Tiêu đề WORKBOOK - RESPI HEMA (KEY) ✅

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