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PQ-200T: Respiratory P3 [2024]
1. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) A. Dyspnea B. Barrel Chest C. Clubbing of the fingers D. Shallow respirations E. Bradycardia Correct Answers: Dyspnea is correct : Dyspnea is experienced by clients who have emphysema due to inadequate oxygen exchange in the lungs. Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the diaphragm becomes, permanently flattened by overdistention of the lungs. The muscles of the rib cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of emphysema. Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity, which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels. Shallow respirations is correct. Clientss who have emphysema lose lung elasticity; consequently, respirations become increasingly shallow and more rapid. 2. A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion? A. Prone B. Supine C. Side-lying D. Upright Correct Answer: D. Upright
Optimal positioning for allowing maximal lung expansion and comfort in children who have respiratory insufficiency or failure is sitting upright or leaning forward.
3. A nurse is caring for a client who was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer? A. Ciprofloxacin B. Fluconazole C. Tobramycin D. Vancomycin Correct Answer: A. Ciprofloxacin Ciprofloxacin is the antibiotic of choice to prevent systemic infection with anthrax. 4. A nurse is collecting data in a client who is one day postoperative. The nurse should recognize which of the following findings is a manifestation of atelectasis? A. Distended neck veins B. Dysphagia C. Dyspnea D. Pedal edema Correct Answer: C. Dyspnea The nurse should recognize dyspnea, decreased breath sounds, decreased oxygen saturation, and anxiety, are manifestations of atelectasis. 5. A nurse is assisting with the care of a client who has adult respiratory distress (ARDS). Which of the following actions should the nurse take? A. Administer low-flow oxygen continuously via nasal cannula.
D. Clamp the chest tube near the water seal. Correct answer: A. Continue to monitor the client. The nurse should expect the fluid in the water seal chamber to fluctuate with client respiration. A failure to rise and fall indicates a flaw in the chest tube system.
8. A nurse is caring for a client who has atelectasis. The nurse should instruct the client to lie on his back with a quarter turn elevating his right side and his head lower than his feet to mobilize secretions from which of the following lung segments? A. Anterior segment of the right upper lobe B. Anterior segment of the right middle lobe C. Posterior segment of the right middle lobe D. Posterior segment of the right lower lobe Correct Answer: B. Anterior segment of the right middle lobe The nurse should have the client lie with the right side higher than the left to mobilize secretions from the right lung and place the head lower than his feet to promote downward flow of secretions from the middle lobe. The nurse should use postural drainage 2 to 3 times daily, before meals, and provide treatments to loosen bronchial secretions first, as prescribed. 9. An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make? A. “Gloves are not necessary if you wash your hands well.” B. “Wear a gown whenever you come in close contact with the client.” C. “Wear a mask when entering the client’s room.” D. “Place a mask on the client when you check her vital signs.”
Correct Answer: C. “Wear a mask when entering the client’s room.” Since a client who has pneumonia requires droplet precautions, it is necessary for the AP to wear a mask while caring for this client. 10.A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Dry cough Correct Answer: B. Increasing dyspnea Atelectasis is a closure or collapse of the alveoli due to obstruction or hypoventilation, causing shortness of breath and pleural pain. 11.A nurse is performing pulmonary hygiene for a client who has pneumonia. The nurse should have the client lie on his back with his head to mobilize secretions from which of the following lung segments? A. Anterior segment of the right upper lobe B. Anterior segment of the right middle lobe C. Posterior segment of the right middle lobe D. Posterior segment of the right lower lobe Correct Answer: A. Anterior segment of the right upper lobe The nurse should place the client supine (on the back) to promote drainage from the anterior portion of the lung, and elevate the client’s head to promote flow of draining downward from the right upper lobe. The nurse should use postural drainage 2 to 3 times daily, before meals, and provide treatments to loosen bronchial secretions first, as prescribed.
A client who has a pneumothorax will have diminished or absent breath sounds on the affected side due to partial or total collapse of the lung. 15.A nurse is caring for a client who has a chest tube inserted for a pneumothorax. Which of the following actions should the nurse take? A. Empty the collection chamber on the client’s chest tube every 4 hr. B. Strip the client’s chest tube every 2 hr. C. Pin the chest tube to the client’s gown. D. Tape the connections on the client’s chest tube. Correct Answer: D. Tape the connections on the client’s chest tube. The nurse should securely tape all connections on the client’s chest tube to maintain a closed system and prevent a break in the connection. 16.A school nurse receives a telephone call from a parent who suspects their school-age child may have coronavirus-2 (SARS-Cov-2). Which of the following instructions should the nurse give as secondary prevention? A. The child should wear a mask to school. B. The child should be immunized prior to coming to school. C. The child should be tested to determine the cause of their illness. D. The child should be taken to the hospital if they develop difficulty breathing. Correct Answer: C. The child should be tested to determine the cause of their illness. The nurse instructing the child to obtain testing for coronavirus is an example of secondary prevention. A measure that is implemented to provide early detection and treatment is secondary prevention.
17.A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client? A. Contact B. Droplet C. Protective D. Airborne Correct Answer: D. Airborne The nurse should initiate airborne precautions when a client has an infection that spreads through small droplets that remain airborne for longer periods, such as tuberculosis and measles. The client requires a negative pressure airflow room, and staff should wear an N95 respirator when in contact with the client. 18.A nurse is reinforcing teaching with a client who has pleurisy. Which of the following statements by the client indicates an understanding of the teaching? A. “I should be on the affected side.” B. “This condition is chronic.” C. “I should take shallow breaths while I have pleurisy.” D. “I should expect to develop a fever and a productive cough.” Correct Answer: A. “I should be on the affected side.” Lying on the affected side may provide relief of discomfort. 19.A nurse is collecting data from an older adult client who has chronic obstructive pulmonary disease (COPD), arthritis, cataracts, and a BMI of 18.5. Which of the following findings should the nurse identify as a potential barrier to the client's nutritional goal? A. Diet restrictions to manage the client’s condition
