Adult Health Respiratory Exam With Best Solutions
The nurse caring for a client with a pneumothorax and who has had a chest tube
inserted notes
... [Show More] continuous gentle bubbling in the water seal chamber. What action is
most appropriate? - ANS-Check for an air leak, because the bubbling should be
intermittent.
The nurse is caring for a client who suffered an inhalation injury from a wood stove. The
carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse
would anticipate noting which sign in the client? - ANS-Flushing
The emergency department nurse is assessing a client who has sustained a blunt injury
to the chest wall. Which finding indicates the presence of a pneumothorax in this client?
- ANS-Diminished breath sounds
The nurse is caring for a client hospitalized with acute exacerbation of chronic
obstructive pulmonary disease. Which findings would the nurse expect to note on
assessment of this client? Select all that apply. - ANS-A hyperinflated chest noted on
the chest x-ray
3.
Decreased oxygen saturation with mild exercise
The nurse instructs a client to use the pursed-lip method of breathing and evaluates the
teaching by asking the client about the purpose of this type of breathing. The nurse
determines that the client understands if the client states that the primary purpose of
pursed-lip breathing is to promote which outcome? - ANS-Promote carbon dioxide
elimination.
The nurse is preparing a list of home care instructions for a client who has been
hospitalized and treated for tuberculosis. Which instructions should the nurse include on
the list? Select all that apply. - ANS-Activities should be resumed gradually.
A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
4.
Respiratory isolation is not necessary because family members already have been
exposed.
5.
Cover the mouth and nose when coughing or sneezing and put used tissues in plastic
bags.
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted
in the client, should be reported immediately to the health care provider? - ANSBronchospasm
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should
plan to limit the suctioning time to a maximum of which time period? - ANS-10 seconds
The nurse is suctioning a client via an endotracheal tube. During the suctioning
procedure, the nurse notes on the monitor that the heart rate is decreasing. Which
nursing intervention is appropriate? - ANS-Stop the procedure and reoxygenate the
client.
The nurse is assessing the respiratory status of a client who has suffered a fractured
rib. The nurse should expect to note which finding? - ANS-Pain, especially with
inspiration
A client with a chest injury has suffered flail chest. The nurse assesses the client for
which most distinctive sign of flail chest? - ANS-Paradoxical chest movement
The nurse is assessing a client with multiple trauma who is at risk for developing acute
respiratory distress syndrome. The nurse should assess for which earliest sign of acute
respiratory distress syndrome? - ANS-Increased respiratory rate
The nurse has conducted discharge teaching with a client diagnosed with tuberculosis
who has been receiving medication for 2 weeks. The nurse determines that the client
has understood the information if the client makes which statement? - ANS-"I should not
be contagious after 2 to 3 weeks of medication therapy."
The nurse is assessing the functioning of a chest tube drainage system in a client who
has just returned from the recovery room following a thoracotomy with wedge resection.
Which are the expected assessment findings? Select all that apply. - ANS-Drainage
system maintained [Show Less]