N240 Olol - Test 1 - Nclex Questions From Book And 3500 For Test 1

Front 1

of the following O2 admin. devices, which has the advantage of providing high O2 concentration?

Back 1

a. venturi mask
b. non-rebreather mask
c. face tent
d. catheter



b-

Front 2

Which respiratory volume is the max. volume of air that can be inhaled after max. expiration?

Back 2

inspiratory reserve volume

is normally 3000ml

Front 3

What is the term that describes injuries that occur when a person is caught btw objects, run over by a moving vehicle, or compressed by machinery?

Back 3

crush injuries

Front 4

A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the 2nd chamber of the Pleur-evac isn't bubbling. Which nursing assumption would be most invalid?

Back 4

1. the tubing from the client to the chamber is blocked
2. there is a leak somewhere in the tubing system
3. the client's affected lung has reexpanded
4. the tubing needs to be cleared of fluid

2- bubbling in the 2nd chamber of a Pleur-evac system signifies that air is moving from the collection chamber to the water seal chamber. It's normal for bubbling during inspiration, but continous bubbling signifies a leak in the closed system.

Front 5

A nursing instructor is observing a nursing student suctioning fluids from a client through a trach tube
which observation by the nursing instructor would indicate an inappropriate action?

Back 5

suctioning each hour

Front 6

A nurse is preparing for removal of an endotracheal tube from a client. In preparing to assist the physician in this procedure, which initial nursing action is most appropriate?

Back 6

1. suction the endo tube
2. deflate the cuff
3. turn the ventilator off
4. obtain a code cart and place it at the bedside



1. since this will be removed when pt has been weaned it should be suctioned first then the cuff deflated. no reason for a code cart

Front 7

A client is intubated with an endotraceal tube by the anesthesiologist. What is the responsibility of the nurse regarding checking for tube placement immediately following tube insertion ?

Back 7

1. the nurse is not responsible for tube placement
2. arrange for a chest radiograph
3. auscultate the lungs for the presence of bilateral breath sounds
4. instill air into the endo. tube and listen for it being forced into the lungs



3.auscultating is an immediate action

Front 8

What are some adverse effects of suctioning

Back 8

cynosis, excessively rapid or slow hear rate, or sudden development of bloody secretions. stop and report to MD immediately

Front 9

The client with a newly inserted trach. has a Risk for Impaired Gas Exchange. the nurse would assess for which of the following items as the best indicator of adequate ongoing resp. status?

Back 9

1. moderate amts of trac. secretions
2. small to moderate amt of frank bl. suctioned from the tube
3. resp rate of 18 breaths/min
4. O2 sat of 91%




3. within normal range
a new trach could cause excessive secretions, bleeding into the trachea, restricted lung expansion caused by immobility, or concurrent respiratory conditions so a normal respiration is good

Front 10

The nurse is monitoring the resp status of a client following insertion of a trac. The nurse understands that O2 sat. measurements obtained by pulse oximetry may be inaccurate if the client has which of the following coexisting problems?

Back 10

1. hypotension
2. fever
3. respiratory failure
4. epilepsy




1. hypotension, shock or the use of peripheral vasoconstructing meds. may result in inaccdurate pulse ox. readings from impaired peripheral perfusion.

Front 11

The nurse is monitoring the function of a Pleur-evac system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse interprets that as

Back 11

1. the client has residual pneumothorax
2. the system is patent
3. suction should be added to the system
4. the system has a leak



2. this is normal and is called tidaling

Front 12

The nurse is caring for the postoperative pneumonectomy client and assesses the client for which adverse s/s indicating Pulmonary edema?

Back 12

1. resp rate of 20 b/min
2. pain with deep breathing
3. lung crackles
4. increased chest tube drainage

3. s/s of PE are dyspnea, cough, frothy sputum, crackles, and possibly cyanosis.

Front 13

The nurse is developing a plan of care for a client at risk for acute resp distress syndrome. The nurse includes to assess for early signs by monitoring the client for?

Back 13

1. dyspnea
2. frothy sputum
3. diminished breath sounds
4. edema



1. in most cases dyspnea and tachypnea are the 1st clinical manifestations.

Front 14

A nurse is caring for a client on a mech,. ventilator who has a nasogastric tube in place. The nurse is assessing the Ph of the hastric aspirate and notes that the pH is 4.5. Based on this finding, which of the following nursing actions would be most appropriate?

Back 14

1. document the findings
2. reassess the pH in 4 hrs
3. instill 30 ml sterile water
4. adm. as-needed dose of prescribed antacid



4. monitor this type of pt every 12 hrs or at beginning of shift. a pH less than 5 can put pt at risk for stress ulcers

Front 15

A nurse caring for a client on a mech vent, hears the high-pressure alarm. The nurse suspects that the most likely cause is?

Back 15

1. a disconnection of the vent. tubing
2. an exaggerated client inspiratory effort
3. generation of extreme negative pressure by the client
4. accumulation of resp. secretions



4. when the preset peak inspiratory pressure limit is reached by the ventilator b4 it has delivered a set tidal volume sets off a high-pressure alarm
causes include tubing obstruction or kinks, breathing "out of phase" or "buckling the ventilator", accumulation of secretions, condensation of water in the vent. tubing, coughing or Valsalva's maneuvers, increased airway resistance, bonchospams, decreased pulmonary compliance or pneumothorax.

Front 16

A nurse caring for a client on a mech. vent. The low-pressure alarm sounds. The nurse suspects that which of the following is the cause of this alarm?

Back 16

1. tubing obstruction or kink
2. the accumulation of secretions
3. condensation of water in the vent. tubing
4. disconnection of the vent.tubing




4, it sounds when little or no pressure is generated during the del of the machine breaths. Causes include disconnection of the tubing or a cuff leak. also by exaggerated client resp effort generating extreme negative pressure

Front 17

While caring for a client with a chest tube, he sat up and accidentally disconnected the tubing. What should the nurse do?

Back 17

1. place the end in sterile water
2. contact the physician
3. call a resp. therapist
4. encourage the Valsalva's maneuver




1. causes an underwater seal

Front 18

If the chest tubing pulls out of the pleural cavity, what should the nurse do?

Back 18

apply an occulisive dressing then contact the Physician

Front 19

A cliet as the nurse why his O2 flow rate could not be increased to more than 2 L/min. The nurse responds that this would be harmful b/c it could?

Back 19

1. increase the risk of pneumonia from drier air passages
2. be drying to nasal passages
3. decrease the client's oxygen-based respiratory drive
4. decrease the client's carbon dioxide-based respiratory drive




3 - normally respiratory rate varies with the amt of carbon dioxide present in the blood. In clients with COPD, this natural center becomes ineffective after exposure to high carbon dioxide levels for prolonged periods of time. Instead, the level of O2 provides the resp. stimulus. The COPD client cannot not increase O2 rates independently b/c it could obliterate the resp. drive, leading to resp. failure

Front 20

The nurse knows that the natural consequence of insufficient surfactant is?

Back 20

1. collaspe of alveoli and decreased compliance
2. bronchoconstriction and stridor
3. decreased ciliary action and retained secretions
4. atelectasis and viral infections




1- surfactant decreases surface tension in the lungs. this prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" b/c of decreased compliance.

Front 21

A nurse is caring for a client who is retaining carbon dioxide because of respiratory dx. The nurse anticipates that as the client's Co2 level rises, the pH should?

Back 21

1. rise
2. fall
3. remain unchanged
4. double




2- CO2 acts as an acid in the body. Therefore with a rise in CO2 is a corresponding fall in pH. This concept forms the basis for key aspects of acid-base balance.

Front 22

A nurse reads in the progress notes of a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. The nurse interprets this occurrence as the presence of?

Back 22

1. anatomical dead space
2. physiological dead space
3. shunting
4. ventilation-perfusion matching




3- shunting occurs when a portion of the lung area has adequate capillary perfusion but is not being ventilated. As a result, no gas exchange occurs.

Front 23

A nurse is monitoring the status of the client who is being treated for dyspnea. The nurse is aware that which of the following factors will decrease the work of breathing for this client?

Back 23

1. increased mucous production
2. interstitial pulmonary edema
3. increased airway resistance
4. bronchodilation




4- bronchodilation decreases the airway resistance and decreases the work of breathing for the cline. Clients with dyspnea who have increased mucous production, edema or bronchospasm have increased airway resistance, which increase the work of breathing for the client

Front 24

A nurse explains to a client that gas exchange occurs through a process called?

Back 24

diffusion

means that oxygen and carbon dioxide move across the alveolar-capillary membrane b/c of a pressure gradient.

Front 25

A client has a chest tube attached to a Pleur-evac drainage system. As part of routine nursing care, the nurse would ensure that?

Back 25

1. the connection btw the chest tube and the drainage system is taped and that an occlusive dressing is maintained at the insertion site

Front 26

A nurse is planning care for a client scheduled for insertion of a trach. What equipment should the nurse plan to have at the bedside when the client returns from surgery?

Back 26

1. oral airway
2. epinephrine
3. obturator
4. tracheostomy set with the next larger size




3- a replacement tube of the same size and an obturator are kept at the bedside at all times. also a curved hemostat also should be kept at bedside to hold the trachea open if dislodgment occurs

Front 27

A nurse witnesses an accident wherin an automobile hits a pedestrian. The nurse stops at the scene and assesses the victum. The nurse notes that the client is responsive and has suffered a flail chest involving at least 3 ribs. The nurse does which of the following to assist the client's respiratory status until help arrives?

Back 27

1. the nurse assists the victum to sit u[
2. the nurse turns the client onto the side of the flail chest
3. the nurse removes the victum's shirt
4. the nurse applies firm but gentle pressue with the hands to the flail segment


4-
this stabilizes the chest wall,

Front 28

A nurse is caring for the following group of clients on the clinical nursing unit. The nurse interpretes that which of these clients is at most at risk for the development of pulmonary embolism?

Back 28

1. a 65-yr old man out of bed 1 day after prostate resection
2. a 73-yr old woman who has just had a pinning of a hip fracture
3. a 25-yr old woman with diabetic ketoacidosis
4. a 38-yr old man with pulmonary contusion after an auto accident


2=
immobilized client

Front 29

A nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal resp functioning and the nurse provides instructions to assist the client toward this goal. Which statement by the client indicates that further instructions are needed?

Back 29

1. I will let u know at once if I have trouble breathing
2. I will lie on the affected side for an hour
3. I can expect a chest x-ray to be done shortly
4. I will notify you if I feel a crackling sensation on my chest




2- the client would be turned on the unaffected side for 1 hr to facilitate lung expansion

Front 30

A physician writes an order to begin to wean the client from the mechanical vent. by use of intermittent mandatory ventilation/synchronized intermittent mandatory vent. The nurse determines that the process of weaning will occur by?

Back 30

1. gradually decreasing the resp rate on the vent. until the client assumes the work of breathing
2. providing pressure support to decrease the workload of breathing and increase the clinet's ability to initiate spontaneous breathing efforts
3. attaching a T-pc to the vent. and providing supplemental O2 that is 10% higher than the vent. setting
4. removing the vent. from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amt of time



1- the resp rate is decreased gradually until the clien assumes all of the work of breathing. works exceptionally well in the weaning of clients from short-term mech. vent such as that used in clients who have undergone surgery. The resp rate is decreased hourly until the client is weaned and is ready for extubation

Front 31

A nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical vent. The nurse notes that the tidal volume is set at 700 ml and determines that the tidal volume indicates/

Back 31

1. the number of breaths that the client will recieve per min. by the ventilator
2. the amt of air delievered with each set breath
3. the fraction of inspired O2 that is delivered to the client through the vent.
4. a breath that has a greater volume than the preset tidal volume



2- the resp rate is the number of breaths to be delivered by the vent.

Front 32

A nurse is reviewing the ABG results of a client in the resp care unit and notes a pH of 7.38, PaCo2 of 38 mm Hg, PaO2 of 86 mm Hg and HCO2 of 23 mEq/L. The nurse interprets the client's blood gases indicate which of the following?

Back 32

1. normal results
2. metabolic alkalosis
3. metabolic acidosis
4. respiratory acidosis


1 normal results

Front 33

A client experienced an open pneumothorax and a sucking chest wound, which has been covered with an occlusive dressing. The client begins to experience sever dyspnea, and the blood pressure begins to fall. The nurse first should?

Back 33

1. remove the dressing
2. reinforce the dressing
3. call the physician
4. measure O2 saturation by oximetry


1- placement of a dressing over
a sucking chest would could convert an open pneumothroax to a closed (tension) pneumothorzx. This could result in a sudden decline in resp. status, mediastinal shift, twisting of the great vessels, and circulatory compromise. If this occurs, the nurse removes the dressing immediately, allowing air to escape. The nurse then contacts the physician and monitors the client's vital signs and oxygen saturation

Front 34

A nurse is assisting a physician with the removal of a chest tube. The nurse most appropriately instructs the client to?

Back 34

1. stay very still
2. inhale and exhale quickly
3. exhale slowly
4. perfom Valsalva's maneuver




4- Valsalva's manuver is to take a deep breath, exhale, and bear down. the tube is quickly withdrawn, and an airtight dressing is taped in place.

Front 35

An ER nurse is assessing a client who sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?

Back 35

1. a sucking sound at the site of injury
2. diminished breath sounds
3. a low respiratory rate
4. the presence of a barrel chest


2- basic symptoms of a closed pneumothorax are shortness of breath and chest pain.

Front 36

A nurse reviews the arterial blood gas values of a client. The results indicate respi. acidosis. Which of the following values would indicate that is acid-base imbalance exists?

Back 36

1. ph of 7.48
2. PCO2 of 32 mm Hg
3. Ph of 7.30
4. HCO3 of 20 mEQ/L




3

Front 37

ABG shows:
pH 7.50
Pco2 30 mm Hg
Hco3 25 mEq/L

This readings is?

Back 37

1. resp acid uncompensated
2. resp alka. uncompensated
3. metabolic acid. uncompensated
4. metabolic acid partially compensated


2

Front 38

A nurse is careing for a client with ARDS. Which of the following would the nurse expect to note in the client?

Back 38

1. decreased resp. rate
2. pallor
3. low arterial Pao2
4 an elevated arterial Pao2

3
the earliest clinical sign of ARDS is an increased resp rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. ABG reveals increasing hypoxemia, with a Pao2 of less than 60 mm Hg

Front 39

A client is suspected of having a PE. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of PE?

Back 39

1. decreased respirations
2. bradypnea
3. dyspnea
4. bradycardia

3. signs are, tachypnea, tachycardia, dyspnea and chest pain

Front 40

A client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest?

Back 40

1. cyanosis
2. hypotension
3. dyspnea, especially on exhalation
4. paradoxical chest movement




4

Front 41

A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the vent. sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of?

Back 41

1. displaced endotracheal tube
2. ARD
3. pulmonary embolism
4. right pneumothorax




4. is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. can cause increased airway pressure b/c of resistancde to lung inflatio.

Front 42

The nurse is preparing to care for a client who will be weaned from a cuffed trach tube. The nurse is planning to use a trach plug and plans to insert it into the opening in the outer cannula. Which of the following nursing intervention is required b4 plugging the tube?

Back 42

1. place the inner cannula into the tube
2. deflate the cuff on the tube
3. ensure that the client is able to swallow
4. ensure that the client is able to speak

2-
plugging a trch tube usually is done by inserting the trach plug into the opening of the outer cannula. This closes off the trach and air flow, and respiration occurs normally through the nose and mouth. When plugging a cuffed trach tube, the cuff must be deflated. If the cuff remains inflated,k ventilation cannot occur and respiratory arrest could result. The inner cannula is removed b4 plugging the trach tube

Front 43

The client who has just suffered a large flail chest is experiencing sever pain and dyspnea. The client's central venous pressure is rising, and the arterial blood pressure is failing. The nurse interprets that the client is experiencing

Back 43

1. mediastinal flutter
2. mediastinal shift
3. hypovolemic shock
4. fat embolism



1-the client with severe flail chest will have sig. paradoxical chest movement. This causes the medistinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client's central venous pressure rises, the filling of the right side of the heart is impaired and the arterial bl. pressure falls.

Front 44

A client who has a pneumonectomy is in the post anethesia care unit. The nurse's primary concern at this time would be to maintain?

Back 44

1. blood replacement
2. ventilatory exchange
3. closed chest drainage
4. supplementary oxgenation




2. oxygen and carbon dioxide exchange is the priority

Front 45

A client is admitted to the intensive care unit with ARDS. When assessing this client the nurse should expect to find?

Back 45

1. Hypertension
2. Tenacious sputum
3. an altered mental state
4. a slow rate of breathing




3- this is secondary to cerebral hypoxia, which accompanies ARDS; cognition and level of consciousness are reduced

Front 46

A client's resp status necessitates endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for this cline at this time would be to?

Back 46

3- the effectiveness of therapy is measured by the client's response - assess your patient!

Front 47

A client has been admitted to the ER with multiple injuries including fractured ribs. Because of the broken ribs, the nurse should assess for signs of?

Back 47

1. pneumonia
2. Hematemesis
3. pulmonary edema
4. respirtory acidosis



4- pain causes shallow breathing, which results in carbon dioxide retention

Front 48

A client is placed on a ventilator. Because hyperventilation can occur when mechanical ventilation is used, the nurse should monitor the client for signs of?

Back 48

1. hypoxia
2. hypercapnia
3. metabolic acidosis
4. respiratory alkadosis




4- increased rate and depth of breathing results in excessive elimination of CO2, and resp. alkalosis could result

Front 49

After surgery in the inguinal area, the client complains of pain on the right side of the chest, becomes dyspneic and begins to cough violently. The nurse suspects that a PE has occured. The nurse should immediatley?

Back 49

1. ausculate the chest
2. obtain vital signs
3. elevate the head of the bed
4. position the clien on the right side



3- this promotes breathing by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion

Front 50

The nurse knows that when a client has a trach tube with a high-volume, low-pressure cuff, it is used primarily to prevent?

Back 50

1. lung infection
2. leakage of air
3. mucosal necrosis
4. tracheal secretions



3- these cuffs do not compress the capillary beds and thus do not cause tracheal damage

Front 51

A 21-yr old client comes to the ER with the chief complaint of left-sided chest pain following a racquetball game. A chest x-ray exam reveals a left pneumothorax. When assessing the left side of the client's chest, the nurse would expect to find?

Back 51

1. a dull sound on percussion
2. vocal fremitus on palpatation
3. rales and rhonchi on ausculatation
4. an absence of breath sounds on ausculation



4- the left lung has collapsed; there are no breath sounds

Front 52

A client with a pneumothorax asks, "Why did they put this tube into my chest?". The nurse should explain that the purpose of the chest tube is to?

Back 52

1. check for bleeding in the lung
2. monitor the function of the lung
3. drain fluid from the pleural space
4. remove air from the pleural space




4- with a pneumothorax, a chest tube attached to a closed chest drainage system removes trapped air and helps to reestablish negative pressure within the pleural space resulting in lung reinflation

Front 53

The nurse in the ER has been notified that a person with a gunshot would to the right side of the chest will arrive soon. The nurse should plan to?

Back 53

1. reserve an operating room
2. prepare equipment for a trach
3. arrange for a portable x-ray machine
4. obtain equipment for chest tube insertion




4. the priorty is to stabilize the respiratory status.

Front 54

A chest tube is inserted after a crushing chest injury. The observation that indicates a desired response to treatment of the client's chest injury would be?

Back 54

1. increased breath sounds
2. increased respiratory rate
3. crepitus detected on palpatation of the chest
4. constant bubbling in the drainage collection chamber



1- the chest tube normalizes intrathoracic pressure, drains fluid and air from the pleural space, and improves pulmonary function

Front 55

On the way to an x-ray exam a clien with a chest tube becomes confused and pulls the chest tube out. the nurse's immediate action should be to?

Back 55

1. place him in the Trendelenburg's position
2. hold the insertion site open with a Kelly clamp
3. obtain a sterile Vaseline gauze to cover the opening
4. cover the opening with the cleanest material availible



4- this is an emergency situation and atmospheric air must be prevented from entering the thoracic cavity. The client's resp status take priority over the potential for infection

Front 56

A client has a trac tube attached to a trac collar for delivery of humidified oxygen. The client will need suctioning primarily because the?

Back 56

1. humified oxygen is saturated with fluid
2. inner cannula of the trach tubes irritates the mucosa
3. weaing process increases the amt of respirtory secretions
4. trac tubes interfer with the ability to cough effectively



4-

Front 57

A client arrive in the ER with multiple crushing wounds of the chest, abd. and legs. The assessments that assume the greatest priority are?

Back 57

1. level of conciousness and pupil size
2. abd. contusion and other wounds
3. pain, resp rate and blood pressure
4. quality of respirations and presence of pulses




4- basic life functions must be maintained or reestablished

Front 58

When caring for a client who has had chest tubes inserted the nurse's primary responsibility would be to?

Back 58

1. maintain a closed system
2. monitor o2 SAT levels
3. place the client in the supine position
4. encourage deep breathing and coughing



1- an airtight system is needed to reestabilsh negative pressure and reinflate the lung

Front 59

The position that would provide the greated respiratory capacity for a client with dyspnea would be the?

Back 59

1. sims position
2. supine position
3. orthopneic position
4. semi-fowlers



3- orthopneic position
this lowers the diaphragm and provides for max. thoracic expansion
This is a variation of high Fowler's position and is used for patients who have difficulty breathing.

1. The position of the bed remain the same as high fowler's (90° angle).
2. Bring the bedside table across the bed and place one or two pillows on top of the table.
3. Have the patient lean forward across the table with her arms on or beside the pillows. Have her rest her head on the pillows.
4. Place another pillow low behind the patient's back for support.