Auscultation of a client’s lungs reveals crackles in the left posterior base. The nursing intervention is to: A. Repeat auscultation after asking the client to deep breathe and cough. B. Instruct the client to limit fluid intake to less than 2000 ml/day. C. Inspect the client’s ankles and sacrum for the presence… Read More »
A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: A. Area of redness is measured in 3 days and determines whether tuberculosis is present. B. Skin test doesn’t differentiate between active and dormant tuberculosis infection. … Read More »
The most reliable index to determine the respiratory status of a client is to: A. Observe the chest rising and falling. B. Observe the skin and mucous membrane color. C. Listen and feel the air movement. D. Determine the presence of a femoral pulse. Correct Answer: C. Listen and… Read More »
A female adult client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: A. 15 to 60 seconds. B. 5 to 20 minutes. C. 30 to 40 minutes. D. 45 to 60 minutes. … Read More »
A client with COPD has developed secondary polycythemia. Which nursing diagnosis would be included in the plan of care because of the polycythemia? A. Fluid volume deficit related to blood loss. B. Impaired tissue perfusion related to thrombosis. C. Activity intolerance related to dyspnea. D. Risk for infection related to suppressed… Read More »
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A. The system is functioning normally. B. The client has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed. Correct Answer:… Read More »
The physician has scheduled a client for a left pneumonectomy. The position that will most likely be ordered postoperatively for his is the: A. Nonoperative side or back B. Operative side or back C. Back only D. Back or either side. Correct Answer: B. Operative side or back Following… Read More »
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the: A. Lips B. Mucous membranes C. Nail beds D. Earlobes Correct Answer: B. Mucous membranes Skin color doesn’t affect the… Read More »
Assessing a client who has developed atelectasis postoperatively, the nurse will most likely find: A. A flushed face. B. Dyspnea and pain. C. Decreased temperature. D. Severe cough and no pain. Correct Answer: B. Dyspnea and pain Atelectasis is a collapse of the alveoli due to obstruction or hypoventilation.… Read More »
For a male client with an endotracheal (ET) tube, which nursing action is most essential? A. Auscultating the lungs for bilateral breath sounds. B. Turning the client from side to side every 2 hours. C. Monitoring serial blood gas values every 4 hours. D. Providing frequent oral hygiene. Correct… Read More »