Berman 50

Question 1

The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?

1. The ability to cough
2. Filtration and humidification of inspired air
3. The sneeze reflex initiated by irritants in the nasal passages
4. Decrease in oxygen-carrying capacity of the trachea

Answer 1

2. Filtration and humidification of inspired air

Question 2

When planning care, for which client should the nurse include close observation for a decreased or absent cough reflex?

1. The client with a nasal fracture
2. The client with impairment of vagus nerve conduction
3. The client with a sinus infection
4. The client with reduction in respiratory membrane conduction

Answer 2

2. The client with impairment of vagus nerve conduction

Question 3

The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint? Select all that apply:

1. Use of accessory muscles
2. Increased respiratory depth
3. Increased respiratory rate
4. Decreased respiratory depth
5. Decreased respiratory rate

Answer 3

Correct Answer: 1, 2, 3, 4

Question 4

The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis?

1. Increased hematocrit
2. Decreased BUN
3. Increased blood sugar
4. Increased sedimentation rate

Answer 4

1. Increased hematocrit

Question 5

A client diagnosed with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per minute via nasal cannula is complaining of shortness of breath. What action should the nurse take?

1. Increase the oxygen to 3 liters per minute via nasal cannula.
2. Lower the head of the client’s bed to the semi-Fowler’s position.
3. Have the client breathe through pursed lips.
4. Encourage the client to breathe more rapidly.

Answer 5

3. Have the client breathe through pursed lips.

Question 6

After learning of a terminal illness and life expectancy, the client begins to hyperventilate and complains of being light-headed with the fingers, toes, and mouth tingling. What action should be taken by the nurse?

1. Prepare to resuscitate the client.
2. Have the client concentrate on slowing down respirations.
3. Place the client in Trendelenburg’s position and ask him to cough forcefully.
4. Administer 25 mg of meperidine (Demerol) according to the prn pain order.

Answer 6

2. Have the client concentrate on slowing down respirations.

Question 7

The client is experiencing severe shortness of breath, but is not cyanotic. What laboratory value should the nurse review in an attempt to understand this phenomenon?

1. Blood sugar
2. Hemoglobin and hematocrit
3. Cardiac enzymes
4. Serum electrolytes

Answer 7

2. Hemoglobin and hematocrit

Question 8

A client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition?

1. Cheyne-Stokes
2. Biot’s
3. Cluster
4. Kussmaul’s

Answer 8

4. Kussmaul’s

Question 9

Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?

1. Ineffective Breathing Pattern
2. Anxiety
3. Ineffective Airway Clearance
4. Impaired Gas Exchange

Answer 9

3. Ineffective Airway Clearance

Question 10

The nurse encourages the client to expectorate sputum rather than swallowing it. What is the rationale for this direction?

1. Sputum contains bacteria that should be expectorated.
2. Swallowing sputum is dangerous to the system.
3. The nurse should view the sputum for quality and quantity.
4. The client is likely to aspirate the sputum while attempting to swallow it.

Answer 10

3. The nurse should view the sputum for quality and quantity.

Question 11

The nurse is planning a time schedule for a client’s twice-daily postural drainage. Which time schedule would be best?

1. 0800 and 1100
2. 1200 and 1800
3. 0700 and 2000
4. 0900 and 2100

Answer 11

3. 0700 and 2000

Question 12

A client is receiving oxygen by nonrebreather mask, but the bag is deflating on inspiration. What action should be taken by the nurse?

1. Turn the client to the left side.
2. Increase the percentage of oxygen being delivered.
3. Check for an airtight seal between the client’s face and the mask.
4. Increase the liter flow of oxygen being delivered.

Answer 12

4

Question 13

The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time?

1. Tape the airway in place.
2. Suction the client.
3. Turn the client’s head to the side.
4. Insert a nasal trumpet.

Answer 13

3

Question 14

A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action should the nurse plan for this client?

1. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes.
2. Remove the tracheostomy ties and replace them with an elastic bandage.
3. Remove the tracheostomy inner cannula.
4. Tape the tracheostomy obturator to the head of the bed.

Answer 14

4

Question 15

The nurse needs to hyperinflate a client prior to suctioning. How should the nurse proceed with this requirement?

1. Turn the suction level up to 60 cm prior to inserting the catheter.
2. Increase the oxygen flow to the client by 20% prior to suctioning.
3. Provide 2 to 3 breaths at 1.5 times the tidal volume prior to suction.
4. Instruct the client to cough forcefully from the abdomen prior to suction.

Answer 15

3

Question 16

The nurse who is assessing a client’s chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take?

1. Discontinue the chest tube suction.
2. Collaborate with the client’s physician.
3. Mark the area involved and remove the tube.
4. Reinforce the chest tube dressing.

Answer 16

2

Question 17

The nurse is preparing to assist with the removal of a chest tube that is a simple insertion without a purse-string suture. What materials should the nurse gather for this procedure?

1. An occlusive dressing
2. A 4 × 4 gauze
3. An adhesive gauze pad dressing
4. A non-adherent gauze dressing

Answer 17

1

Question 18

The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What statement made by the client would indicate that this client needs further instruction?

1. “I will replace my cotton blankets with polyester ones.”
2. “My son will not be able to smoke when I am around.”
3. “I will have my electrical appliance checked for grounding.”
4. “I will buy a fire extinguisher for my bedroom.”

Answer 18

1

Question 19

A client with a nasotracheal tube in place has been restless and pulling at the tube. How should the nurse assess if the tube is still in place?

1. Count the client’s respirations.
2. Assess the depth of the client’s respirations.
3. Auscultate for bilateral breath sounds.
4. Deflate the cuff and listen for minimal leak.

Answer 19

3

Question 20

The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive pulmonary disease. What is the nurse’s next action?

1. Fill the humidifier with normal saline.
2. Pad the tubing where it contacts the client’s ears.
3. Set the oxygen delivery to 5 liters.
4. Secure the cannula with ties around the client’s head.

Answer 20

2

Question 21

The nurse who is performing care for a client with a new tracheostomy needs to change the ties. What is the best method for changing these ties?

1. Remove the old ties, clean the area well, and then put on new ties.
2. Attach the new tape and tie with a square knot behind the client’s neck.
3. Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and replace the ties.
4. Remove the outer cannula, replace the soiled ties, and reinsert.

Answer 21

3

Question 22

The nurse is planning the care of a client who has need for frequent suctioning. What should the nurse delegate to the UAP?

1. Both oral and tracheal suctioning
2. Only oral suctioning
3. Only tracheal suctioning
4. Neither oral nor tracheal suctioning

Answer 22

2

Question 23

During tracheal suctioning, the nurse notes that the client’ heart rate has increased from 80 to 100 bpm. Based upon this assessment, what action should the nurse take?

1. Immediately discontinue suctioning.
2. Prepare to resuscitate the client.
3. Continue to suction until the airway is clear.
4. Complete the suction episode as quickly as possible.

Answer 23

4

Question 24

A client who is being mechanically ventilated has copious amounts of secretions ranging from thick and tenacious to frothy. In preparing to suction this client, the nurse should take which action?

1. Hyperventilate the client using the settings on the mechanical ventilator.
2. Hyperventilate the client using a manual resuscitator.
3. Avoid hyperventilation, but instill normal saline into the endotracheal tube.
4. Avoid hyperventilation and increase the oxygen to 100% for several breaths.

Answer 24

4

Question 25

A client has been prescribed both a bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications? 1. The medications cannot be used on the same day. 2. The steroid inhaler should be used when immediate effects are necessary. 3. The bronchodilator should be used only when absolutely necessary and only after the steroid inhaler. 4. Both medications have the possible side effect of increased heart rate.

Answer 25

4

Question 26

``` A client complains of difficulty breathing. What will the nurse most likely assess in this client? Standard Text: Select all that apply. 1. Use of accessory muscles 2. Increased respiratory depth 3. Increased respiratory rate 4. Decreased respiratory depth 5. Decreased respiratory rate ```

Answer 26

Correct Answer: 1, 2, 3, 4

Question 27

A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to 1. improve oxygenation. 2. remove irritants from the nasal passages. 3. remove irritants from the trachea or bronchi. 4. close the glottis.

Answer 27

3

Question 28

A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in 1. Ventilation. 2. Alveolar gas exchange. 3. Transportation of oxygen and carbon dioxide. 4. Systemic diffusion.

Answer 28

1

Question 29

A client is demonstrating signs of hypoxia. What laboratory value will help the nurse determine the client’s degree of effective gas exchange? 1. Blood glucose 2. Serum potassium 3. Serum sodium 4. Arterial blood gas

Answer 29

4. Arterial blood gas

Question 30

``` The nurse is determining a client’s ability to transport oxygen from the lungs to body tissues. What factors will influence this ability? Standard Text: Select all that apply. 1. Cardiac output 2. Exercise 3. Diet 4. Erythrocyte count 5. Hematocrit ```

Answer 30

Correct Answer: 1, 2, 4, 5

Question 31

A client’s blood gas analysis results show an increase in carbon dioxide level. What will the nurse most likely assess in this client? 1. Decreased respiration rate 2. Increased respiration rate 3. Increased blood pressure 4. Decreased bowel sounds

Answer 31

2. Increased respiration rate

Question 32

A client’s blood gas results reveal a low oxygen level. The nurse realizes that which area of the body will respond to this level and influence respirations? 1. Alveoli 2. Trachea 3. Bronchioles 4. Carotid bodies

Answer 32

4. Carotid bodies

Question 33

An older client is prescribed diazepam (Valium). What should the nurse monitor in this client? 1. Respirations 2. Urine output 3. Muscle tone 4. Appetite

Answer 33

1. Respirations

Question 34

``` The nurse is assessing an older client. What effects of aging should the nurse keep in mind during this assessment? Standard Text: Select all that apply. 1. Decreased cough reflex 2. Stiffening of blood vessels 3. Alteration in protein synthesis 4. Dry mucous membranes 5. Increased risk of aspiration ```

Answer 34

Correct Answer: 1, 4, 5

Question 35

A client is diagnosed with congestive heart failure. The nurse should assess the client for which conditions that can alter this client’s respiratory function? 1. Conditions that affect the airway. 2. Conditions that affect transport. 3. Conditions that affect the movement of air. 4. Conditions that affect diffusion.

Answer 35

2

Question 36

``` The nurse is conducting a health history for a client with a respiratory disorder. What should the nurse include in this assessment? Standard Text: Select all that apply. 1. Lifestyle 2. Presence of cough 3. Sputum production 4. Pain 5. Diet ```

Answer 36

Correct Answer: 1, 2, 3, 4

Question 37

``` A client is concerned about maintaining a healthy respiratory system. What should the nurse instruct the client to do to promote a healthy respiratory status? Standard Text: Select all that apply. 1. Use pursed-lip breathing. 2. Exercise regularly. 3. Do not smoke. 4. Breathe through the nose. 5. Breathe through the mouth. ```

Answer 37

Correct Answer: 2, 3, 4

Question 38

Which client statement indicates to the nurse that instruction about the use of a humidifier has been effective? 1. “A humidifier takes moisture out of the air.” 2. “A humidifier tightens secretions.” 3. “A humidifier prevents my lungs from getting too dry.” 4. “A humidifier replaces the use of oxygen.”

Answer 38

3

Question 39

The nurse documents that a prescribed expectorant has been effective for a client. What did the nurse evaluate in this client? 1. Respiratory rate 24 and labored 2. Audible wheeze upon auscultation 3. High-pitched cough present 4. Presence of a productive cough

Answer 39

4

Question 40

The nurse is performing nasotracheal suctioning of a client. What should the nurse do when suctioning this client? 1. Apply suction for 5–10 seconds. 2. Plan to suction for 10 minutes. 3. Apply suction while inserting the catheter. 4. Apply suction for 20–30 seconds.

Answer 40

1

Question 41

The nurse wants to delegate the Yankauer suctioning of a client to UAP. What will the nurse ensure that UAP know before delegating this activity? 1. How to apply suction during the insertion of the catheter 2. Not to apply suction during the insertion of the catheter 3. How to maintain sterile technique 4. How to listen for lung sounds

Answer 41

2

Question 42

The nurse has completed nasopharyngeal suctioning of a client. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Amount, consistency, color, and odor of sputum 2. Amount of sterile solution used to flush the catheter 3. Lung sounds before the procedure 4. Lung sounds after the procedure 5. Oxygen saturation after the procedure

Answer 42

Correct Answer: 1, 3, 4, 5

Question 43

The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a client’s medical record. What should this documentation include? Standard Text: Select all that apply. 1. Lung sounds before and after suctioning 2. Characteristics of suctioned sputum 3. Integrity of the skin around the stoma 4. Side on which the tracheostomy tie knot is located 5. Flow rate of oxygen

Answer 43

Correct Answer: 1, 2, 3, 5

Question 44

The nurse is planning care for a client who was admitted after having a myocardial infarction. Based upon this history, the nurse's greatest concern is that this client might develop which health problem? 1. Chronic renal failure 2. A gastric ulcer 3. Hypoxemia 4. A cerebral vascular accident

Answer 44

3

Question 45

Before administering the prescribed medication propranolol (Inderal) to a client, the nurse contacts the health care provider to question the order. What health problems did the client have that caused the nurse to question the medication order? Standard Text: Select all that apply. 1. COPD 2. Asthma 3. Arthritis 4. Gastritis 5. Heart failure

Answer 45

1,2

Question 46

The nurse is planning care for a client with an oral endotracheal tube. Which interventions should be included in this client’s plan of care? Standard Text: Select all that apply. 1. Insert an oropharyngeal airway. 2. Provide nasal care every 2 to 4 hours. 3. Provide oral hygiene every 2 to 4 hours. 4. Adjust non-humidified airflow as prescribed. 5. Move the tube to opposite sides of the mouth every 8 hours.

Answer 46

Correct Answer: 1, 2, 3, 5