Question 1

The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD)who has a breathing rate of 32 per minutes,elevated blood pressure,and fatigue.Which nursing diagnosis is the priority for this client?

Accepted Answer

A)  Ineffective Coping 
B)  Ineffective Airway Clearance 
C)  Anxiety 
D)  Ineffective Breathing Pattern

Question 2

The nurse is providing care to a client who has a tracheostomy.The nurse will monitor the client for complications related to the loss of which protective mechanism?

Accepted Answer

A)  The ability to cough 
B)  Filtration and humidification of inspired air 
C)  Decrease in oxygen-carrying capacity of the trachea 
D)  The sneeze reflex initiated by irritants in the nasal passages

Question 3

The nurse is planning care for a child with respiratory syncytial virus (RSV)bronchiolitis with the nursing diagnosis of Impaired Gas Exchange.Which interventions should be included in the child's plan of care? Select all that apply.

Accepted Answer

A)  Weigh daily. 
B)  Monitor vital signs and pulse oximetry. 
C)  Administer oxygen as prescribed. 
D)  Weigh diapers. 
E)  Provide frequent rest periods.

Question 4

The nurse is planning care for a new mother of African-American descent who smoked during the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS).Which interventions are appropriate for the nurse to include in the plan of care for the new mother and baby? Select all that apply.

Accepted Answer

A)  Information on bottle-feeding the infant 
B)  Reasons why the child should sleep with others 
C)  Ages at which the child should receive immunizations 
D)  Using bedding that is firm 
E)  Smoking cessation information

Question 5

The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS).Which conditions will the nurse include in the teaching session? Select all that apply.

Accepted Answer

A)  Septic shock 
B)  Viral pneumonia 
C)  Aspirin overdose 
D)  Head injury 
E)  Angioplasty

Question 6

The nurse is providing care to clients on a medical-surgical unit.Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply.

Accepted Answer

A)  Encouraging deep breathing exercises 
B)  Assisting with positioning 
C)  Providing suctioning 
D)  Prescribing bronchodilators 
E)  Monitoring activity intolerance

Question 7

The nurse working in the emergency department (ED)is assessing an infant client.Whch findings support the diagnosis of respiratory syncytial virus (RSV)? Select all that apply.

Accepted Answer

A)  Rhinorrhea 
B)  Irritability 
C)  Grunting 
D)  Bradypnea 
E)  Tachypnea

Question 8

The nurse is providing care to a client who is diagnosed with acute respiratory distress syndrome (ARDS).Which clinical manifestation does the nurse anticipate for this client who is experiencing hypoxia as a result of the ARDS diagnosis?

Accepted Answer

A)  Fluid imbalance 
B)  Hypertension 
C)  Bradycardia 
D)  Dyspnea

Question 9

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%.Which nursing diagnosis is a priority for this client?

Accepted Answer

A)  Risk for Infection 
B)  Impaired Spontaneous Ventilation 
C)  Risk for Acute Confusion 
D)  Decreased Cardiac Output

Question 10

An infant with respiratory syncytial virus (RSV)bronchiolitis is prescribed intubation to maintain an adequate airway.Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? Select all that apply.

Accepted Answer

A)  An advanced practice nurse 
B)  A dietitian 
C)  The primary healthcare provider 
D)  A respiratory therapist 
E)  A play therapist

Question 11

The nurse is providing care to a client diagnosed with chronic obstruction pulmonary disease (COPD)after years of experiencing emphysema.Which clinical manifestation does the nurse anticipate when assessing this client?

Accepted Answer

A)  Tachycardia 
B)  Cough 
C)  Barrel chest 
D)  Wheezing

Question 12

A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS).The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygen therapy?

Accepted Answer

A)  Oxygen via a nasal cannula 
B)  Mechanical ventilation 
C)  Oxygen via a facial mask 
D)  Oxygen via a venturi mask

Question 13

A client asks why asthma medication is needed even though the client's last attack was several months ago.Which response by the nurse is appropriate?

Accepted Answer

A)  "The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack." 
B)  "The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him." 
C)  "The medication is still needed to decrease inflammation in your airways and help prevent an attack." 
D)  "The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it."

Question 14

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD)? Which factors in the client's history support the current diagnosis? Select all that apply.

Accepted Answer

A)  Working in an industrial environment 
B)  Working in an office setting with air conditioning 
C)  History of asthma 
D)  Current cigarette smoking 
E)  Playing golf several times a week

Question 15

The nurse is providing care to a client experiencing the acid-base balance of respiratory acidosis.Which effects does the nurse anticipate based on this diagnosis? Select all that apply.

Accepted Answer

A)  Increased CO2 
B)  Vasoconstriction 
C)  Decreased O2 
D)  Decreased intracranial pressure (ICP) 
E)  Increased pulse rate

Question 16

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance.Which action by the nurse is the most appropriate?

Accepted Answer

A)  Encourage strenuous activity. 
B)  Consult a dietitian for low-calorie meals. 
C)  Consult physical therapy for endurance and musculoskeletal function. 
D)  Encourage dependence with activities of daily living.

Question 17

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS).Which interventions are appropriate to decrease an infant's risk for SIDS? Select all that apply.

Accepted Answer

A)  Using firm bedding 
B)  Ensuring the room temperature is at least 80 degrees F at all times 
C)  Avoiding smoking around infants 
D)  Recommending bed sharing 
E)  Placing the infant in a prone-position for sleeping

Question 18

The nurse is providing care for a client admitted during an acute exacerbation of asthma.Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client?

Accepted Answer

A)  Inhaled short-acting beta-agonists 
B)  Oral corticosteroids 
C)  Inhaled long-acting beta-agonists 
D)  Oral anticholinergics

Question 19

A client diagnosed with chronic obstructive pulmonary disease (COPD)has a pulse oximetry reading of 93%,increased red blood and white blood cell count,temperature of 101°F,pulse 100 bpm,respirations 35 bpm,and a chest x-ray that showed a flattened diaphragm with infiltrates.Based on this data,which prescription does the nurse question for this client?

Accepted Answer

A)  Antibiotic therapy 
B)  Nonsteroidal anti-inflammatory agents 
C)  Oxygen by nasal cannula at 3-4 liters/minute 
D)  Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents

Question 20

While performing nasotracheal suctioning,the nurse notes the older adult client is moving the head around and pulling at the nurse's hand to remove the suction catheter.Which actions by the nurse are appropriate? Select all that apply.

Accepted Answer

A)  Remove the suction catheter 
B)  Lower the head of the bed 
C)  Hyperinflate the client's lungs 
D)  Apply restraints to the client's arms and legs 
E)  Hyperoxygenate the client

Exam 15: Oxygenation

The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minutes,elevated blood pressure,and fatigue.Which nursing diagnosis is the priority for this client?

The nurse is providing care to a client who has a tracheostomy.The nurse will monitor the client for complications related to the loss of which protective mechanism?

The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis with the nursing diagnosis of Impaired Gas Exchange.Which interventions should be included in the child's plan of care? Select all that apply.

The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS) .Which conditions will the nurse include in the teaching session? Select all that apply.

The nurse is providing care to clients on a medical-surgical unit.Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply.

The nurse working in the emergency department (ED) is assessing an infant client.Whch findings support the diagnosis of respiratory syncytial virus (RSV) ? Select all that apply.

The nurse is providing care to a client who is diagnosed with acute respiratory distress syndrome (ARDS) .Which clinical manifestation does the nurse anticipate for this client who is experiencing hypoxia as a result of the ARDS diagnosis?

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%.Which nursing diagnosis is a priority for this client?

An infant with respiratory syncytial virus (RSV) bronchiolitis is prescribed intubation to maintain an adequate airway.Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? Select all that apply.

The nurse is providing care to a client diagnosed with chronic obstruction pulmonary disease (COPD) after years of experiencing emphysema.Which clinical manifestation does the nurse anticipate when assessing this client?

A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS) .The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygen therapy?

A client asks why asthma medication is needed even though the client's last attack was several months ago.Which response by the nurse is appropriate?

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD) ? Which factors in the client's history support the current diagnosis? Select all that apply.

The nurse is providing care to a client experiencing the acid-base balance of respiratory acidosis.Which effects does the nurse anticipate based on this diagnosis? Select all that apply.

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance.Which action by the nurse is the most appropriate?

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS) .Which interventions are appropriate to decrease an infant's risk for SIDS? Select all that apply.

The nurse is providing care for a client admitted during an acute exacerbation of asthma.Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client?

While performing nasotracheal suctioning,the nurse notes the older adult client is moving the head around and pulling at the nurse's hand to remove the suction catheter.Which actions by the nurse are appropriate? Select all that apply.