Tiêu đề WORKBOOK - RESPI HEMA (KEY) ✅

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