Flashcards in Respiratory Disorders Deck (192)
The home health-care nurse is talking on the telephone to a male client diagnosed with
hypertension and hears the client sneezing. The client tells the nurse that he has been
blowing his nose frequently. Which question should the nurse ask the client?
1. “Have you had the flu shot in the last two (2) weeks?”
2. “Are there any small children in the home?”
3. “Are you taking over-the counter-medicine for these symptoms?”
4. “Do you have any cold sores associated with your sneezing?”
3. A client diagnosed with hypertension
should not take many of the over-thecounter
medications because they work
by causing vasoconstriction, which will increase
The school nurse is presenting a class to students at a primary school on how to prevent
the transmission of the common cold virus. Which information should the nurse discuss?
1. Instruct the children to always keep a tissue or handkerchief with them.
2. Explain that children current with immunizations will not get a cold.
3. Tell the children that they should go to the doctor if they get a cold.
4. Include a demonstration of how to wash hands correctly
4. Hand washing is the single most useful
technique for prevention of disease.
Which information should the nurse teach the client diagnosed with acute sinusitis?
1. Instruct the client to complete all the ordered antibiotics.
2. Teach the client how to irrigate the nasal passages.
3. Have the client demonstrate how to blow the nose.
4. Give the client samples of a narcotic analgesic for the headache.
1. The client should be taught to take all
antibiotics as ordered. Discontinuing
antibiotics prior to the full dose results in
the development of antibiotic-resistant
bacteria. Sinus infections are difficult to
treat and may become chronic and will then
require several weeks of therapy or possibly
surgery to control.
The client has been diagnosed with chronic sinusitis. Which signs and symptoms would
alert the nurse to a potentially life-threatening complication?
1. Muscle weakness.
2. Purulent sputum.
3. Nuchal rigidity.
4. Intermittent loss of muscle control.
3. Nuchal rigidity is a sign/symptom of meningitis, which is a life-threatening potential
complication of sinusitis resulting from the
close proximity of the sinus cavities to the
The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which
assessment data should the nurse notify the health-care provider about prior to surgery?
1. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%.
2. The client has an oral temperature of 100.2°F and a dry cough.
3. There are one (1) to two (2) white blood cells in the urinalysis.
4. The client’s current International Normalized Ratio (INR) is 1.0.
2. A low-grade temperature and a cough could
indicate the presence of an infection, in
which case the health-care provider would
not want to subject the client to anesthesia
and the possibility of further complications.
The surgery would be postponed.
The influenza vaccine is in short supply. Which group of clients would the public health
nurse consider priority when administering the vaccine?
1. Elderly and chronically ill clients.
2. Child-care workers and children younger than age four (4) years.
3. Hospital chaplains and health-care workers.
4. Schoolteachers and students living in a dormitory.
1. The elderly and chronically ill are at greatest
risk for developing serious complications
if they contract the influenza virus.
The client diagnosed with sinusitis who has undergone a Caldwell Luc procedure is
complaining of pain. Which intervention should the nurse implement first?
1. Administer the narcotic analgesic IVP.
2. Perform gentle oral hygiene.
3. Place the client in a semi-Fowler’s position.
4. Assess the client’s pain.
4. Prior to intervening the nurse must assess
to determine the amount of pain and possible
complications occurring that could be
masked if narcotic medication is administered.
The charge nurse on a surgical floor is making assignments. Which client should be
assigned to the most experienced registered nurse (RN)?
1. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday
and has moderate pain.
2. The six (6)-year-old client scheduled for a tonsillectomy and adenoidectomy this
morning who will not swallow medication.
3. The 18-year-old client who had a Caldwell Luc procedure three (3) days ago and has
purulent drainage on the drip pad.
4. The 45-year client diagnosed with a peritonsillar abscess who requires IVPB antibiotic
therapy four (4) times a day.
3. The postoperative client with purulent
drainage could be developing an infection.
The experienced nurse would be needed to
assess and monitor the client’s condition.
The client diagnosed with influenza A is being discharged from the emergency department
with a prescription for antibiotics. Which statement by the client indicates an
understanding of this prescription?
1. “These pills will make me feel better fast and I can return to work.”
2. “The antibiotics will help prevent me from developing a bacterial pneumonia.”
3. “If I had gotten this prescription sooner I could have prevented this illness.”
4. “I need to take these pills until I feel better; then I can stop taking the rest.”
2. Secondary bacterial infections often accompany influenza, and antibiotics are often
prescribed to help prevent the development
of a bacterial infection.
The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies
the client problem “altered communication.” Which intervention should the
1. Instruct the client to drink a mixture of brandy and honey several times a day.
2. Encourage the client to whisper instead of trying to speak at a normal level.
3. Provide the client with a blank note pad for writing any communication.
4. Explain that the client’s aphonia may become a permanent condition.
3. Voice rest is encouraged for the client
Which nursing task could be delegated to an unlicensed nursing assistant?
1. Feed a client who is postoperative tonsillectomy the first meal of clear liquids.
2. Encourage the client diagnosed with a cold to drink a glass of orange juice.
3. Obtain a throat culture on a client diagnosed with bacterial pharyngitis.
4. Escort the client diagnosed with laryngitis outside to smoke a cigarette.
2. Clients with colds are encouraged to drink
2000 mL of liquids a day. The unlicensed
nursing assistant could do this.
The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative
1. Vitamin C, 2000 mg daily.
2. Strict bed rest.
3. Humidification of the air.
4. Decongestant therapy.
1. Alternative therapies are therapies that are
not accepted medical practice. These may
be encouraged as long as they do not interfere
with the medical regimen. Vitamin C
in large doses is thought to improve the
immune system’s functions.
The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs
and symptoms would the nurse expect to find when assessing the client?
1. Confusion and lethargy.
2. High fever and chills.
3. Frothy sputum and edema.
4. Bradypnea and jugular vein distention.
1. The elderly client diagnosed with pneumonia
may present with weakness, fatigue,
lethargy, confusion, and poor appetite but
not have any of the classic signs and symptoms
The nurse is planning the care of a client diagnosed with pneumonia and writes a
problem of “impaired gas exchange.” Which would be an expected outcome for this
1. Performs chest physiotherapy three (3) times a day.
2. Able to complete activities of daily living.
3. Ambulates in the hall and back several times during each shift.
4. Alert and oriented to person, place, time, and events.
4. Impaired gas exchange results in hypoxia,
the earliest sign and symptom of which is a
change in the level of consciousness.
The nurse in a long-term care facility is planning the care for a client with a percutaneous
gastrostomy (PEG) feeding tube. Which interventions would the nurse include
in the plan of care?
1. Inspect the insertion line at the nare prior to instilling formula.
2. Elevate the head of the bed after feeding the client.
3. Place the client in the Sims position following each feeding.
4. Change the dressing on the feeding tube every three (3) days.
2. Elevating the head of the bed uses gravity
to keep the formula in the gastric cavity
and help prevent it from refluxing into the
esophagus, which predisposes the client to
The client diagnosed with a community-acquired pneumonia is being admitted to the
medical unit. Which nursing intervention has the highest priority?
1. Administer the oral antibiotic stat.
2. Order the meal tray to be delivered as soon as possible.
3. Obtain a sputum specimen for culture and sensitivity.
4. Have the unlicensed nursing assistant weigh the client.
3. To determine the antibiotic that will effectively treat an infection, specimens for
culture are taken prior to beginning the
medication. Administering antibiotics prior
to cultures may make it impossible to
determine the actual agent causing the
The 56-year-old client diagnosed with tuberculosis (TB) is being discharged.
Which statement made by the client indicates an understanding of the discharge
1. “I will take my medication for the full three (3) weeks prescribed.”
2. “I must stay on the medication for months if I am to get well.”
3. “I can be around my friends because I have started taking antibiotics.”
4. “I should get a TB skin test every three (3) months to determine if I am well.”
2. Compliance with treatment plans for TB
includes multi-drug therapy for six (6)
months to one (1) year for the client to be
free of the TB bacteria.
The employee health nurse is administering tuberculin skin testing to employees who
have possibly been exposed to a client with active tuberculosis. Which statement indicates
the need for radiological evaluation instead of skin testing?
1. The client’s first skin test indicates a purple flat area at the site of injection.
2. The client’s second skin test indicates a red area measuring four (4) mm.
3. The client’s previous skin test was read as positive.
4. The client has never shown a reaction to the tuberculin medication.
3. If the client has ever reacted positively,
then the client should have a chest x-ray to
look for causation and inflammation.
The nurse is caring for the client diagnosed with pneumonia. Which information
should the nurse include in the teaching plan? Select all that apply.
1. Place the client on oxygen by nasal cannula.
2. Plan for periods of rest during activities of daily living.
3. Place the client on a fluid restriction of 1000 mL per day.
4. Restrict the client’s smoking to two (2) to three (3) cigarettes per day.
5. Monitor the client’s pulse oximetry readings every four (4) hours.
1. The client diagnosed with pneumonia will
have some degree of gas-exchange deficit.
Administering oxygen would help the
2. Activities of daily living require energy and
therefore oxygen consumption. Spacing the
activities allows the client to rebuild oxygen
reserves between activities.
5. Pulse oximetry readings provide the nurse
with an estimate of oxygenation in the periphery.
While feeding the client diagnosed with aspiration pneumonia, the client becomes
dyspneic, begins to cough, and is turning blue. Which nursing intervention would the
nurse implement first?
1. Suction the client’s nares.
2. Turn the client to the side.
3. Place the client in the Trendelenburg position.
4. Notify the health-care provider.
2. Turning the client to the side allows for
the food to be coughed up and come out of
the mouth, rather than be aspirated into
The day shift charge nurse on a medical unit is making rounds after report. Which
client should be seen first?
1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to
be sent to the lab.
2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged
3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading
4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation
level of 89%.
3. A pulse oximetry reading of 92% means
that the arterial blood oxygen saturation is
somewhere around 60%–70%.
The client is admitted with a diagnosis of rule out tuberculosis. Which type of isolation
procedures should the nurse implement?
1. Standard Precautions.
2. Contact Precautions.
3. Droplet Precautions.
4. Airborne Precautions.
4. Tuberculosis bacteria are capable of disseminating
over distances on air currents.
Clients with tuberculosis are placed in
negative air pressure rooms where the air
in the room is not allowed to crosscontaminate
the air in the hallway.
The nurse observes the unlicensed nursing assistant (NA) entering an airborne isolation
room and leaving the door open. Which action would be the nurse’s best
1. Close the door and discuss the NA’s action when the NA comes out of the room.
2. Make the NA come back outside the room and then reenter closing the door.
3. Say nothing to the NA but report the incident to the nursing supervisor.
4. Enter the client’s room and discuss the matter with the NA immediately.
1. Closing the door reestablishes the negative
air pressure, which prevents the air from
entering the hall and contaminating the
hospital environment. When correcting an
individual, it is always best to do so in a
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs
and symptoms would the nurse look for when assessing the client?
1. Pleuritic chest discomfort and anxiety.
2. Asymmetrical chest expansion and pallor.
3. Leukopenia and CRT 3 seconds.
4. Substernal chest pain and diaphoresis.
1. Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever,
chills, dyspnea, and cough.
When assessing the client with COPD, which health promotion information would be
most important for the nurse to obtain?
1. Number of years the client has smoked.
2. Risk factors for complications.
3. Ability to administer inhaled medication.
4. Possibility for lifestyle changes.
4. The possibility of lifestyle changes is most
important in health promotion. The most
important is smoking cessation. The nurse
needs to assess if the client has the willingness to consider cessation of smoking and carry out the plan. If the client refuses to stop, treatment will need to be altered.
The client diagnosed with an exacerbation of COPD is in respiratory distress. Which
intervention should the nurse implement first?
1. Assist the client into a sitting position at 90 degrees.
2. Give oxygen at six (6) LPM via nasal cannula.
3. Monitor vital signs with the client sitting upright.
4. Notify the health-care provider about the client’s status.
1. The client should be assisted into a sitting
position either on the side of the bed or in
the bed. This position decreases the work
of breathing. Some clients find it easier
sitting on the side of the bed leaning over
the bed table. The nurse needs to maintain
the client’s safety.
When assessing the client with the diagnosis of COPD, which data would require the
nurse to take immediate action?
1. Large amounts of thick white sputum.
2. Oxygen flow meter set on eight (8) liters.
3. Use of accessory muscles during inspiration.
4. Presence of a barrel chest and dyspnea.
2. The nurse should decrease the oxygen rate. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the oxygen level increases, the drive to breathe may be eliminated. Careful monitoring is important to prevent complications.
While the nurse is caring for the client diagnosed with COPD, which outcome would
require a revision in the plan of care?
1. The client has no signs of respiratory distress.
2. The client shows an improved respiratory pattern.
3. The client demonstrates intolerance to activity.
4. The client participates in establishing goals.
3. The expected outcome should be that the
client is showing an improved activity tolerance; because the client is not meeting the expected outcome, the plan of care needs
revision. The nurse needs to collaborate
with the health-care team and with the
client to establish interventions that will
assist in improving the client’s outcome.
The nurse is caring for the client diagnosed with end-stage COPD. Which data would
warrant immediate intervention by the nurse?
1. The client’s pulse oximeter reading is 92%.
2. The client’s arterial blood gas level is 74.
3. The client has SOB when walking to the bathroom.
4. The client’s sputum is rusty colored.
4. Rusty-colored sputum may indicate blood
in the sputum and would require further
assessment by the nurse.