RESPIRATORY SYSTEM ASSESSMENT 2

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This Assessment Is Powered By ACHIEVERS' NCLEX-RN CONSULT [www.achieversnclexrn.com].

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Assessment Areas: ASTHMA, PNEUMONIA &

COPD. PASSMARK: 40/60.

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A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which of the following prescriptions should the nurse perform first? *

1 point

1. Albuterol nebulizer.

2. Chest x-ray.

3. IV Hydrocortisone

4. Sputum culture.

Q2. A client with a severe asthma exacerbation following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status. Which clinical manifestations support the nurse's assessment of impending respiratory failure? Select all that apply.
*

1 point

1.Arterial pH 7.50

2.PaCO2 55 mm Hg (7.3 kPa)

3.PaO2 58 mm Hg (7.7 kPa)

4.Paradoxical breathing

5.Restlessness and drowsiness

Required

Q3. The nurse has become aware of the following client situations. The nurse should first follow up with the client who
*

1 point

A. has an irregular pulse that is receiving treatment for atrial fibrillation.

B. has pneumonia who had an increase in temperature to 102°F (39°C).

C. is receiving nebulizer treatments for asthma that suddenly stops wheezing.

D. has active pulmonary tuberculosis (TB) and refuses prescribed medications.

Q4. A female client with a history of frequent exacerbations of asthma asks the nurse to explain to her why she is at greater risk for fractures than other women her age. What is the nurse's best response? *

1 point

1. "The steroids you are taking decrease calcium in the bone by sending it to the blood."

2. "Taking steroids causes bone calcium to increase, thus causing osteoporosis."

3. "Clients who have asthma are not able to exercise enough to prevent fractures from occurring."

4. "Asthma should not put you at increased risk for fractures but you are at risk for decreased blood glucose levels."

Q5. The nurse provides care for a school-age child newly diagnosed with asthma. The nurse teaches the child's parent about the child's return to school. Which instruction does the nurse include in the teaching? *

1 point

1. Provide the child's teacher with the inhaler and instructions on its use.

2. Have the child use the inhaler before going to school to prevent an attack.

3. Tell the child to carry the inhaler and spacer in a pocket at all times.

4. Provide the school nurse with an inhaler, spacer, prescription, and directions for use.

Q6.The nurse provides discharge teaching to a client recently diagnosed with asthma. Which prescribed medication should the nurse instruct the client to use during an acute asthma episode?
*

1 point

1. Fluticasone.

2. Guaifenesin.

3. Theophylline.

4. Albuterol.

Q7. The nurse provides education to a client who is newly diagnosed with asthma. Which client statement indicates to the nurse the need for additional teaching? *

1 point

1. "I can still include anchovies on my pizza."

2. "I will seek emergency care if I have difficulty talking."

3. "I will use my flow meter at least twice per day."

4. "I will take acetaminophen for headaches."

Q8. The nurse counsels the parent of a school-age client diagnosed with asthma. The health care provider prescribes albuterol and beclomethasone via metered dose inhaler. Which statement by the parent indicates that teaching is effective?
*

1 point

1. "Albuterol should be taken as needed when my child is short of breath. The beclomethasone should be taken every day to prevent asthma attacks."

2. "Both of the medications should be taken on a regular basis, at the same time each day."

3. "The beclomethasone is to be used only when my child is wheezing and is short of breath."

4. "Both inhalers should be used immediately before my child participates in physical exercise."

Q9. The nurse is instructing the parents of a child with asthma about a peak flow meter. Which statement, if made by the parents, would indicate effective teaching?
*

1 point

A. "Before use, I should put the sliding marker at the top of the numbered scale."

B. "I should have my child sit at a 45-degree angle while performing this procedure."

C. "My child should inhale as quickly as they can through the mouthpiece."

D. "I should record the highest of the three readings."

Q10. A client is admitted to the hospital for treatment of an acute asthma attack. The client is receiving an aminophylline infusion. Which of the following assessment findings indicate the client is experiencing the desired effect of aminophylline?

1 point

a. Decreased wheezing

b. Decreased heart rate

c. Increased blood pressure

d. Increased mucous production

Q11. Which of the following medication classes are considered quick-relief or rescue medications for a child having an acute asthma attack?

Select all that apply.

1 point

A. Corticosteroids

B. Leukotriene modifiers

C. Short-acting beta-2 agonists

D. Anticholinergics

Required

Q12. A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following statements by the client indicates the teaching was effective? *

1 point

A. "This medication can decrease my immune response."

B. "I take this medication to prevent asthma attacks."

C. "I need to take this medication with food."

D. "This medication has a slow onset to treat my symptoms."

Q13. A nurse is assessing a client with asthma. Which of the following is a risk factor associated with this disease?
*

1 point

A. Gender

B. Environmental allergies

C. Alcohol use

D. Race

Q14. A nurse is completing discharge teaching with a client who has a new prescription for prednisone (Deltasone) for asthma. Which of the following client statements indicates a need for further teaching? *

1 point

A. "I will drink plenty of fluids while taking this medication."

B. "I will tell the doctor if I have black, tarry stools."

C. "I will take my medication on an empty stomach."

D. "I will monitor my mouth for canker sores."

Q15. A nurse in the emergency department is caring for a client who was admitted with an acute asthma attack. Which of the following indicates the client's respiratory status is declining? (Select all that apply.) *

1 point

A. SaO2 95%

B. Wheezing

C. Retraction of sternal muscles

D. Pink mucous membranes

E. Premature ventricular complexes (PVCs)

Required

Q16. The nurse reviews a client’s medical history prior to administering prescribed medications. Which finding should be reported to the client’s healthcare provider (HCP) before the administration of the prescribed labetalol? *

1 point

1. History of tachycardia.

2. History of anxiety.

3. History of asthma.

4. History of essential hypertension.

Q17. A teenage client with asthma reports becoming very anxious and fearful each time an asthma attack occurs. What would be the nurse's best response to the client? *

1 point

1. "I understand that you feel anxious. But you must stop this behavior."

2. "The feelings that you described can occur in individuals with asthma. You may find that learning relaxation exercises may help."

3. "I am concerned that feeling anxious during an asthma attack means you need more education about asthma."

4. "Everyone with asthma experiences tough times with their symptoms. You are learning to manage your asthma."

Q18. A nurse at the family clinic is educating the mother of a 13-year-old regarding how to avoid acute asthma attacks. Which statement, if made by the mother, indicates effective teaching?
*

1 point

A. “Dogs and cats would be okay to have as a family pet.”

B. “I can take my daughter to the mountains to ski.”

C. “Swimming would be a good exercise for my daughter.”

D. “Cold weather may make symptoms better.”

Q19. A nurse in the Emergency Department is admitting a client with an asthma exacerbation, headache, and fever of 101.4 F. Which of the following medication orders should the nurse question? *

1 point

1. Aspirin

2. Ipratopium

3. Acetaminophen

4. Albuterol

Q20. The nurse is providing teaching to the client prescribed albuterol for the management of asthma. The nurse is including reportable side effects in the teaching plan. Which of the following side effects is the priority? *

1 point

1. Nervousness

2. Headache

3. Palpitation

4. Muscle aches

21. A chronic obstructive pulmonary disease (COPD) patient is being discharged home with oxygen BNC at 2 L/M. Which instructions should the nurse provide regarding oxygen safety at home? Select all that apply.
*

1 point

1. Avoid wearing cotton fabric clothing.

2. Utilize water-based lubricants, not oil-based.

3. Keep the oxygen tank upright and away from heat.

4. Check to make sure smoke detectors are working.

5. When you smoke, keep your oxygen tank 2 feet away.

Required

Q22. A patient with a history of COPD underwent a colon resection for colon cancer 3 days ago. The patient begins having a COPD exacerbation and is placed on a venturi mask. What education should the nurse provide the patient to improve oxygenation postoperatively? Select all that apply.

1 point

1. Deep breathing exercises.

2. Positioning exercises.

3. Incentive spirometer use.

4. Pursed-lip breathing.

5. Open mouth breathing.

Required

Q23. The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). The results are: pH 7.35; PCO2 62 (8.25 kPa); PO2 70 (9.31 kPa) (34 mmol/L); HCO3 34. The nurse should first: *

1 point

1. Apply a 100% nonrebreather mask.

2. Assess the vital signs.

3. Reposition the client.

4. Prepare for intubation.

Q24. The nurse takes the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply. *

1 point

1."I have been drinking alcohol almost daily since age 20."

2."I have been overweight for as long as I can remember."

3."I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year."

4."I know I eat too much fast food."

5."I was a car mechanic for about 40 years and had my own garage."

Required

Q25. An elderly client is admitted with chronic obstructive pulmonary disease (COPD) exacerbation. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe. Which prescription should the nurse question? *

1 point

1.Albuterol 2.5 mg by nebulizer

2.Intravenous (IV) methylprednisolone 125 mg now and every 6 hours

3.IV morphine 2 mg now and may repeat every 2 hours

4.Oxygen at 2 L/min by nasal cannula.

Q26. Which of the following clients should receive priority for a nurse’s assessment at the beginning of the shift? *

1 point

A. A client with pancreatitis who has nausea and vomiting

B. A client who had a hip replacement the previous day and is complaining of 8/10 pain

C. An elderly client who fell out of bed last night and has new-onset lethargy and confusion

D. An elderly client who has lung cancer and COPD with an oxygen saturation of 89% by pulse oximetry

Q27. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has an increased red blood cell count (RBC). The nurse understands that this finding is likely from
*

1 point

A. Increased carbon dioxide levels

B. Low blood oxygen levels

C. Insensible water loss

D. Decreased fluid intake

Q28. A client with a new diagnosis of chronic obstructive pulmonary disease (COPD) asks the nurse if this disease is terminal. Which is the best response from the nurse?
*

1 point

1. "I can call your family or clergy to come sit with you while you wait."

2. "Do you know that smoking is the most likely cause for this disease?"

3. "This must be very difficult. Let's talk more about how you're feeling now."

4. "Your condition can be easily treated with medications such as breathing treatments."

Q29. A client with chronic obstructive pulmonary disease (COPD) has oxygen therapy ordered. Which principle should guide the nurse in managing the delivery of oxygen to this client?
*

1 point

a. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PaO2.

b. Clients with COPD require higher concentrations (6-8 L) of oxygen since hypoxemia is their stimulus to breathe.

c. The concentration of oxygen should be low since the stimulus to breathe in clients with COPD is an elevated PaCO2.

d. The concentration of oxygen should be high since the stimulus to breathe in clients with COPD is an elevated PaCO2.

Q30. A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse?
*

1 point

A. "There are portable oxygen delivery systems that you can take with you."

B. "When you go out, you can remove the oxygen and then reapply it when you get home."

C. "You probably will not be able to go out as much as you used to."

D. "Home health services will come to you so you will not need to get out."

Q31. A nurse is providing discharge teaching to a client who has COPD and has a new prescription for albuterol (Proventil). Which of the following statements made by the client indicates an understanding of the teaching? *

1 point

A. "This medication can increase my blood sugar levels."

B. "This medication can decrease my immune response."

C. "I can have an increase in my heart rate while taking this medication."

D. "I can have mouth sores while taking this medication."

Q32. A 90-year-old male with COPD, CHF, and hypertension is brought to the emergency department by ambulance. A nebulizer is in place upon arrival. After blood tests are drawn, the patient’s arterial blood gas shows the values below. What is this patient exhibiting?
pH: 7.18, CO2: 67, Bicarbonate: 23
*

1 point

A. Respiratory acidosis

B. Metabolic acidosis

C. Respiratory alkalosis

D. Metabolic alkalosis

Q33. A nursing assistant tells the nurse that her patient with COPD reports he did not get his annual flu shot this year and has not had a pneumonia vaccination. The nurse should instruct the CNA that which of the following is the priority?
*

1 point

A. Blood pressure 150/80 mmHg

B. Respiratory rate 26 breaths/min

C. Heart rate 92 beats/min

D. Oral temperature of 101.4 degrees F

Q34. Which of the following diets would be most appropriate for a client with COPD? *

1 point

A. Low fat, low cholesterol

B. Bland, soft diet

C. Low-Sodium diet

D. High calorie, high-protein diet

Q35. A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:
*

1 point

A. 1 L/min

B. 2 L/min

C. 6 L/min

D. 10 L/min

Q36. A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can’t produce an effective cough, the nurse should monitor closely for: *

1 point

A. Pleural effusion

B. Pulmonary edema

C. Atelectasis

D. Oxygen toxicity

Q37. A nurse is planning an educational session on fluticasone/salmeterol for a group of clients who have been prescribed this medication. What teaching points should the nurse include?

SATA

1 point

1. Swallow the capsule when having an acute asthma episode.

2. Rinse mouth after medication administration to decrease infection.

3. Take this medication every day, even on days when breathing fine.

4. Administer by HandiHaler DPI, twice daily.

5. Carry a rescue inhaler, such as albuterol, when leaving home.

Required

Q38. Your newly assigned client has a history of chronic obstructive pulmonary disease (COPD). When you enter his room, you find his oxygen is running at 6 L/min, his color is flushed, and his respirations are 8/min. What should you do first?
*

1 point

A. Place client in high Fowler’s position

B. Lower the oxygen rate

C. Take baseline vital signs

D. Obtain an EKG

Q39. A nurse on a medical unit is planning care for a client who has COPD. Which of the following actions should the nurse include in the plan *

1 point

A. Suction the client's airway every 4 hours

B. Limit the client's fluid intake to control secretions

C. Provide the client with a high protein diet

D. Administer the client's bronchodilator following each meal

Q40. A client with chronic obstructive pulmonary disease reports recent weight loss and poor appetite. The client states that bloating, exhaustion, and shortness of breath make eating "not worth the effort." Which statements by the nurse are appropriate to help improve the client's nutritional status? Select all that apply.
*

1 point

1."Avoid drinking fluids while you are eating meals."

2."Eat small, frequent meals that are high in calories and protein."

3."Exercise before you eat, to improve your appetite."

4."Increase your intake of high-fiber foods, such as broccoli and cabbage."

5."Perform oral hygiene before eating meals."

Required

Q41. 20-cigarette a day smoking patient with pneumonia is discharged home on oxygen therapy at nighttime. What patient education instructions should the nurse provide the patient regarding oxygen therapy at home?

Select all that apply.

1 point

1. Education on oxygen safety precautions.

2. Education on smoking cessation programs.

3. Education on posting signs in the yard about oxygen use.

4. Education on how to turn the oxygen on at the exact rate.

5. Education on the various oil-based products to use with oxygen.

Required

42. The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP? *

1 point

1.Blood-tinged sputum

2.Positive blood cultures

3.Positive, purulent sputum culture

4.Rhonchi and crackles

Q43. An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia? *

1 point

1.Advanced age

2.Environmental exposure

3.Nutritional deficit

4.Obesity

Q44. The nurse assesses these symptoms in a client with bacterial pneumonia: chills, elevated temperature, tachypnea, productive cough of yellow sputum, shortness of breath, and fatigue. Based on the assessment data, what is the most appropriate nursing diagnosis (ND) for this client? *

1 point

1.Impaired gas exchange

2.Impaired spontaneous ventilation

3.Ineffective breathing pattern

4.Risk for infection

Q45. A nurse is planning care for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following interventions should the nurse include in the plan?

1 point

A. Attach a humidifier bottle to the base of the flow meter.

B. Prevent skin breakdown around the ears by removing the nasal cannula for 30 min twice a day.

C. Secure the oxygen tubing to the bed sheet near the client's head.

D. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

Q46. The nurse provides care for clients in a senior citizens center. The client tells the nurse, "I had pneumonia once, and I do not want to get it again." Which question is most important for the nurse to ask? *

1 point

1.“How often do you cough and deep breathe?”

2.“Have you received a flu shot this year?”

3.“Do you attempt to avoid crowds?”

4.“How much sleep do you receive each night?”

Q47. An older adult client with pneumonia has a temperature of 101.2o F (38.4o C), pulse of 112 beats/min, respirations of 22 breaths/min, and BP of 90/50 mm Hg. For which findings will the nurse notify the health care provider? (Select all that apply.) *

1 point

1. Lactic acid level 5.0 mEq/L (0.555 mmol/L).

2. White blood cell count of 15,000 (15 x 103/microL).

3. Blood pressure of 90/50 mm Hg.

4. Apical heart rate of 112 beats per minute.

5. Oral temperature of 101.9 degrees F (38.8 degrees C).

Required

Q48. A nurse is assigned to care for a client with pneumonia. The health care provider (HCP) has prescribed "amoxicillin/clavulanate potassium 500 mg PO TID" for treatment. The medication is available in 250 mg tablets. After calculating the dosing, the nurse finds that the client will receive two tablets every 8 hours. When verifying the client's understanding, the client states, "I should take the medication with food, and if I feel fine before I finish the prescription, I can stop it and save the rest of the pills for the next time I get pneumonia." After rechecking the dosage calculation, the nurse decides to do which of the following? *

1 point

A. Hold medication administration and clarify the dosage with the HCP

B. Administer one tablet only

C. Administer the medication as prescribed and monitor the client's cardiac function

D. Reinforce client teaching and administer the medication as prescribed

Q49. The nurse is caring for a 60-year-old client admitted for the treatment of pneumonia. The nurse has identified a nursing diagnosis of impaired gas exchange. Which of the following interventions are independent actions the nurse can take to improve gas exchange? Select all the apply *

1 point

A. Administer the appropriate antibiotics based on the client's underlying pathology

B. Instruct the client on the use of incentive spirometry

C. Monitor the client's pulse ox continuously

D. Instruct the client on deep breathing techniques and the importance of coughing

E. Encourage the client to remain in the seated or semi-Fowlers position

Required

Q50. The nurse is developing a plan of care for a client admitted P. aeruginosa pneumonia. Which of the following should the nurse include in the client’s plan of care? *

1 point

A. Instruct the client to wear an N95 mask when ambulating in the hall.

B. Initiate a vascular access device and encourage by-mouth fluids.

C. Obtain daily weights every morning using the same scale.

D. Administer prescribed oseltamivir within 48 hours of symptom onset.

51. The nurse is caring for a client receiving mechanical ventilation. Which of the following actions would not reduce the client's risk of ventilator-acquired pneumonia (VAP)?

*

1 point

A. Oral care with chlorhexidine

B. Obtain a specimen for culture via tracheal suctioning

C. Elevate the head of the bed to 45 degrees

D. Performing hand hygiene before and after suctioning

Q52. The nurse is caring for a client with pneumonia receiving six liters a minute of nasal cannula oxygen. The client has a SpO2 of 81%, and the arterial blood gas (ABG) returns with a PaO2 of 68 mm Hg. Which immediate intervention should the nurse take?
*

1 point

A. Notify the rapid response team (RRT).

B. Obtain a prescription for a chest radiograph.

C. Increase nasal cannula oxygen to seven liters a minute.

D. Auscultate the lung fields for adventitious sounds.

53. A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8° C (100° F), respirations 30/min, BP 130/76, heart rate 100/min, and SaO2 91% on room air. (Using a scale of 1 to 4, with 1 being the highest priority, prioritize the following nursing interventions.)

A. Administer antibiotics as prescribed.
B. Administer oxygen therapy.
C. Perform a sputum culture.
D. Administer an antipyretic medication to promote client comfort.

[Use ALPHABETS ONLY, LEAVING NO SPACE IN BETWEEN OR A COMMA]. Example: ABCD, CABD, DCBA

1 point

Q54. Which of the following clients have an increased risk for developing pneumonia? (Select all that apply.) *

1 point

A. Client who has dysphagia

B. Client who has AIDS

C. Client who was vaccinated for pneumococcus and influenza 6 months ago

D. Client who is postoperative and has received local anesthesia

E. Client who has a closed head injury and is receiving ventilation

Required

Q55. The nurse instructs a client about deep breathing and coughing exercises that will be performed postoperatively. Which statement by the client indicates that teaching has been effective? *

1 point

1. "Coughing and deep breathing should be performed hourly to prevent pneumonia."

2. "Coughing and deep breathing are needed to prevent blood clots."

3. "Coughing and deep breathing will aide with healing by increasing available oxygen."

4. "Coughing and deep breathing will help resolve any blood clots that have formed. "

Q56. The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication? *

1 point

A. Passive range of motion

B. Sequential compression devices (SCDs)

C. Early ambulation

D. Prophylactic antibiotics

Q57. A 65-year-old man with a 45-year history of smoking

reports a change in his cough pattern, a nonproductive

cough, and generally not feeling well. The chest x-ray

reveals an infiltrate. A nurse should suspect:

1 point

1. Pneumonia.

2. Chronic obstructive pulmonary disease (COPD).

3. Pulmonary edema.

4. Tuberculosis

58. A nurse has received morning report on multiple clients. What client should the nurse assess first? *

1 point

1. Client on 2/L min, of oxygen by nasal cannula with pneumonia.

2. Client with Crohn’s disease reporting two semi-loose stools.

3. Client one day post-appendectomy reporting abdominal cramps.

4. Client on heparin drip reporting bleeding gums when brushing teeth.

Q59. Patients with spinal cord injuries are at a greater risk for atelectasis and pneumonia due to ineffective clearance of secretions. The nurse provides health teaching to a patient recovering from SCI at T6 about the use of an incentive spirometer. She determines that he needs FURTHER teaching when she observes him doing the following:

Select one:

1 point

1. Sitting up in bed to use the incentive spirometer

2. Inhaling, placing his lips around the mouthpiece and exhaling slowly

3. Creating a seal around the mouthpiece by closing lips tightly

4. Holding his breath for 3 seconds before exhaling

Q60. Clients with chronic illnesses are more likely to get pneumonia when which of the following situations is present? *

1 point

A. Dehydration

B. Group living

C. Malnutrition

D. Severe periodontal disease

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