care Of Clients With Respiratory Disorders

1. A client has active TB. Which of the following clinical manifestations will he exhibit?

Chest and lower backpain

Headache and fever

Fever, night sweats, chills, hemoptysis

Fever of more than 140F and nausea

Fever, chills, ng=ight sweats and hemoptysis are the characteristic manifestations of a client with active TB.

Explanation

Fever, chills, ng=ight sweats and hemoptysis are the characteristic manifestations of a client with active TB.

2. A 40-year old male returned ti his room an hour ago following bronchoscopy. He is requesting for a glass of water. The nurse must first:

Keep the client on NPO until an order is written.

Check the vital sign.

Check the gag reflex and swallowing reflexes.

Encourage deep breathing and coughing.

After the bronchoscopy, the nurse must check the gag and swallowing reflexes before resuming intakes to prevent aspiration.

Explanation

After the bronchoscopy, the nurse must check the gag and swallowing reflexes before resuming intakes to prevent aspiration.

3. A client with chest tube has accidentally removed it. What should be done first?

Lie the client down on the left side.

Lie the client on the right side.

Apply an occlusive dressing over the site.

Reinsert the chest tube that fell out.

In cases a chest tube is accidentally removed, apply an occlusive dressing over the site to prevent tension pneumothorax and collapse of the lungs.

Explanation

In cases a chest tube is accidentally removed, apply an occlusive dressing over the site to prevent tension pneumothorax and collapse of the lungs.

4. A 19-year old client comes to the emergency department with acute asthma. His respiratory rate is 44 bpm and he appears in acute respiratory distress. Which of the following actions should be taken first?

Take a full nursing history

Administer bronchodilator by nebulizer

Provide emotional support to the client

Administer oxygen 6L/m

The first nursing intervention for a client with acute asthmatic attack is to OPEN THE AIRWAY. Administer bronchodilator by nebulizer.

Explanation

The first nursing intervention for a client with acute asthmatic attack is to OPEN THE AIRWAY. Administer bronchodilator by nebulizer.

5. A client was admitted to the hospital with client chest pain and shortness of breath. Arterial blood gases were: pH=7.52, pCO2= 27, HCO3= 22. These values indicate:

Respiratory alkalosis

Respiratory acidosis

Metabolic alkalosis

Metabolic acidosis

ABG values of pH=7.52, pCO2= 27, HCO3= 22 indicate respiratory alkalosis (pH is high- alkalosis; pCO2 is low- respiratory alkalosis).

Explanation

ABG values of pH=7.52, pCO2= 27, HCO3= 22 indicate respiratory alkalosis (pH is high- alkalosis; pCO2 is low- respiratory alkalosis).

6. Which of the following additional assessment data should immediately be gathered to determine the status of a client with a respiratory rate of 4 breaths/minute?

ABG and breath sounds

Level of consciousness and a pulse oximetry values

Breath sounds and reflexes

Heart sounds and reflexes

Level of consciousness and pulse oximetry values are most important assessment data that should immediately be gathered in a client whose respiratory rate is very slow. (4 breaths per minute) to determine much oxygen the client needs.

Explanation

Level of consciousness and pulse oximetry values are most important assessment data that should immediately be gathered in a client whose respiratory rate is very slow. (4 breaths per minute) to determine much oxygen the client needs.

7. A client with emphysema is observed to have labored breathing and exhibits slow, shallow respiration.. This endangers him to develop :

Respiratory alkalosis

Respiratory acidosis

Metabolic alkalosis

Metabolic acidosis

Slow, shallow respirations will cause carbon dioxide retention. This leads to RESPIRATORY ACIDOSIS.

Explanation

Slow, shallow respirations will cause carbon dioxide retention. This leads to RESPIRATORY ACIDOSIS.

8. A 52 yera old client is being discharged following laryngectomy for cancer of the larynx. Prior to discharge, the nurse assesses the following psychomotor skills:

Administering injections, changing dressing and chest physiotherapy

Taking the blood pressure, pulse rate and monitoring serum glucose

Suctioning and caring for tracheostomies and tracheostomy tube

Tube feeding, taking aerosol medications and taking blood pressure

The client who had undergone laryngectomy for cancer of the larynx has permanent tracheostomy. He should learn the skills od suctioning and care of tracheostomy and tracheostomy tube.

Explanation

The client who had undergone laryngectomy for cancer of the larynx has permanent tracheostomy. He should learn the skills od suctioning and care of tracheostomy and tracheostomy tube.

9. A 74-year old is diagnosed with tuberculosis. Which of the following laboratory reports most accurately confirms the diagnosis?

Chest X-ray

Sputum culture

Complete blood count

Mantoux test

the most accurate laboratory test that confirms diagnosis of TB is sputum culture.

Explanation

the most accurate laboratory test that confirms diagnosis of TB is sputum culture.

10. Which of the following would be considered most normal in the water - seal chamber withig the first 24 hours postoperatively with a two-bottle water-seal drainage?

No fluctuation in the water - seal tube

Intermittent, slight bubbling from the water-seal tube

Bright-red blood bloody drainage

Continuous bubbling in the water-seal tube

Ia a two-bottle seal drainage, INTERMITTENT, SLIGHT BUBBLING from the water-seal bottle (chamber) is NORMAL. (But if Pleur-evac is used, there should be NO bubbling in the water-seal chmaber).

Explanation

Ia a two-bottle seal drainage, INTERMITTENT, SLIGHT BUBBLING from the water-seal bottle (chamber) is NORMAL. (But if Pleur-evac is used, there should be NO bubbling in the water-seal chmaber).

11. Which of the following breathing techniques does the nurse teache a client with pulmonary emphysema that will assist in exhalation?

Push on abdomen during exhalation.

Sit in high-Fowler's position with legs extended

Lean forward 30 to 40 degrees with each exhalation.

Sit up with shoulders back.

The breathing technique that will assist in exhalation of a client with emphysema is to lean forward 30 to 40 degrees with each exhalation.

Explanation

The breathing technique that will assist in exhalation of a client with emphysema is to lean forward 30 to 40 degrees with each exhalation.

12. The nurse enters the room of a client with COPD. The client's oxygen is running at 8L/min. The nurse's best initial nursing action is:

Check the doctor's order

Lower the oxygen rate at 2L/min

Take the vital sign

Put the client in Fowler's position

The safest amount of oxygen to be given to a patient with COPD is 2L/min. High oxygen concentration will depress the drive for breathing and respiratory arrest may occur.

Explanation

The safest amount of oxygen to be given to a patient with COPD is 2L/min. High oxygen concentration will depress the drive for breathing and respiratory arrest may occur.

13. The most comfortable position for the client with COPD is:

Semi-Fowler's pisition

Sitting upright leaning forward

Lateral position

High-Fowler's position

The most comfortable position for the client with COPD is SITTING UPRIGHT, LEANING FORWARD. This position enhances lung expansion and exhalation of carbon dioxide as well.

Explanation

The most comfortable position for the client with COPD is SITTING UPRIGHT, LEANING FORWARD. This position enhances lung expansion and exhalation of carbon dioxide as well.

14. The nurse teaches an adolescent who has had a tonsillectomy which of the following?

Avoid coughing and cleaning the throat the first week postoperatively.

Do not eat or drink anything for the first 24 hours.

If your stool is black for the first few days postop, notify the doctor.

Avoid cold beverages to prevent irritation of the throat.

After tonsillectomy, the client should be instructed to avoid coughing and clearing the throat the first week postop. This is to prevent bleeding.

Explanation

After tonsillectomy, the client should be instructed to avoid coughing and clearing the throat the first week postop. This is to prevent bleeding.

15. A 49-year old client with cancer of the lung just had thoracentesis. The nurse would position the client:

On the affected side

On the unaffected side

Semi-fowler's position

On his back

After the thoracentesis, the client should be positioned on the unaffected side to prevent leakage of pleural into the thoracic cavity.

Explanation

After the thoracentesis, the client should be positioned on the unaffected side to prevent leakage of pleural into the thoracic cavity.

16. Before starting on Isoniazid (INH), a client will probably have which of the following laboratory tests?

AST and ALT

BUN, serum creatinine

Serum glucose level

Blood uric acid level

INH is hepatotoxic. Liver enzyme studies like AST and ALT should be check before starting INH.

Explanation

INH is hepatotoxic. Liver enzyme studies like AST and ALT should be check before starting INH.

17. Which of the following will the nurse interpret as positive Mantaux test?

Redness greater than 5mm.

Swelling greater than 7mm.

Induration greater than 20mm.

Exudates covering more than 12mm.

Mantoux test is induration greater than 10mm.

Explanation

Mantoux test is induration greater than 10mm.

18. The client had undergone total laryngectomy. He has permanent tracheostomy. Which of the following action needs intervention during tracheal suctioning?

The nurse dons sterile gloves and uses sterile suction catheter.

The nurse administers 100% oxygen before and after the suctioning.

The nurse applies suction for 30 seconds at a time.

The nurse applies suction during withdrawal of the suction catheter tip.

When the nurse applies suction fir 30 seconds at a time, her nursing action needs intervention (need to be corrected). Prolonged suctioning may cause hypoxia, vagal stimulation and bleeding.

Explanation

When the nurse applies suction fir 30 seconds at a time, her nursing action needs intervention (need to be corrected). Prolonged suctioning may cause hypoxia, vagal stimulation and bleeding.