Saunders Nclex PN test

Saunders Nclex PN test Leave the first rating Students also studied Terms in this set (62) Science MedicineNursing Save NCLEX -Respiratory Disorders !!103 terms school_20166Preview Saunders NCLEX-PN 85 terms gbatiste13Preview respiratory 49 terms cudal_marjPreview NCLEX 34 terms hol The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration.On the basis of this finding, which conclusion should the nurse make?The chest tube is functioning as expected.The nurse is caring for a restless client who keeps biting down on an orotracheal tube. The nurse uses which intervention to prevent the client from obstructing the airway with the teeth?Oral airway The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client?Dyspnea during exertion Presence of a productive cough Difficulty breathing while talking The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse should review the results of which diagnostic test to confirm this diagnosis?Sputum culture he nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next?Notify the registered nurse (RN).

The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when an alarm sounds.Which action should the nurse do first?Check the client.The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene?The student suctions the client's tracheotomy tube for 15 seconds.A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube.Which is the nurse's priority intervention?Check the client for spontaneous breathing.The nurse is assisting in admitting a client who is suspected of having tuberculosis (TB) to the nursing unit.The nurse plans to admit the client to which type of room?Venting to the outside, six air exchanges per hour, and ultraviolet light A client has just returned from intrathoracic surgery where a chest tube was placed. The nurse notes a small amount of serosanguineous drainage on the chest tube's dressing. Which action should the nurse take?Reinforce the dressing.The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement?Check the amount of suction pressure being applied.The nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. Which statement represents the nurse's accurate interpretation of this finding?This finding requires further data collection.The nurse is assisting in preparing a list of instructions for an adult client who is being discharged following a tonsillectomy. Which instructions should the nurse include in the list?Avoid hot fluids.Avoid rough foods.Rest for the next 24 hours.The nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer?Cough The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problems?Hypotension Use of peripheral vasoconstrictors

The nurse is talking with a client who is going to have a radical neck dissection and total laryngectomy. Which client statement indicates a need for further teaching concerning postoperative management?"I will require a lot of pain med after surgery." The nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure?Places the stethoscope on the client's gown The nurse has finished suctioning a client. The nurse should use which parameters to best determine the effectiveness of suctioning?Breath sounds are clear The client is diagnosed with pleurisy. The nurse should expect to see which signs and symptoms?Pleural friction rub Sharp, knife-like pain Pain that occurs most often during inspiration A client has a chest tube that is attached to a chest drainage system. The chest tube becomes disconnected.What should the nurse do immediately?Put open end under sterile water.A client with chronic obstructive pulmonary disease (COPD) on bed rest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, which is the priority client activity for the nurse to incorporate in the plan of care?Instruct the client to reposition himself.A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action?Check the client.A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation?Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out The nurse is caring for the client who is at risk for lung cancer because of an extremely long history of heavy cigarette smoking. The nurse tells the client to report which frequent early symptom of lung cancer?Nonproductive hacking cough A clinic nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. Which intervention should the client be encouraged to perform?Avoid foods that are highly seasoned.The nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Which instructions should the nurse provide to the client?Protect the stoma from water.Soaps should be avoided near the stoma.Wash the stoma daily using a washcloth.Apply a thin layer of petroleum jelly to the skin surrounding the stoma.

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?Stridor The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax?Shortness of breath The nurse is preparing to assist a primary health care provider with the insertion of a chest tube. The nurse anticipates that which supplies will be required for the chest tube insertion site?Elastoplast tape Sterile 4 × 4 gauze pads Povidone-iodine solution Petrolatum (Vaseline) gauze The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis?High-grade fever A client is at risk of developing a pulmonary embolism.The nurse monitors for which initial sign/symptom?Chest pain that occurs suddenly The nurse is preparing a plan of care for the client who will be returning from surgery following a right lung wedge resection. Included in the plan of care is that in the postoperative period, the nurse should avoid which positioning?On the right side The nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub that was auscultated the previous day. How should this finding be interpreted?Pleural fluid has accumulated in the inflamed area.A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which manifestation of histoplasmosis?Dyspnea The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client?The client is breathing through the nose.The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made?Coughing occurs with suctioning.