Fundamentals Of Nursing NCLEX Quiz 17

1. Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective?

“I should breathe out as fast and as hard as possible into the device.”

“I should inhale slowly and steadily to keep the balls up.”

“I should use the device three times a day. after meals.”

“the entire device should be washed thoroughly in sudsy water once a week.”

Proper use of an SMI requires the client to take slow. steady inhalations. every hour or two. 5 to 10 reps each time. Only the mouthpiece can be successfully rinsed or wiped clean. The device should not be submerged in water (option 4).

Explanation

Proper use of an SMI requires the client to take slow. steady inhalations. every hour or two. 5 to 10 reps each time. Only the mouthpiece can be successfully rinsed or wiped clean. The device should not be submerged in water (option 4).

2. Which term does the nurse document to best describe a client experiencing shortness of breath while lying down who must assume an upright or sitting position to breed more comfortably and effectively?

Dyspnea

Hyperpnea

Orthopnea

Acapnea

Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea.

Explanation

Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea.

3. A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse respond by saying that the corticosteroids will do which of the following?

Promote bronchodilation.

Help the client to cough.

Prevent respiratory infection.

Decrease inflammation in the airways.

Glucocorticoids are prescribed because of their anti-inflammatory effect. Options 1. 2. and 4 are not achieved with glucocorticoids.The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients care? 1.Percussion and postural drainage should be done before lunch.

Explanation

Glucocorticoids are prescribed because of their anti-inflammatory effect. Options 1. 2. and 4 are not achieved with glucocorticoids.The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients care? 1.Percussion and postural drainage should be done before lunch.

4. While a client with chest tubes is ambulating. the connection between the tube and the water seal dislodges. Which action by Nurse Flora is most appropriate?

Assist the client to ambulate back to bed.

Reconnect to the tube to the water seal.

Assess the clients lung sounds with a stethoscope.

Have the client cough forcibly several times.

The tube should be reconnected to the water seal as quickly as possible. Assisting the client back to bed (option 1) and assessing the clients lung (option 3) are possible actions after the system is reconnected.

Explanation

The tube should be reconnected to the water seal as quickly as possible. Assisting the client back to bed (option 1) and assessing the clients lung (option 3) are possible actions after the system is reconnected.

5. Nurse Peter makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has:

Anemia.

An infection.

A fractured rib.

A tumor of the medulla.

Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. Option 2 would depend on where the infection is located. Option 3: A fractured rib would interrupt transport of oxygen from the atmosphere to the airways. Option 4: Damage to the medulla would interfere with neural stimulation of the respiratory system.

Explanation

Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. Option 2 would depend on where the infection is located. Option 3: A fractured rib would interrupt transport of oxygen from the atmosphere to the airways. Option 4: Damage to the medulla would interfere with neural stimulation of the respiratory system.

6. Nurse Winona teaches a patient how to use an incentive spirometer. What patient outcome will support the conclusion that the use of the incentives spirometer was effective?

Supplemental oxygen use will be reduced.

Inspiratory volume will be increased.

Sputum will be expectorated.

Coughing will be stimulated.

An incentive spirometry or provides a visual goal for and measurement of inspiration. It encourages the patient to execute and maintain a sustained inspiration. A sustained inspiration opens airways. increases the inspiratory volume. and reduces the risk of atelectasis. Patients who use an incentive spirometer may or may not be receiving oxygen (option1). Although sputum may be expectorated after the use of an incentive Iran mature. this is not the primary reason for its use (option 3). Although the deep breathing associated with the use of an incentive barometer may stimulate coughing. this is not the primary reason for its use (option 4).

Explanation

An incentive spirometry or provides a visual goal for and measurement of inspiration. It encourages the patient to execute and maintain a sustained inspiration. A sustained inspiration opens airways. increases the inspiratory volume. and reduces the risk of atelectasis. Patients who use an incentive spirometer may or may not be receiving oxygen (option1). Although sputum may be expectorated after the use of an incentive Iran mature. this is not the primary reason for its use (option 3). Although the deep breathing associated with the use of an incentive barometer may stimulate coughing. this is not the primary reason for its use (option 4).

7. Which action by the nurse represents proper nasopharyngeal/nasotracheal suctioning technique?

Lubricate the suction catheter with petroleum jelly before and between insertion.

Apply suction intermittently while inserting the suction catheter.

Rotate the catheter while applying suction.

Hyper oxygenate with 100% oxygen for 30 minutes before and after suctioning

Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and the side. Suction catheters may only be lubricated with water or water-soluble lubricant and petroleum jelly such as Vaseline has an oil base (option one). no suction should ever be applied while the catheters being inserted because this can traumatize tissues (option two). The client should be hyper-oxygenated for only a few minutes before and after suctioning and this is generally limited to clients who are intubated or have a tracheostomy (option four).

Explanation

Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and the side. Suction catheters may only be lubricated with water or water-soluble lubricant and petroleum jelly such as Vaseline has an oil base (option one). no suction should ever be applied while the catheters being inserted because this can traumatize tissues (option two). The client should be hyper-oxygenated for only a few minutes before and after suctioning and this is generally limited to clients who are intubated or have a tracheostomy (option four).

8. Nurse Trixie is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action?

Tells the client to raise two fingers to indicate pain or distress.

Changes twill tape holding the tracheostomy and place.

Cleans the incision site.

Checks the tightness of the ties and knot

Prior to starting the procedure. it is important to develop a means of communication by which the client can express pain or discomfort. The twill tape is not changed until after performing tracheostomy care (option 2). Cleaning the incision should be done after cleaning the inner cannula (option 3). Checking the tightness of the ties and knot is done after apply new twill tape (option 4).

Explanation

Prior to starting the procedure. it is important to develop a means of communication by which the client can express pain or discomfort. The twill tape is not changed until after performing tracheostomy care (option 2). Cleaning the incision should be done after cleaning the inner cannula (option 3). Checking the tightness of the ties and knot is done after apply new twill tape (option 4).

9. Nurse Aleli is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients care?

Percussion and postural drainage should be done before lunch.

The order should be coughing. percussion. positioning. and then suctioning.

Percussion and postural drainage should always be preceded by three minutes of 100% oxygen.

Postural drainage result in expectoration of large amounts of mucus. Client sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity. which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort.

Explanation

Postural drainage result in expectoration of large amounts of mucus. Client sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity. which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort.

10. To prevent postoperative complications. Nurse Kim assists the client with coughing and deep breathing exercises. This is best accomplished by implementing which of the following?

Coughing exercises one hour before meals and deep breathing one hour after meals.

Forceful coughing as many times as tolerated.

Huff coughing every two hours or as needed.

Diaphragmatic and pursed lip breathing 5 to 10 times. four times a day

Huff coughing helps keep the airways open and secretions mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough (such as postoperatively) deep breathing and coughing should be performed at the same time. Only at mealtimes is not sufficient (option 1). Extended forceful coughing fatigues the client. especially postoperatively (option 2). Diaphragmatic and pursed lip breathing are techniques used for clients with obstructive airway disease (option 4).

Explanation

Huff coughing helps keep the airways open and secretions mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough (such as postoperatively) deep breathing and coughing should be performed at the same time. Only at mealtimes is not sufficient (option 1). Extended forceful coughing fatigues the client. especially postoperatively (option 2). Diaphragmatic and pursed lip breathing are techniques used for clients with obstructive airway disease (option 4).