Tiêu đề WORKBOOK - RESPI HEMA (KEY) ✅

COMPREHENSIVE PHASE WORKBOOK RESPI HEMA NOVEMBER 2024 Philippine Nurse Licensure Examination Review 1. A client was admitted to the intensive care unit 36 hours ago following extensive pulmonary traumA. Which clinical manifestation would first alert the nurse that the client is experiencing adult respiratory distress syndrome (ARDS)? A. Blood-tinged, frothy sputum B. Dense pulmonary infiltrates with a “whited-out” appearance C. An increase in respiratory rate D. Increasing hypoxemia 2. A client with a history of asthma presents in the physician’s office with complaints of difficulty breathing. While performing the initial assessment, the nurse becomes concerned that the client’s respiratory status has worsened based on which of the following? A. Wheezing throughout the lung fields B. Noticeably diminished breath sounds C. Loud wheezing only on expiration D. Mild wheezing on inspiration 3. A home health nurse is visiting a client with severe chronic obstructive pulmonary disease (COPD) who is complaining of increased shortness of air. The client is on home oxygen at 2 L/min via an oxygen concentrator with a respiratory rate of 23 breaths/min. The most appropriate nursing action is to A. call emergency services to come to the home. B. reassure the client of being unnecessarily anxious. C. conduct further assessment of the client’s respiratory status. D. consider increasing the oxygen to 4 L/min during the home visit. 4. The nurse is admitting a client with suspected tuberculosis (TB) to the acute care unit. The nurse places the client in airborne precautions until a confirmed diagnosis of active TB can be made. Which of the following tests is a priority to confirm the diagnosis? A. Chest x-ray that is positive for lung lesions B. Positive purified protein derivative (PPD) test C. Sputum positive for blood (hemoptysis) D. Sputum culture positive for Mycobacterium tuberculosis 5. A student health nurse is conducting tuberculosis (TB) testing. Students who had the purified protein derivative (PPD) test 48 hours ago have returned to have the results read and documented. The nurse determines that the test is positive if which of the following is present? A. The client complains of itching at the site B. There is a large area of erythema C. There is an induration of 10 mm or greater D. A bruise is present at the site of injection 6. The nurse is aware that the optimal tidal volume for ventilator weaning is what setting? A. 1-2 ml/kg B. 3-5 ml/kg C. 5-8 ml/kg D. 8-10 ml/kg 7. A client with no history of respiratory disease has a sudden onset of dyspnea, chest pain, and tachycardia. A pulmonary embolism is suspected. The nurse anticipates which set of therapeutic orders to be prescribed for this client? Select all that apply: 1. Semi-Fowler’s position 2. Oxygen at 2 L/min 3. High-Fowler’s position 4. Nonsteroidal antiiflammatory 5. Oxygen at 4 L/min 6. Anti-coagulant therapy A. 1, 2, 3 B. 1, 2, 3, 4 C. 2, 3, 6 D. 1, 4, 5, 6 8. A client with pulmonary edema is currently receiving 6 L/min of oxygen per nasal cannulA. The most recent arterial blood gas (ABG) results indicate the following: pH= 7.30, pCO2=50 mm Hg, pO2 = 56 mm Hg, HCO3 = 24 mm Hg. The nurse anticipates that the physician will order which of the following? A. Change nasal cannula to face mask at 6 L/min oxygen B. Add one ampule of sodium bicarbonate to the client’s current intravenous fluids C. Change nasal cannula to partial rebreather mask at 8 L/min oxygen D. Intubate the client and place on mechanical ventilation 9. A registered nurse is planning the schedule for the day. Which of the following nursing tasks may the nurse delegate to a licensed practical nurse? A. Develop instructions for the client on pursed-lip breathing B. Clarify an order with the physician C. Instruct a client on a bronchoscopy D. Administer a purified protein derivative (PPD) to a client 10. The nurses assesses a Mantoux test to be positive when the induration is 10 mm or more when read at what time frame? A. 6-12 hours B. 12-24 hours C. 24-48 hours D. 48-72 hours 11. The nurse has just received orders to provide chest physiotherapy for a client two times per day. The nurse evaluates which schedule to be most therapeutic? A. 7:00 A.m. and 1:00 p.m. B. 6:00 A.m. and 4:00 p.m. C. 9:00 A.m. and 5:00 p.m. D. 8:00 A.m. and 8:00 p.m. 12. The nurse assesses fluctuations in the water seal chamber of a client’s closed chest drainage system. The nurse evaluates this finding as indicating A. the system is functioning properly. B. an air leak is present. C. the tubing is kinked. D. the lung has re-expanded. 13. The nurse assesses a college-age client complaining of shortness of breath after jogging and tightness in his chest. Upon further questioning, the client denies a sore throat, TOP RANK REVIEW ACADEMY, INC. Page 1 | 7
fever, or productive cough. The nurse notifies the physician that this client’s clinical manifestations are most likely related to A. pneumonia. B. bronchitis. C. pneumoconiosis. D. asthma. 14. Which of the following is a priority to include in the instructions given to a client who has bronchitis? A. Avoid cigarette smoking B. Decrease overweight status C. Increase activity D. Avoid malnutrition 15. The nurse is assessing the respiratory status of a client following a thoracentesis. Which finding would indicate further assessment is needed? A. Equal bilateral chest expansion B. Scattered crackles, unchanged from baseline C. Diminished breath sounds on the affected side D. Respiratory rate of 22 breaths/minute 16. The nurse is admitting a client who complains of fever, chills, chest pain, and dyspnea. The client has a heart rate of 110, respiratory rate of 28, and a non-productive hacking cough. A chest x-ray confirms a diagnosis of left lower lobe pneumonia. Upon auscultation of the left lower lobe, the nurse documents which of the following breath sounds? A. Bronchial B. Bronchovesicular C. Vesicular D. Absent breath sounds 17. The nurse is preparing a client with empyema for a thoracentesis. Which of the following should the nurse have available in the event that the procedure is ineffective? A. A ventilator B. A chest tube insertion kit C. An intubation tray D. A crash cart 18. A client is admitted to a burn unit with second and third-degree burns over 18% of the body. An inhalation injury is also suspected. The nurse should monitor which of the following to determine the extent of carbon monoxide poisoning? A. Pulse oximetry B. Urine myoglobin C. Arterial blood gases D. Serum carboxyhemoglobin levels 19. Which of the following should the nurse include when suctioning a client’s tracheostomy? A. Instill sterile saline down the trachea to stimulate a cough, then suction with continuous suctioning B. Insert the catheter until a cough reflex is obtained or until resistance is felt C. Adjust the wall suction to 150 mm Hg for the procedure D. Suction the client’s mouth before entering the trachea 20. The nurse is evaluating the respiratory system of a client who admits to smoking a half pack per day for the last 5 years and 1 pack per day for 10 years prior to that. When evaluating the client’s risk of developing a respiratory disease, the nurse calculates that the client has a smoking history of how many packs over the years? A. 2.5 pack-years B. 10 pack-years C. 12.5 pack-years D. 15 pack-years 21. A client with pneumonia has a poor appetite, is dyspneic and complains of decreased taste sensation, and is receiving chest physiotherapy treatments and breathing treatments. Which of the following actions should the nurse include to improve the client’s appetite? A. Provide mouth care before meals B. Provide juice and fluids at the bedside C. Provide three balanced meals each day D. Increase fluid intake to 3 L a day 22. A client with left-sided heart failure is progressing to pulmonary edema. The nurse assesses the client and reports which of the following manifestations? A. Dry, hacking cough B. Bilateral crackles C. Fever above 36.8°C or 101.5°F D. Peripheral pitting edema 23. The nurse is performing a respiratory assessment of a client with pleurisy and compares the assessment findings with the previous day’s assessment. Currently there is no friction rub, but one was auscultated the previous day. The nurse evaluates this finding as the result of A. the client taking more shallow breaths. B. a decreased inflammatory response. C. the effectiveness of the antibiotics. D. an accumulation of pleural fluid in the inflamed area. 24. The nurse is caring for a client following a cardiac bypass surgery. The nurse notes that in the first hour the chest tube drainage measured 90 ml. During the second hour the drainage dropped to 5 ml. The nurse suspects which of the following? A. The chest tube may be clotted B. The lungs have fully inflated C. The client is recovering normally D. The physician should be notified 25. The nurse should monitor a client admitted with a suspected diagnosis of pulmonary emphysema for which of the following clinical manifestations? Select all that apply: 1. Copious sputum production 2. Bilateral wheezing 3. Marked weight loss 4. Prolonged inspiratory phase 5. Barrel chest appearance 6. Severe dyspnea A. 1, 2, 3, 4 B. 1, 5, 6 C. 2, 3, 4, 6 D. 2, 5, 6 26. The nurse is preparing to delegate which of the following nursing tasks to a licensed practical nurse? A. Administer morphine IV to a client experiencing a pulmonary embolism B. Monitor a client’s chest tube for bubbling C. Assess a client for tactile fremitus D. Perform a sputum culture for a client 27. The nurse is reviewing the normal limits for a head and neck assessment. Which of the following findings would indicate the need for additional investigation? A. A small, discrete, movable lymph node B. The trachea is to the right of the suprasternal notch C. A thyroid gland that is not visible or palpable D. The muscles of the neck are symmetrical 28. The nurse is performing an assessment of the thorax and lungs on a 30-year-old client. Which of the following assessments does the nurse evaluate to be a normal adult finding? A. The thorax is barrel shaped B. The costal margin is greater than 90° C. The accessory muscles are used during inspiration and expiration D. Sternal angles is where the second rib articulates together with the breast bone 29. The nurse correctly documents moist, low-pitched, gurgling breath sounds as A. sonorous wheezes. B. coarse crackles. C. sibilant wheezes. D. pleural friction rub. TOP RANK REVIEW ACADEMY, INC. Page 2 | 7
30. When preparing a client to collect a sputum specimen, it would be essential for the nurse to explain which of the following aspects of the procedure? A. Avoid mouth care prior to collecting the specimen B. Breathe deeply followed by coughing up sputum C. Collect the specimen before bedtime D. Restrict fluids prior to expectorating sputum 31. An emergency department nurse is assessing a 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. A low respiratory rate B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injury 32. A nurse is caring for a 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? A. Hypocapnia B. A hyperinflated chest noted on the chest x-ray C. Increased oxygen saturation with exercise D. A widened diaphragm noted on the chest x-ray 33. A 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: A. Promote oxygen intake. B. Strengthen the diaphragm. C. Strengthen the intercostal muscles. D. Promote carbon dioxide elimination. 34. The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? A. Administers oxygen B. Checks the client’s vital signs C. Ventilates the client manually D. Starts cardiopulmonary resuscitation 35. A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physician? A. Dry cough B. Hematuria C. Bronchospasm D. Blood-streaked sputum 36. A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: A. 1 minute B. 5 seconds C. 10 seconds D. 30 seconds 37. A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? A. Continue to suction. B. Notify the physician immediately. C. Stop the procedure and reoxygenate the client. D. Ensure that the suction is limited to 15 seconds. 38. A nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which of the following? A. Slow deep respirations B. Rapid deep respirations C. Paradoxical respirations D. Pain, especially with inspiration 39. A client with a chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest? A. Cyanosis B. Hypotension C. Paradoxical chest movement D. Dyspnea, especially on exhalation 40. A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A 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: A. Right pneumothorax B. Pulmonary embolism C. Displaced endotracheal tube D. Acute respiratory distress syndrome 41. A nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? A. Bilateral wheezing B. Inspiratory crackles C. Intercostal retractions D. Increased respiratory rate 42. A nurse is assessing a client with chronic airflow limitation and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitation? A. Emphysema B. Bronchial asthma C. Chronic obstructive bronchitis D. Bronchial asthma and bronchitis 43. A nurse has conducted discharge teaching with a client diagnosed with tuberculosis. The client has been taking medication for 11⁄2 weeks. The nurse evaluates that the client has understood the information if the client makes which of the following statements? A. “I need to continue drug therapy for 2 months.” B. “I can’t shop at the mall for the next 6 months.” C. “I can return to work if a sputum culture comes back negative.” D. “I should not be contagious after 2 to 3 weeks of medication therapy.” 44. A nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which of the following items when performing this care? A. Surgical mask and gloves B. Particulate respirator, gown, and gloves C. Particulate respirator and protective eyewear D. Surgical mask, gown, and protective eyewear 45. A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported? A. Hot, flushed feeling B. Sudden chills and fever C. Chest pain that occurs suddenly D. Dyspnea when deep breaths are taken 46. A client who is human immunodeficiency virus– positive has had a Mantoux skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as: A. Positive B. Negative C. Inconclusive D. Indicating the need for repeat testing 47. A client with acquired immunodeficiency syndrome has histoplasmosis. A nurse assesses the client for which of the following signs and symptoms? A. Dyspnea B. Headache C. Weight gain D. Hypothermia TOP RANK REVIEW ACADEMY, INC. Page 3 | 7
48. A nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client reports which of the following early signs of exacerbation? A. Fever B. Fatigue C. Weight loss D. Shortness of breath 49. A nurse is taking the history of a client with silicosis. The nurse assesses whether the client wears which of the following items during periods of exposure to silica particles? A. Mask B. Gown C. Gloves D. Eye protection 50. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? A. Face tent B. Venturi mask C. Aerosol mask D. Tracheostomy collar 51. The nurse is admitting a client suspected of having sickle cell anemiA. The client has a fever of 38.9°C or 102°F, faint yellow-tinged sclera, and is complaining of abdominal pain. Which of the following clinical manifestations further support this diagnosis? Select all that apply: 1. Rapid but regular breathing 2. Pale, dilute urine 3. Skin ulcers on the lower extremities 4. Swollen fingers 5. Pallor 6. Fatigue A. 1, 2, 4, 5, 6 B. 1, 3, 4, 5, 6 C. 2, 3, 5, 6 D. 3, 4, 5, 6 52. The nurse making a care plan for a client with severe thrombocytopenia should include which of the following? A. Careful examination of spinal fluid obtained by lumbar puncture B. A private room with reverse isolation precautions C. A void intramuscular administration of medications D. Careful monitoring of urinary output while titrating the dosage of furosemide (Lasix) 53. A client with lung cancer is admitted with a new diagnosis of acute disseminated intravascular coagulation (DIC). Which of the following actions is a priority? A. Obtain a diet history from the client for the last 3 days B. Assess the client for any indications of internal or external bleeding C. Take the family to the family lounge and discuss home care for a client with DIC D. Call the dialysis unit to determine when the client may be transferred 54. The nurse has instructed a client with a hematological disorder about the functions of the hematologic system. The client indicates a need for further teaching by describing the function of the hematologic system as A. “the coagulation and clotting of blooD.” B. “the exchange of oxygen and carbon dioxide at the alveoli.” C. “the transportation of oxygen and carbon dioxide to cells of the body.” D. “to fight infection.” 55. The nurse is admitting a client with severe shortness of breath. The nurse assesses which of the following clinical manifestations to be present in the client with pernicious anemia? Select all that apply: 1. Oral temperature greater than 38°C or 100.5°F 2. Dark-brown urine 3. Paresthesia 4. White and yellow patches on the tongue 5. Mental confusion 6. Muscle weakness A. 1, 3, 4, 5 B. 1, 3, 6 C. 2, 4, 5, 6 D. 3, 5, 6 56. The nurse is discharging a client with aplastic anemiA. Which of the following statements made by the client would demonstrate the need for additional teaching by the nurse? A. “I’m a little nervous about the side effects of my medicines and will call if I have questions.” B. “I have a lot of sisters and brothers. I hope one of them will match for my bone marrow transplant.” C. “I’m going back to my job in the toddler room at a day care center tomorrow.” D. “Diabetes runs in my family, so we will be checking my glucose levels while I am on the prednisone.” 57. A client with a chronic bleeding duodenal ulcer is admitted to the hospital. What clinical manifestations should the nurse assess for in a client with a 30% blood volume loss? Select all that apply: 1. Postural hypotension 2. Dizziness 3. Tachycardia with activity 4. Swelling 5. Blood pressure below normal at rest 6. Pain A. 1, 2, 3, 6 B. 4, 5, 6 C. 1, 3 D. 2, 4 58. Which of the following should the nurse include in the instructions provided to a client with sickle cell anemia? Select all that apply: 1. Administer pain medications 2. Encourage fluids 3. Treat the presence of infection 4. Avoid informing others of the condition 5. Vigorous exercise is permitted 6. Inform the client that the disorder is not hereditary A. 1, 2, 3 B. 2, 3, 4 C. 4, 5, 6 D. 3, 4, 5, 6 59. The nurse is evaluating a client with an enlarged spleen. Which of the following diagnostic tests would confirm the diagnosis? A. Urinalysis B. CAT scan of the chest C. Blood cultures D. CAT scan of the abdomen 60. The nurse has started a transfusion of packed red blood cells. The nurse should immediately stop the transfusion when which of the following occurs? A. Fever and back pain B. Dry mouth C. Hypothermia and pallor D. Heart rate of 74 beats per minute 61. The nurse is caring for a client with neutropeniA. Which of the following blood tests would indicate to the nurse the desired response to treatment? A. Increased granulocytes B. Decrease in platelet count C. Normal hemoglobin D. Liver functions above normal 62. The nurse is preparing to administer a red blood cell transfusion to a client. The client tells the nurse of being terrified of contracting HIV from the transfusion. Which of the following statements is the most appropriate by the nurse? A. “Don’t worry. I’ve given a lot of transfusions and I’ve never had a client get HIV, yet.” B. “I understand your concerns. The blood supply is not 100% safe. Why don’t you get someone in your family to donate blood for you?” TOP RANK REVIEW ACADEMY, INC. Page 4 | 7