Question 1

The nurse is providing care to a client with a diagnosis of asthma.Which nursing interventions will help to maintain normal respirations for this client?

Accepted Answer

A) Positioning the client for maximum lung expansion 
B) Providing frequent position changes 
C) Encouraging ambulation 
D) Monitoring pulse oximetry 
E) Assessing breath sounds 
A) Positioning the client for maximum lung expansion 
B) Providing frequent position changes 
C) Encouraging ambulation 
D) Monitoring pulse oximetry 
E) Assessing breath sounds A,B,C

Question 2

Which is not a teaching point that the nurse would include when instructing a client to perform breathing exercises?

Accepted Answer

A) Breathing in deeply through the nose with the mouth closed 
B) Avoiding arching the back 
C) Holding the breath for 30-40 seconds 
D) Breathing out slowly 
A) Breathing in deeply through the nose with the mouth closed 
B) Avoiding arching the back 
C) Holding the breath for 30-40 seconds 
D) Breathing out slowly C

Question 3

The nurse is caring for a client who had major abdominal surgery yesterday.Which assessment finding would indicate inadequate airway clearance that might be cleared with coughing and deep breathing?

Accepted Answer

A) Tachypnea with rales heard in the upper lobes and over the trachea 
B) Bradypnea with wheezing heard throughout all lung fields 
C) Tachypnea with wheezing heard throughout all lung fields 
D) Tachypnea with rhonchi heard in the lower lobes 
A) Tachypnea with rales heard in the upper lobes and over the trachea 
B) Bradypnea with wheezing heard throughout all lung fields 
C) Tachypnea with wheezing heard throughout all lung fields 
D) Tachypnea with rhonchi heard in the lower lobes A

Question 4

While reviewing the client's medical record,the nurse learns the client has atelectasis.Which statement indicates an appropriate understanding of this term?

Accepted Answer

A) "The lung has partially collapsed." 
B) "A lobe of the lung has collapsed." 
C) "Air sacs within the lung have collapsed." 
D) "A complete collapse of the lung has occurred." 
A) "The lung has partially collapsed." 
B) "A lobe of the lung has collapsed." 
C) "Air sacs within the lung have collapsed." 
D) "A complete collapse of the lung has occurred."

Question 5

Which activity could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

A) Answering the client's questions about proper procedure when performing breathing exercises 
B) Assisting the client to sit upright in order to perform breathing exercises 
C) Evaluating the effectiveness of breathing exercises 
D) Evaluating the client's technique when using an incentive spirometer 
A) Answering the client's questions about proper procedure when performing breathing exercises 
B) Assisting the client to sit upright in order to perform breathing exercises 
C) Evaluating the effectiveness of breathing exercises 
D) Evaluating the client's technique when using an incentive spirometer

Question 6

After observing the client use the incentive spirometer,which item is not required in the nurse's documentation?

Accepted Answer

A) Volume or flow levels achieved 
B) Number of times the client coughs after use of the device 
C) Type of spirometer 
D) Breath sound auscultation before and after use of the device 
A) Volume or flow levels achieved 
B) Number of times the client coughs after use of the device 
C) Type of spirometer 
D) Breath sound auscultation before and after use of the device

Question 7

The nurse is teaching the client how to use the flow-oriented sustained maximal inspiration (SMI)device.Which teaching point is not appropriate for this client?

Accepted Answer

A) Sealing the lips tightly around the mouthpiece 
B) Inhaling slowly and deeply until the piston is elevated to the preset level 
C) Holding the breath for 6 seconds 
D) Removing the mouthpiece and exhaling normally 
A) Sealing the lips tightly around the mouthpiece 
B) Inhaling slowly and deeply until the piston is elevated to the preset level 
C) Holding the breath for 6 seconds 
D) Removing the mouthpiece and exhaling normally

Question 8

The nurse finds the client sitting upright and leaning on the arms or elbows.Which piece of documentation accurately describes the client's position?

Accepted Answer

A) The client has assumed the orthopneic position. 
B) The client has assumed the COPD position. 
C) The client has assumed the tripod position. 
D) The client is sitting upright. 
A) The client has assumed the orthopneic position. 
B) The client has assumed the COPD position. 
C) The client has assumed the tripod position. 
D) The client is sitting upright.

Question 9

The nurse observes a client while using the prescribed incentive spirometer.Which items will the nurse include when documenting this observation in the nursing notes?

Accepted Answer

A) Type of spirometer 
B) Number of breaths taken 
C) Education provided 
D) Medications administered 
E) Code status 
A) Type of spirometer 
B) Number of breaths taken 
C) Education provided 
D) Medications administered 
E) Code status

Question 10

The nurse is caring for a client requiring mechanical ventilation who is deeply sedated and receiving paralytic medications.Which nursing intervention would assist the client to optimize oxygenation?

Accepted Answer

A) Hyperventilating the client once an hour 
B) Hyperoxygenating the client once an hour 
C) Encouraging coughing and deep breathing 
D) Frequent repositioning 
A) Hyperventilating the client once an hour 
B) Hyperoxygenating the client once an hour 
C) Encouraging coughing and deep breathing 
D) Frequent repositioning

Exam 24: Breathing Exercises

The nurse is providing care to a client with a diagnosis of asthma.Which nursing interventions will help to maintain normal respirations for this client?

Which is not a teaching point that the nurse would include when instructing a client to perform breathing exercises?

The nurse is caring for a client who had major abdominal surgery yesterday.Which assessment finding would indicate inadequate airway clearance that might be cleared with coughing and deep breathing?

While reviewing the client's medical record,the nurse learns the client has atelectasis.Which statement indicates an appropriate understanding of this term?

Which activity could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

After observing the client use the incentive spirometer,which item is not required in the nurse's documentation?

The nurse is teaching the client how to use the flow-oriented sustained maximal inspiration (SMI)device.Which teaching point is not appropriate for this client?

The nurse finds the client sitting upright and leaning on the arms or elbows.Which piece of documentation accurately describes the client's position?

The nurse observes a client while using the prescribed incentive spirometer.Which items will the nurse include when documenting this observation in the nursing notes?

The nurse is caring for a client requiring mechanical ventilation who is deeply sedated and receiving paralytic medications.Which nursing intervention would assist the client to optimize oxygenation?

Foundational Skills

Vital Signs

Health Assessment

Diagnostic Testing

Client Hygiene

Bed-Making

Infection Control

Heat and Cold Therapy

Pain Management

Positioning the Client

Mobilizing the Client

Fall Prevention and Restraints

Maintaining Joint Mobility

Drug Calculations

Administering Oral and Enteral Medications

Administering Topical Medications

Administering Parenteral Medications

Administering Intravenous Therapy

Feeding Clients

Assisting With Urinary Elimination

Assisting With Fecal Elimination

Caring for Clients With Peritoneal Dialysis

Promoting Circulation

Oxygen Therapy

Suctioning

Caring for the Client With a Tracheostomy

Assisting With Mechanical Ventilation

Caring for the Client With Chest Tube Drainage

Administering Emergency Measures to the Hospitalized Client

Performing Wound and Pressure Ulcer Care

Orthopedic Care

Performing Perioperative Care

End-Of-Life Care

Filters