NCLEX Q A Respiratory

P a g e | 1 NCLEX Q A Respiratory 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.

• Excessive bubbling in the water seal chamber
• Vigorous bubbling in the suction control chamber
• Drainage system maintained below the client's chest
• 50 mL of drainage in the drainage collection chamber
• Occlusive dressing in place over the chest tube insertion site
• 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?

• Stay very still.
• Exhale very quickly.
• Inhale and exhale quickly.
• Perform the Valsalva maneuver.

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?

• Do nothing, because this is an expected finding.
• Check for an air leak, because the bubbling should be intermittent.
• Increase the suction pressure so that the bubbling becomes vigorous.
• Clamp the chest tube and notify the health care provider immediately.

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?

• Coma
• Flushing
• Dizziness
• Tachycardia

Rationale:

Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.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?

P a g e | 2

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

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 findings would the nurse expect to note on assessment of this client? Select all that apply.

• A low arterial PCo2 level
• 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

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?

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

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 1 sputum culture is negative, the client is no longer considered infectious and

usually can return to former employment.

P a g e | 3 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

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 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?

• 5 seconds
• 10 seconds
• 30 seconds
• 60 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?

• 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.

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

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

P a g e | 4 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

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?

• "I need to continue medication therapy for 1 month."
• "I can't shop at the mall for the next 6 months."
• "I can return to work if a sputum culture comes back negative."
• "I should not be contagious after 2 to 3 weeks of medication therapy."

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?

• Hot, flushed feeling
• Sudden chills and fever
• Chest pain that occurs suddenly
• Dyspnea when deep breaths are taken

A client who is human immunodeficiency virus (HIV)–positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

• Positive
• Negative
• Inconclusive
• Need for repeat testing

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?

• Dyspnea
• Headache
• Weight gain
• Hypothermia

Rationale:

Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.