問題一覧
1
Which purpose will percussion have for a client with respiratory difficulties?
Percussion loosens pulmonary secretions.
2
A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained thick secretions. Which action by the nurse will decrease secretions in a client with bronchial pneumonia who is having difficulty maintaining airway clearance because of thick secretions?
Increase fluid intake to at least 2 L per day.
3
Which term best describes breath sounds that are high-pitched and creaking on expiration?
Wheezes
4
Which action should the nurse choose to implement if thrombophlebitis is suspected in a postoperative client complaining of calf pain?
Maintain bed rest and notify the primary health care provider.
5
Which factor is causing severe dyspnea in a client with a diagnosis of cancer of the lung?
Bronchial obstruction or pleural effusion
6
Which is the primary cause of otitis media in young children?
An obstructed eustachian tube
7
Which intervention would the nurse implement after assessing a client with Guillain-Barré syndrome and noting several recent changes including a respiratory rate of 32 breaths per minute, abnormal chest movement, and decreasing vital capacity?
Prepare the client for mechanical ventilation.
8
Which describes how coarse rhonchi sound in a client with chronic obstructive pulmonary disease (COPD)?
Moist rumbling sounds that clear after coughing
9
Which sign or symptom would the nurse assess in a client with a diagnosis of pulmonary edema? Select all that apply.
Crackles, Coughing, Orthopnea
10
Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis?
Saline irrigation
11
In clients who all have low oxygen saturation levels, which client will benefit the most from receiving oxygen via a nasal cannula?
The client with an increase in visitors while sitting in a chair
12
Which client has the highest risk for developing a pulmonary embolism?
Obese client with leg trauma
13
A school-age child with cystic fibrosis has recurrent episodes of bronchitis, and the parents ask the nurse why this happens. Which reason would the nurse include in the reply?
"Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria."
14
Which intervention would the nurse question when observing a student nurse caring for an unconscious client with increasing intracranial pressure?
Suctioning the oropharynx routinely
15
Which symptom would be expected in a client experiencing anaphylactic shock after multiple bee stings?
Bronchial constriction and decreased peripheral resistance
16
Which action made by the client discharged home on oxygen via nasal cannula requires further teaching regarding safety?
Applies petroleum to dried areas under cannula
17
The nurse is providing immediate postoperative care to a client who had a thyroidectomy. Which manifestation specific to thyroidectomy would the nurse monitor for in this client?
Signs of respiratory obstruction
18
Which would be the cause of dyspnea in a client with hypertension?
Left heart failure
19
Which preoperative teaching is most important for the nurse to include when completing laryngectomy education?
Establishing a means for communicating postoperatively
20
Which would the nurse look for when monitoring for hemorrhage after a rhinoplasty?
Excessive swallowing
21
Which teaching would a nurse provide to visitors of a client prescribed transmission-based airborne precautions with positive sputum smears for acid-fast bacilli (AFB)?
Wear a particulate respirator mask
22
Which complication would the nurse monitor for in a client with chronic asthma?
Atelectasis
23
Where would the nurse place the stethoscope to determine the presence of a pleural friction rub?
d
24
Which action will the nurse take when noticing a client with chest trauma begins to experience dyspnea, tachycardia, restlessness, anxiety, decreased movement of the chest wall. and absent breath sounds on the affected side?
Prepare for insertion of a chest tube.
25
A nurse teaches a 13-year-old child with seasonal allergies that the prescribed phenylephrine nasal spray must be used exactly as directed. Which complication may occur if the nasal spray is used incorrectly?
Increased nasal congestion
26
Which assessment finding would the nurse assess for that could suggest a pulmonary embolus? Select all that apply.
Dyspnea, Hemoptysis, Feeling of impending doom
27
Which scenario would the nurse consider as the data collection component of the nursing process? Select all that apply.
"The nurse checks the client's health history for allergy to iodine before inserting a urinary catheter.", "The nurse checks if the client has a history of substance abuse before administering nasal medications.", "The nurse checks the medical records of the client to know if the client has had a rectal surgery in the past year before placing an internal fecal catheter."
28
Which is the nursing action for a client with a chest injury? Select all that apply.
Palpating for bony crepitus, Assessing for external signs of injury, Observing the rate, depth, and effort of breathing
29
After multiple upper respiratory infections, a school-age child undergoes a tonsillectomy and adenoidectomy. Two weeks after surgery, the nurse assesses the child's condition. On which would the nurse focus? Select all that apply.
Taste, Smell, Hearing, Breathing
30
Which reason could cause a client to have epistaxis? Select all that apply.
tumors , trauma , allergies , hypertension , Overuse of decongestant nasal sprays, foreign bodies
31
Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing?
Eustachian tubes
32
Which action would the nurse complete when caring for a client with severe dyspnea receiving oxygen through a Venturi mask?
Monitor oxygen saturation levels when eating.
33
Which health care provider's prescription would the nurse question while caring for a client suffering from chronic obstructive pulmonary disease (COPD)?
O 2 per nasal cannula at 7 L/min
34
A child is hospitalized with an exacerbation of chronic bronchitis. Which action would a nurse take to decrease retained secretions?
Increase the daily fluid intake.
35
Which complications are most commonly associated with chronic obstructive pulmonary disease (COPD)?
Cardiac problems
36
Which addictive drug may cause stuffy nose, bronchitis and asthma, lung cancer, decreased testosterone and sperm count, and diminished immune function in chronic users?
Cannabis
37
A nurse is providing postprocedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, which nursing intervention is the priority?
Monitor the vital signs every 15 minutes
38
Which finding indicates a need for more staff education about oxygen therapy through a nasal cannula?
Oxygen flow rate is set to 8 L per minute.
39
At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. Which is the nurse's initial action?
Suctioning the mouth
40
Which suggestion would the nurse provide to help the client with obstructive airway disease to successfully manage coughing spasms?
Postpone the planned vacation to go snow skiing.
41
A client is prescribed prolonged bed rest after surgery. Which complication would the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space?
Pulmonary embolism
42
Which condition is the nurse attempting to prevent when encouraging a surgical client to turn from side to side and complete deep-breathing exercises?
Respiratory acidosis
43
Which term would the nurse use for soft, crackling, bubbling breath sounds more obvious on inspiration?
crackles
44
Which data will the nurse collect first on a client involved in a car crash who exhibits frequent swallowing?
inspect the back of the throat for bleeding.
45
Which statement indicates additional teaching is need in a client who recently was diagnosed with emphysema?
"Complete bed rest is necessary."
46
Which complication is the nurse trying to prevent by encouraging a client to turn side to side and complete deep-breathing exercises after abdominal surgery?
Respiratory acidosis
47
Which nursing intervention will be beneficial for the client with a respiratory disorder complaining of fatigue?
Encouraging adequate periods of rest
48
Which action will the nurse take when a cient who has blunt trauma to the nose is noted to have nasal swelling, ecchymosis around the eyes, and watery pink-tinged nasal drainage?
Send a specimen of the fluid to the laboratory for analysis.
49
Which sign would the nurse expect to observe in a client with an inhalation injury in addition to a burn injury? Select all that apply.One, some, or all responses may be correct.
Cough, Facial burns, Restlessness, Black soot around mouth and nose, Elevated carboxyhemoglobin levels
50
Which substance has potential to cause a pulmonary embolus? Select all that apply.
fat, air , tumor, blood clot , amniotic fluid , clump of bacteria