 15 seconds.
• Stop the procedure and reoxygenate the client.

Rationale: During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

• Slow deep respirations
• Rapid deep respirations
• Paradoxical respirations
• Pain, especially with inspiration
• Pain, especially with inspiration

Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

• Cyanosis
• Hypotension
• Paradoxical chest movement
• Dyspnea, especially on exhalation
• Paradoxical chest movement

Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward.This is a characteristic sign of flail chest.A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?

• Right pneumothorax
• Pulmonary embolism
• Displaced endotracheal tube
• Acute respiratory distress syndrome
• Right pneumothorax

Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.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?

• Bilateral wheezing
• Inspiratory crackles
• Intercostal retractions
• Increased respiratory rate
• Increased respiratory rate

Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.