Respiratory System NCLEX questions

Respiratory System NCLEX questions ScienceMedicineNursing Lorikm Save respiratory 15 terms greg_walker4Preview Med Surg Gastrointestinal NCLEX Q...86 terms Jasmine_Lawson4 Preview Respiratory NCLEX Questions 131 terms rwillia2Preview Respira 43 terms Set The most important action the nurse should do before and after suctioning a client is:

• Placing the client in a supine position
• Making sure that suctioning takes only 10-15 seconds
• Evaluating for clear breath sounds
• Hyperventilating the client with 100% oxygen
• Hyperventilating the client with 100% oxygen

The position of a conscious client during suctioning is:

• Fowler's
• Supine position
• Side-lying
• Prone
• Fowler's

Position a conscious person who has a functional gag reflex in the semi fowler's position with the head turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you.

Presence of overdistended and non-functional alveoli is a condition called:

• Bronchitis
• Emphysema
• Empyema
• Atelectasis

Answer: B.

An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of pus in the lung.

23. The accumulation of fluids in the pleural space is called:

• Pleural effusion
• Hemothorax
• Hydrothorax
• Pyothorax
• Pleural effusion
• Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction

control chamber. What action is appropriate?

• Do nothing, because this is an expected finding.
• Immediately clamp the chest tube and notify the physician.
• Check for an air leak because the bubbling should be intermittent.
• Increase the suction pressure so that bubbling becomes vigorous.

Answer A.Continuous gentle bubbling should be noted in the suction control chamber.Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy).Option C is incorrect. Bubbling should be continuous and not intermittent.Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

• The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing

action is to:

• Call the physician.
• Place the tube in a bottle of sterile water.
• Immediately replace the chest tube system.
• Place the sterile dressing over the disconnection site.

Answer B.If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:

• Call the physician to reinsert the tube.
• Grasp the retention sutures to spread the opening.
• Call the respiratory therapy department to reinsert the tracheotomy.
• Cover the tracheostomy site with a sterile dressing to prevent infection.
• Grasp the retention sutures to spread the opening.

A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

• Stridor
• Occasional pink-tinged sputum
• A few basilar lung crackles on the right
• Respiratory rate of 24 breaths/min

Answer A.The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea.Stridor indicates airway edema and places the client at risk for airway obstruction An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?

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

Answer B.This client has sustained a blunt or a 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.

A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?

• Hypocapnia
• A hyperinflated chest noted on the chest x-ray
• Increase oxygen saturation with exercise
• A widened diaphragm noted on the chest x-ray

Answer B.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.A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that

one of the first symptoms associated with tuberculosis is:

• Dyspnea
• Chest pain
• A bloody, productive cough
• A cough with the expectoration of mucoid sputum

Answer D.One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum.Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not

exceed:

• 1 L/min
• 2 L/min
• 6 L/min
• 10 L/min

Answer B.Oxygen is used cautiously and should not exceed 2 L/min.Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.