RESPI (SAUNDERS; NCLEX-RN)

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?

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.

1. A low arterial Pco2 level

2. A hyper inflated chest noted on the chest x-ray

3. Decreased oxygen saturation with mild exercise

4. A widened diaphragm noted on the chest x-ray

5. Pulmonary function tests that demonstrate increased vital capacity

2,3

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse include on the list? Select all that apply.

1. Activities should be resumed gradually.

2. Avoid contact with other individuals, except family members, for at least 6 months.

3. 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.

6. When one sputum culture is negative, the client is no longer considered infectious a

1,3,4,5

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, would the nurse immediately report to the primary health care provider?

Hematuria

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding?

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?

Paradoxical chest movement

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse would assess for which earliest sign of acute respiratory distress syndrome?

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?

“I won’t be contagious after 2 to 3 weeks of medication therapy.”

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse would wear which items when performing this care?

Particulate respirator, gown, and gloves

A client has experienced pulmonary embolism. The nurse would assess for which symptom, which is most commonly reported?

Chest pain that occurs suddenly

A client who is human immunodeficiency virus (HIV)–positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

Positive

A client with acquired immunodeciency syndrome (AIDS) has histoplasmosis. The nurse would assess the client for which expected finding?

Dyspnea

The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

Shortness of breath

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse would ask the client whether the client wears which item during periods of exposure to silica particles?

Mask

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position would the nurse instruct the client to assume?

Sitting up and leaning on an overbed table

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply.

1. Dyspnea

2. Headache

3. Night sweats

4. A bloody, productive cough

5. A cough with the expectoration of mucoid sputum

1,3,4,5

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse would check the results of which diagnostic test that will confirm this diagnosis?

Sputum culture

A client has a prescription to take guaifenesin. The nurse determines that the client understands the proper administration of this medication if the client states that they will perform which action?

Increase water intake when taking the medication

The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid overdose. Which supportive medical equipment would the nurse plan to have at the client’s bedside?

Resuscitation equipment

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and would tell the client that which undesirable effect is associated with this medication?

Bronchospasm

Terbutaline is prescribed for a client with bronchitis. Which disorder in the client’s medical history requires caution by the nurse?

Diabetes mellitus

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?

Liver function tests

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

Peripheral neuritis

A client is to begin a 6-month course of therapy with isoniazid. The nurse would plan to teach the client to take which action?

Report yellow eyes or skin immediately.

A client has been started on long-term therapy with rifampin. The nurse would provide which information to the client about the medication?

Causes orange discoloration of sweat, tears, urine, and feces

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that they will immediately report which finding?

Difficulty in discriminating the color red from

green

A client with tuberculosis is starting antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse would ensure that which baseline study has been completed?

Liver enzyme levels

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse would administer the medication using which procedure?

Salmeterol first and then the beclomethasone

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse would monitor for which side and adverse effects of rifabutin? Select all that apply.

1. Signs of hepatitis

2. Flulike syndrome

3. Low neutrophil count

4. Vitamin B6 deficiency

5. Ocular pain or blurred vision

6. Tingling and numbness of the fingers

1,2,3,5

A client begins therapy with theophylline. The nurse plans to teach the client to limit the intake of which items while taking this medication?

Coffee, cola, and chocolate

The nurse has just administered the first dose of omalizumab to a client with asthma. Which statement by the client alerts the nurse of a life-threatening effect?

“My lips and tongue are swollen.”

The nurse is teaching a client who is beginning antiviral therapy for influenza. Which statement by the client indicates an understanding of the instructions?

“I must take the medication exactly as pre-

scribed.”

The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the client would the nurse note as an expected side effect of this combination medication?

“I feel as though my heart is racing.”

The nurse is assessing a client admitted with injuries sustained in a motor vehicle accident. Which of the following injuries poses the greatest risk to the client?

Fractures of the ribs

Which one of the following findings is characteristic of a tension pneumothorax?

Tracheal deviation toward the unaffected side

The nurse is caring for a client with a closed chest drainage system. If the tubing becomes disconnected from the system, the nurse should:

Form a water seal and obtain a new connector

The physician has ordered Theo-Dur (theophylline) for a client with emphysema. An expected side effect associated with the medication is:

Palpitations

Which condition would contraindicate the use of chest physiotherapy for a client with pneumonia?

Recent abdominal cholecystectomy

The nurse is interpreting the result of a client’s TB skin test. Which one of the following factors is responsible for a false positive TB skin test?

Inoculation with BCG vaccine

The physician has ordered Cytoxan (cyclophosphamide) for a client with pulmonary fibrosis. The nurse should instruct the client to:

Notify the doctor of a sore throat or fever

The physician has received a limited supply of influenza vaccine. Which one of the following clients should receive priority in receiving the influenza immunization?

A resident in a nursing home

The physician has ordered pyrazinamide for a client with tuberculosis. The nurse should tell the client to:

Increase his fluid intake

The nurse is caring for a client with Legionnaires’ disease. Which one of the following types of isolation should the nurse use when caring for the client?

No isolation precautions are needed