Respiratory !!!!!!!!!!!!!

1. 27 After a patient has undergone a rhinoplasty, which nursing

intervention will be included in the plan of care?
Instruct the
patient to keep the head elevated for 48 hours to minimize
swelling and pain.
2. 27 When teaching the patient with allergic rhinitis about
management of the condition, the nurse explains that
identification and avoidance of environmental triggers are
the best way to avoid symptoms.
3. 27 After discussing management of upper respiratory infections
(URI) with a patient who has acute viral rhinitis, the nurse
determines that additional teaching is needed when the patient
says I can use my nasal decongestant spray until the
congestion is all gone.
4. 27 An RN is observing a nursing student who is suctioning a
hospitalized patient with a tracheostomy in place. Which action
by the student requires the RN to intervene?
The student puts
on clean gloves and uses a sterile catheter to suction.
5. 27 When the nurse is deflating the cuff of a tracheostomy tube to
evaluate the patients ability to swallow, it is important to
suction the patients mouth and trachea before deflation of
the cuff.
6. 27 The nurse is caring for a spontaneously breathing patient who
has a tracheostomy. To determine that the patient can protect
the airway when eating without having the tracheostomy cuff
inflated, the nurse will deflate the cuff and
have the patient
drink a small amount of grape juice and observe for coughing.
7. 27 A patient with a tracheostomy has a new order for a
fenestrated tracheostomy tube. Which action will be included in
the plan of care? Assess the ability to swallow before using the
fenestrated tube.
8. 27 When inflating the cuff on a tracheostomy tube to the
appropriate level, the best action by the nurse will be to
use a
manometer to ensure cuff pressure is at an appropriate level.
9. 27 A patient with laryngeal cancer has received teaching about
radiation therapy. Which statement by the patient indicates that
the teaching has been effective?
I will need to buy a water
bottle to carry with me.
10.
The nurse is obtaining a health history from a 67-year-old
patient with a 40 pack-year smoking history, complaints of
hoarseness and tightness in the throat, and difficulty swallowing.
Which question is most important for the nurse to ask?
How
much alcohol do you drink in an average week?
11.
27 A patient scheduled for a total laryngectomy and radical
neck dissection for cancer of the larynx asks the nurse, How will

I talk after the surgery? The best response by the n27 A patient
who had a total laryngectomy has a nursing diagnosis of hopele
You will have a permanent opening into your neck, and
you will need to have rehabilitation for some type of voice
restoration.
12.
27 A patient who had a total laryngectomy has a nursing
diagnosis of hopelessness related to loss of control of personal
care. Which information obtained by the nurse is the best
indicator that the problem identified in nursing diagnosis is
resolving? The patient asks how to clean the tracheostomy
stoma and tube.
13.
27 After completing discharge instructions for a patient
with a total laryngectomy, the nurse determines that additional
instruction is needed when the patient says,
I must keep the
stoma covered with a loose sterile dressing at all times.
14.
27 Which action should the nurse take first when a patient
develops a nosebleed? Pinch the lower portion of the nose for 10
minutes.
15.
27 When the nurse is caring for a patient who has had a
total laryngectomy and radical neck dissection during the first 24
hours after surgery, what is the priority nursing action?
Assess breath sounds.
16.
27 A patient with an uncuffed tracheostomy tube coughs
violently during suctioning and dislodges the tracheostomy tube.
Which action should the nurse take first? Insert the obturator
and attempt to reinsert the tracheostomy tube.
17.
27 Which of these patients in the respiratory disease clinic
should the nurse assess first? A 23-year-old, complaining of a
sore throat, who has a hot potato voice
18.
27 The nurse obtains the following assessment data in a
76-year-old patient who has influenza. Which information will be
most important to communicate to the health care provider?
Diffuse crackles in the lungs
19.
27 Which of these nursing actions can the RN working in a
long-term care facility delegate to an experienced LPN/LVN who
is caring for a patient with a permanent tracheostomy?
Suctioning the tracheostomy when needed
20.
The nurse is caring for a hospitalized 82-year-old patient
who has nasal packing in place to treat a nosebleed. Which of
the following assessment findings will require the most
immediate action by the nurse?
The oxygen saturation is
89%.
21.
27 The teaching plan for a patient with acute sinusitis will
need to include which of the following interventions (select all
that apply)?
hot shower will increase sinus drainage and
decrease pain,(OTC) antihistamines can be used to relieve

congestion and inflammation, Saline nasal spray can madehome

and used to wash out secretions, more comfortable you keep
your head in an upright position.
22.
27 The nurse is reviewing the charts for five patients who
are scheduled for their yearly physical examinations in October.
Which of the following patients will require the inactivated
influenza vaccination (select all that apply)?
A 36-year-old
female patient who is pregnant, A 30-year-old patient who takes
corticosteroids for rheumatoid arthritis
23.
27 The nurse enters the room of a patient who has just
returned from surgery for a total laryngectomy and radical neck
dissection and notes the following problems. In which order
should the nurse address the problems?____________________
The patient is in a side-lying position with the head of the
bed flat, The patient is coughing blood-tinged secretions from the
tracheostomy, The Hemovac in the neck incision contains 200
mL of bloody drainage,(NG) tube disconnected suction clamped
off
24.
28 Following assessment of a patient with pneumonia, the
nurse identifies a nursing diagnosis of ineffective airway
clearance. Which information best supports this diagnosis? The
weak, nonproductive cough indicates that the patient is unable
to clear the airway effectively. The other data would be used to
support diagnoses such as impaired gas exchange and
ineffective breathing pattern.
25.
28 During assessment of the chest in a patient with
pneumococcal pneumonia, the nurse would expect to find
increased tactile fremitus.
26.
28 A patient with bacterial pneumonia has rhonchi and
thick sputum. Which action will the nurse use to promote airway
clearance? Assist the patient to splint the chest when coughing.
27.
27 Which statement by a patient who has been
hospitalized for pneumonia indicates a good understanding of
the discharge instructions given by the nurse? I will continue to
do the deep breathing and coughing exercises at home.
28.
28 Which nursing action will be most effective in
preventing aspiration pneumonia in patients who are at risk?
Place patients with altered consciousness in side-lying
positions.
29.
28 After a patient with right lower-lobe pneumonia has
been treated with intravenous (IV) antibiotics for 2 days, which
assessment data obtained by the nurse indicates that the
treatment has been effective?
The patients white blood cell
(WBC) count is 9000/l.
30.
28 The health care provider writes an order for
bacteriologic testing for a patient who has a positive tuberculosis

skin test. Which action will the nurse take?

Obtain
consecutive sputum specimens from the patient for 3 days.
31.
27 Which information about a patient who has a recent
history of tuberculosis (TB) indicates that the nurse can
discontinue airborne isolation precautions?
Three sputum
smears for acid-fast bacilli are negative.
32.
28 The nurse recognizes that the goals of teaching
regarding the transmission of pulmonary tuberculosis (TB) have
been met when the patient with TB covers the mouth and nose
when coughing.
33.
28 Which information will the nurse include in the patient
teaching plan for a patient who is receiving rifampin (Rifadin) for
treatment of tuberculosis?
Your urine, sweat, and tears will
be orange colored.
34.
28 When teaching the patient who is receiving standard
multidrug therapy for tuberculosis (TB) about possible toxic
effects of the antitubercular medications, the nurse will give
instructions to notify the health care provider if the patient
develops yellow-tinged skin.
35.
28 An alcoholic and homeless patient is diagnosed with
active tuberculosis (TB). Which intervention by the nurse will be
most effective in ensuring adherence with the treatment
regimen? Arranging for a daily noontime meal at a community
center and giving the medication then
36.
28 After 2 months of tuberculosis (TB) treatment with a
standard four-drug regimen, a patient continues to have positive
sputum smears for acid-fast bacilli (AFB). Which action should
the nurse take next?
Ask the patient whether medications
have been taken as directed.
37.
28 A staff nurse has a tuberculosis (TB) skin test of 16-mm
induration. A chest radiograph is negative, and the nurse has no
symptoms of TB. The occupational health nurse will plan on
teaching the staff nurse about the use and side effects of
isoniazid (INH).
38.
28 When caring for a patient who is hospitalized with
active tuberculosis (TB), the nurse observes a family member
who is visiting the patient. The nurse will need to intervene if the
family member puts on a surgical face mask before visiting the
patient.
39.
28 Which action by the occupational health nurse at a
manufacturing plant where there is potential exposure to inhaled
dust will be most helpful in reducing incidence of lung disease?
Require the use of protective equipment.
40.
28 When developing a teaching plan for a patient with a 42
pack-year history of cigarette smoking, it will be most important

for the nurse to include information about

options for
smoking cessation
41.
28 A lobectomy is scheduled for a patient with stage I non
small cell lung cancer. The patient tells the nurse, I would rather
have radiation than surgery. Which response by the nurse is
most appropriate?
Tell me what you know about the
various treatments available.
42.
28 An hour after a thoracotomy, a patient complains of
incisional pain at a level 7 out of 10 and has decreased left-sided
breath sounds. The pleural drainage system has 100 mL of
bloody drainage and a large air leak. best for the nurse to take
next? Administer the prescribed PRN morphine.
43.
28 A patient with newly diagnosed lung cancer tells the
nurse, I think I am going to die pretty soon. Which response by
the nurse is best?Can you tell me what it is that makes you
think you will die so soon?
44.
28 The health care provider inserts a chest tube in a
patient with a hemopneumothorax. When monitoring the patient
after the chest tube placement, the nurse will be most concerned
about 400 mL of blood in the collection chamber.
45.
28 A patient experiences a steering wheel injury as a result
of an automobile accident. During the initial assessment, the
emergency department nurse would be most concerned about
paradoxic chest movement.
46.
28 When assessing a 24-year-old patient who has just
arrived after an automobile accident, the emergency department
nurse notes that the breath sounds are absent on the right side.
The nurse will anticipate the need for
insertion of a chest
tube with a chest drainage system.
47.
28 A patient who has a right-sided chest tube following a
thoracotomy has continuous bubbling in the suction-control
chamber of the collection device. The most appropriate action by
the nurse is to
take no further action with the collection
device
48.
28 When providing preoperative instruction for a patient
scheduled for a left pneumonectomy for cancer of the lung, the
nurse informs the patient that the postoperative care includes
frequent use of an incentive spirometer.
49.
28 To determine the effectiveness of prescribed therapies
for a patient with cor pulmonale and right-sided heart failure,
which assessment will the nurse make? Peripheral edema
50.
28 A patient with primary pulmonary hypertension (PPH) is
receiving nifedipine (Procardia). The nurse will evaluate that the
treatment is effective if the patient reports decreased exertional
dyspnea.

51.
28 A patient with a pleural effusion is scheduled for a
thoracentesis. Before the procedure, the nurse will plan to
position the patient sitting upright on the edge of the bed
and leaning forward
52.
28 After discharge teaching has been completed for a
patient who has had a lung transplant, the nurse will evaluate
that the teaching has been effective if the patient states
I will
call the health care provider right away if I develop a fever.
53.
28 Which of these orders will the nurse act on first for a
patient who has just been admitted with probable bacterial
pneumonia and sepsis? Obtain blood cultures from two sites
54.
28 Which assessment information obtained by the nurse
when caring for a patient who has just had a thoracentesis is
most important to communicate to the health care provider?
Oxygen saturation is 89%
55.
28 A patient who has just been admitted with
pneumococcal pneumonia has a temperature of 101.6 F with a
frequent cough and is complaining of severe pleuritic chest pain.
Which of these prescribed medications should the nurse give
first? azithromycin (Zithromax)
56.
28 Which information obtained by the nurse about a
patient who has been diagnosed with both human
immunodeficiency virus (HIV) and active tuberculosis (TB)
disease is most important to communicate to the health care
provider? The patient is being treated with antiretrovirals for
HIV infection.
57.
28 A patient with pneumonia has a fever of 101.2 F (38.5
C), a nonproductive cough, and an oxygen saturation of 89%.
The patient is very weak and needs assistance to get out of bed.
The priority nursing diagnosis for the patient is impaired gas
exchange related to respiratory congestion
58.
28 The nurse observes nursing assistive personnel (NAP)
doing all the following activities when caring for a patient with
right lower lobe pneumonia. The nurse will need to intervene
when NAP lower the head of the patients bed to 10 degrees
59.
28 A patient with a possible pulmonary embolism
complains of chest pain and difficulty breathing. The nurse finds
a heart rate of 142, BP reading of 100/60, and respirations of 42.
The nurses first action should be to
elevate the head of the
bed to 45 to 60 degrees
60.
28 After the nurse has received change-of-shift report
about the following four patients, which patient should be
assessed first?
A 46-year-old patient who has a deep vein
thrombosis and is complaining of sudden onset shortness of
breath

61.
28 The nurse is performing tuberculosis (TB) screening in a
clinic that has many patients who have immigrated to the United
States. Before doing a TB skin test on a patient, which question is
most important for the nurse to ask?
Have you received the
bacille Calmette-Gurin (BCG) vaccine for TB?
62.
28 A patient is admitted to the emergency department
with an open stab wound to the right chest. What is the first
action that the nurse should take? Tape a nonporous dressing on
three sides over the chest wound.
63.
28 The nurse notes that a patient has incisional pain, a
poor cough effort, and scattered rhonchi after a thoracotomy.
Which action should the nurse take first? Medicate the patient
with the prescribed morphine.
64.
28 The nurse is caring for a patient with primary
pulmonary hypertension who is receiving epoprostenol (Flolan).
Which assessment information requires the most immediate
action?
The patients central intravenous line is
disconnected.
65.
28 A patient who was admitted the previous day with
pneumonia complains of a sharp pain whenever I take a deep
breath. Which action will the nurse take next? Listen to the
patients lungs
66.
28 The nurse notes new onset confusion in an 89-year-old
patient in a long-term care facility. The patient is normally alert
and oriented. In which order should the nurse take the following
actions?
Obtain the oxygen saturation, Check the patients
pulse rate, Notify the health care provider, Document the change
in status
67.
29 A patient with chronic bronchitis who has a new
prescription for Advair Diskus (combined fluticasone and
salmeterol) asks the nurse the purpose of using two drugs. The
nurse explains that
one drug decreases inflammation, and
the other is a bronchodilator.
68.
29 The nurse has completed patient teaching about the
administration of salmeterol (Serevent) using a metered-dose
inhaler (MDI). Which action by the patient indicates good
understanding of the teaching?
The patient attaches a spacer
before using the MDI.
69.
29 When preparing a patient with possible asthma for
pulmonary function testing, the nurse will teach the patient to
withhold bronchodilators for 6 to 12 hours before the
examination.
70.
29 Which information will the nurse include when teaching
the patient with asthma about the prescribed medications?
Tremors are an expected side effect of rapidly acting
bronchodilators

71.
29 When the nurse is evaluating the effectiveness of
therapy for a patient who has received treatment during an
asthma attack, which finding is the best indicator that the
therapy has been effective? Oxygen saturation is >90%.
72.
29 A patient seen in the asthma clinic has recorded daily
peak flows that are 85% of the baseline. Which action will the
nurse plan to take?
Instruct the patient to continue to use
current medications
73.
29 Which action by a patient who has asthma indicates a
good understanding of the nurses teaching about peak flow
meter use? The patient uses the albuterol (Proventil) metereddose inhaler (MDI) for peak flows in the yellow zone.
74.
29 A 32-year-old patient who denies any history of smoking
is seen in the clinic with a new diagnosis of emphysema. The
nurse will anticipate teaching the patient about 1-antitrypsin
testing
75.
29 Which information about a newly admitted patient with
chronic obstructive pulmonary disease (COPD) indicates that the
nurse should consult with the health care provider before
administering the prescribed theophylline?
The patient takes
cimetidine (Tagamet) 150 mg daily
76.
29 A patient with chronic bronchitis has a nursing diagnosis
of impaired breathing pattern related to anxiety. Which nursing
action is most appropriate to include in the plan of care?
Teach
the patient how to effectively use pursed lip breathing.
77.
29 A patient with chronic obstructive pulmonary disease
(COPD) has a nursing diagnosis of imbalanced nutrition: less than
body requirements. An appropriate intervention for this problem
is to offer high calorie snacks between meals and at bedtime
78.
29 When the nurse is interviewing a patient with a new
diagnosis of chronic obstructive pulmonary disease (COPD),
which information will help most in confirming a diagnosis of
chronic bronchitis?
The patient complains about a productive
cough every winter for 3 months
79.
29 After the nurse has finished teaching a patient about
pursed lip breathing, which patient action indicates that more
teaching is needed?
The patient puffs up the cheeks while
exhaling
80.
29 Which finding by the nurse for a patient with a nursing
diagnosis of impaired gas exchange will be most useful in
evaluating the effectiveness of treatment?
Pulse oximetry
reading of 91%
81.
29 To evaluate the effectiveness of therapy for a patient
with cor pulmonale, the nurse will monitor the patient for
jugular vein distention

82.
29 When a hospitalized patient with chronic obstructive
pulmonary disease (COPD) is receiving oxygen, the best action
by the nurse is to maintain the pulse oximetry level at 90% or
greater
83.
Which information will the nurse include in teaching a
patient with chronic obstructive pulmonary disease (COPD) who
has a new prescription for home oxygen therapy?
Oxygen use
can improve the patients prognosis and quality of life.
84.
29 A patient is receiving 35% oxygen via a Venturi mask. To
ensure the correct amount of oxygen delivery, it is most
important that the nurse
keep the air entrainment ports
clean and unobstructed.
85.
29 Postural drainage with percussion and vibration is
ordered twice daily for a patient with chronic bronchitis. The
nurse will plan to carry out the procedure 3 hours after the
patient eats
86.
29 When developing a teaching plan to help increase
activity tolerance at home for a 70-year-old with severe chronic
obstructive pulmonary disease (COPD), the nurse should teach
the patient that an appropriate exercise goal is to
walk for a
total of 20 minutes daily
87.
29 A patient with severe chronic obstructive pulmonary
disease (COPD) tells the nurse, I wish I were dead! I cannot do
anything for myself anymore. Based on this information, which
nursing diagnosis is most appropriate?
Chronic low self-esteem
related to increased physical dependence
88.
29 A patient with chronic obstructive pulmonary disease
(COPD) is admitted to the hospital. How can the nurse best
position the patient to improve gas exchange? Sitting up at the
bedside in a chair and leaning slightly forward
89.
29 Which diagnostic test will the nurse plan to discuss with
a 54-year-old patient with progressively increasing dyspnea who
is being evaluated for a possible diagnosis of chronic obstructive
pulmonary disease (COPD)? Pulmonary function testing
90.
29 Which action will be included in the plan of care for a
23-year-old with cystic fibrosis (CF) who is admitted to the
hospital with increased dyspnea? Perform chest physiotherapy
every 4 hours
91.
29 A patient who is hospitalized with cystic fibrosis (CF)
coughs up large quantities of thick green mucus. The nurse will
plan to teach the patient about
aerosolized tobramycin
(TOBI)
92.
29 A 20-year-old patient with cystic fibrosis (CF) tells the
nurse that she is considering having a child. Which initial
response by the nurse is best?
Do you need any
information to help you with the decision?

93.
29 A patient with chronic obstructive pulmonary disease
(COPD) has rhonchi throughout the lung fields and a chronic,
nonproductive cough. Which nursing action will be most
effective? Educate the patient to use the Flutter airway
clearance device
94.
29 After the nurse has completed diet teaching for a
patient with chronic obstructive pulmonary disease (COPD) who
has a body mass index (BMI) of 20, which patient statement
indicates that the teaching has been effective? I will have ice
cream as a snack every day.
95.
29 When teaching the patient with chronic obstructive
pulmonary disease (COPD) about exercise, which information
should the nurse include?
Use the bronchodilator before you
start to exercise.
96.
29 Which information given by an asthmatic patient while
the nurse is doing the admission assessment is most indicative of
a need for a change in therapy?
The patients only
medications are albuterol (Proventil) and salmeterol (Serevent)
97.
29 When the nurse takes an admission history for a patient
with possible asthma who has new-onset wheezing and
shortness of breath, which information may indicate a need for a
change in therapy?
The patient takes propranolol (Inderal)
for hypertension
98.
29 Which topic will the nurse include in medication
teaching for a patient with newly-diagnosed persistent asthma?
Self-administration of inhaled corticosteroids
99.
29 A patient with cystic fibrosis (CF) has blood glucose
levels that are consistently 200 to 250 mg/dL. Which nursing
action will the nurse plan to implement? Educate the patient
about administration of insulin
100.
29 When caring for a patient with a history of asthma,
which assessment finding should the nurse communicate
immediately to the health care provider? Use of accessory
muscles in breathing
101.
29 Which action should the nurse anticipate taking first
when a patient who is experiencing an asthma attack develops
bradycardia and a decrease in wheezing? Assist with
endotracheal intubation
102.
29 A patient who is experiencing an acute asthma attack is
admitted to the emergency department. The nurses first action
should be to
listen to the patients breath sounds
103.
29 Which finding in a patient who has received
omalizumab (Xolair) is most important to report immediately to
the health care provider?
Flushing and dizziness
104.
29 The nurse in the emergency department receives
arterial blood gas results for four recently admitted patients with

obstructive pulmonary disease. Which patient will require the

most rapid action by the nurse?
20-year-old with ABG results:
pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg
105.
29 Which of these nursing actions included in the care plan
for a patient with chronic obstructive pulmonary disease (COPD)
should the nurse delegate to experienced nursing assistive
personnel (NAP)? Obtain oxygen saturation using pulse oximetry
106.
29 A patient with asthma who has a baseline peak flow
reading of 600 mL calls the nurse, stating that the current peak
flow is 420 mL. Which action should the nurse take first?
Instruct the patient to use the prescribed albuterol
(Proventil)
107.
29 The following medications are prescribed by the health
care provider for a patient having an acute asthma attack. Which
one will the nurse administer first? albuterol (Ventolin) 2.5 mg
per nebulizer
108.
29 The nurse has received a change-of-shift report about
the following patients with chronic obstructive pulmonary
disease (COPD). Which patient should the nurse assess first?
A patient with a respiratory rate of 38
109.
68 To evaluate the effectiveness of prescribed therapies for
a patient with ventilatory failure, which diagnostic test will be
most useful to the nurse?
Arterial blood gas (ABG) analysis
110.
68 While caring for a patient who has been admitted with a
pulmonary embolism, the nurse notes a change in the patients
oxygen saturation (SpO2) from 94% to 88%. The nurse will
increase the oxygen flow rate
111.
A patient with respiratory failure has a respiratory rate of 8
and an SpO2 of 89%. The patient is increasingly lethargic. The
nurse will anticipate assisting with endotracheal intubation and
positive pressure ventilation
112.
68 The pulse oximetry for a patient with right lower lobe
pneumonia indicates an oxygen saturation of 90%. The patient
has rhonchi, a weak cough effort, and complains of fatigue.
Which action is best for the nurse to take?
Assist the patient
with staged coughing
113.
68 When the nurse is caring for an obese patient with left
lower lobe pneumonia, gas exchange will be best when the
patient is positioned
on the right side
114.
68 When admitting a patient in possible respiratory failure
with a high PaCO2, which assessment information will be of most
concern to the nurse? The patient is somnolent
115.
68 A patient with acute respiratory distress syndrome
(ARDS) and acute renal failure has the following medications
prescribed. Which medication should the nurse discuss with the

health care provider before administration?

gentamicin
(Garamycin) 60 mg IV
116.
68 A patient develops increasing dyspnea and hypoxemia 2
days after having cardiac surgery. To determine whether the
patient has acute respiratory distress syndrome (ARDS) or
pulmonary edema caused by left ventricular failure nserting a
pulmonary artery catheter
117.
68 Which assessment finding by the nurse when caring for
a patient with ARDS who is being treated with mechanical
ventilation and high levels of positive end-expiratory pressure
(PEEP) indicates that the PEEP may need to be decreased? The
patient has subcutaneous emphysema
118.
68 Which statement by the nurse when explaining the
purpose of positive end-expiratory pressure (PEEP) to the family
members of a patient with ARDS is correct?
PEEP prevents
the lung air sacs from collapsing during exhalation.
119.
68 When prone positioning is used in the care of a patient
with acute respiratory distress syndrome (ARDS), which
information obtained by the nurse indicates that the positioning
is effective?The patients PaO2 is 90 mm Hg, and the SaO2 is
92%.
120.
68 The nurse obtains the vital signs for a patient admitted
2 days ago with gram-negative sepsis: temperature 101.2 F,
blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which
action should the nurse take next? Obtain oxygen saturation
using pulse oximetry
121.
68 To decrease the risk for ventilator-associated
pneumonia, which action will the nurse include in the plan of
care for a patient who requires intubation and mechanical
ventilation? Elevate head of bed to 30 to 45 degrees
122.
68 A patient has a nursing diagnosis of ineffective airway
clearance related to thick, secretions. Which action will be best
for the nurse to include in the plan of care?
Offer the patient
fluids at frequent intervals
123.
68 A patient with acute respiratory distress syndrome
(ARDS) who is intubated and receiving mechanical ventilation
develops a pneumothorax. Which action will the nurse anticipate
taking?
Lower the positive end-expiratory pressure (PEEP)
124.
68 A patient with chronic obstructive pulmonary disease
(COPD) arrives in the emergency department complaining of
shortness of breath and dyspnea. Which assessment finding by
the nurse is most important to report to the health care provider?
The patients respiratory rate has decreased from 30 to 10
breaths/min
125.
68 When assessing a patient with chronic lung disease, the
nurse finds a sudden onset of agitation and confusion. Which

action should the nurse take first? Assess oxygenation using

pulse oximetry
126.
68 The nurse is caring for a 22-year-old patient who came
to the emergency department with acute respiratory distress.
Which information about the patient requires the most rapid
action by the nurse?
The patients PaO2 is 45 mm Hg
127.
9 Which information will the nurse plan to include when
teaching a patient with narcolepsy about management of the
disorder? Driving an automobile may be possible with
appropriate treatment of narcolepsy.
128.
9 The nurse takes the health history for four patients in the
clinic. Which information regarding the patients sleep is most
important to communicate to the health care provider?
A 41year-old with a body mass index (BMI) of 42 kg/m2 says that the
spouse complains about the patients snoring.
129.
9 A patient with sleep apnea who received a new
prescription for a continuous positive airway pressure (CPAP)
device a week ago returns to the clinic and says that severe
daytime fatigue is still a problem. Which action should the nurse
take first? Ask the patient whether the CPAP is being used every
night
130.
26 A patient with acute shortness of breath is admitted to
the hospital. Which action should the nurse take during the initial
assessment of the patient? Perform a respiratory system
assessment and ask specific questions about this episode of
respiratory distress.
131.
When preparing the patient with a right-sided pleural
effusion for a thoracentesis, how will the nurse position the
patient?
Sitting upright with the arms supported on an over
bed table
132.
26 A patient is admitted with a metabolic acidosis of
unknown origin. Based on this diagnosis, the nurse would expect
the patient to have
Kussmaul respirations
133.
26 On auscultation of a patients lungs, the nurse hears
short, high-pitched sounds during exhalation in the lower 1/3 of
both lungs. The nurse records this finding as
expiratory
wheezes in both lungs.
134.
26 The nurse palpates the posterior chest while the patient
says 99 and notes that no vibration is felt. How should this be
charted?
Absent tactile fremitus
135.
26 A patient with a chronic cough has a bronchoscopy.
Which action will be included in the nursing care plan after the
procedure? Keep the patient NPO until the gag reflex returns
136.
26 When auscultating a patients chest while the patient
takes a deep breath, the nurse hears loud, high-pitched,

blowing sounds at both lung bases. The nurse will document

these as
abnormal sounds
137.
26 While caring for a patient with respiratory disease, the
nurse observes that the patients SpO2 drops from 92% to 88%
while the patient is ambulating in the hallway. Which action
should the nurse take next? Administer the PRN supplemental
O2
138.
26 Which action will the nurse plan to take for a patient
who is scheduled for pulmonary function testing (PFT)?
Teach
deep inhalation and forceful exhalation.
139.
26 The nurse is observing a student who is listening to a
patients lungs. Which action by the student indicates a need to
review respiratory assessment skills?
The student places the
stethoscope over the scapulae and then auscultates
140.
26 A patient with chronic hypoxemia (SaO2 levels of 89%
to 90%) caused by chronic obstructive pulmonary disease
(COPD) has been hospitalized with increasing shortness of
breath. In planning for discharge, Arrange for the patients
spouse to be present during the teaching.
141.
26 A patient is admitted to the emergency department
complaining of sudden onset shortness of breath and is
diagnosed with a possible pulmonary embolus. To confirm the
diagnosis, the nurse will anticipate preparing the patient for a
spiral computed tomography (CT) scan
142.
The nurse is admitting a patient who has a diagnosis of an
acute asthma attack. Which information obtained by the nurse
indicates that the patient may need teaching regarding
medication use? The patient has been using the albuterol
(Proventil) inhaler more frequently over the last 4 days
143.
26 A patient with acute dyspnea is scheduled for a spiral
computed tomography (CT) scan. Which information obtained by
the nurse is most important to communicate to the health care
provider before the CT? The patient is allergic to shellfish
144.
26 When the nurse is analyzing the results of a patients
arterial blood gases (ABGs), which finding indicates the need for
most immediate action?
The partial pressure of oxygen in
arterial blood (PaO2) is 59 mm Hg.
145.
26 When assessing the respiratory system of a 78-year-old
patient, which finding indicates that the nurse should take
immediate action?
Crackles are heard from the lung bases
to the midline.
146.
26 A hypothermic patient is admitted to the emergency
department, and pulse oximetry (SpO2) indicates that the O2
saturation is 96%. Which action should the nurse take next?
Place the patient on high-flow oxygen

147.
After the nurse has received change-of-shift report, which
of these patients should be assessed first?
A patient with
possible lung cancer who has just returned after bronchoscopy
148.
26 The nurse has just received arterial blood gas (ABG)
results on four patients. Which result is most important to report
rapidly to the health care provider? pH 7.31, PaO2 91 mm Hg,
PaCO2 50 mm Hg, and O2 sat 96%
149.
26 The nurse obtains this information when assessing a
patient with chronic obstructive pulmonary disease (COPD) who
has been admitted with increasing dyspnea over the last 3 days.
Which finding is most important to report to the health care
provider? Respirations are 36 breaths/minute
150.
26 When performing an assessment of the patients
respiratory system, the nurse uses the following illustrated
technique to evaluate chest expansion
151.
26 Which nursing actions will be included when sending a
patient for computed tomography (CT) of the chest with contrast
(select all that apply)? Question the patient about allergies to
iodine, Review the recent blood urea nitrogen (BUN) and
creatinine levels
152.
pH
7.35-7.45
153.
PCO2 35-45 mmHg
154.
HCO3 22-26 mEq/L
155.
PO2 80-100mmHg
156.
V/Q influenced by partial pressure of O2 and CO2
157.
pH <7.35 acidosis: increased hydrogen concentration in
blood
158.
pH>7.45
alkalosis: decreased ion concentration in blood
159.
PCO2 <35 alkalosis
160.
PCO2>45 acidosis