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Question 1
Question
The nurse is to teach a client with Chronic Obstructed Pulmonary Disease safety precautions for using oxygen at home. The nurse knows that the client understands the safety principles discussed when he says the following:
Answer
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"Acetone, oil, and alcohol are appropriate substances to use with clients who are using oxygen."
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"Fire extinguishers do not need to be stored."
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"Avoid materials that generate static electricity."
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"Smoking is permitted when oxygen is in use."
Question 2
Question
The nursing intervention that is inappropriate for use with clients having an endotracheal tube is:
Answer
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Communicating frequently with the client, providing a notepad or picture board for the client to use to communicating
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Providing room air
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Frequently assessing nasal and oral mucosa for redness and irritation
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Placing client in a side-lying position
Question 3
Question
Which is the appropriate method to use when a client is suffering respiratory difficulty and in need of suctioning?
Answer
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Dextrose-and-water solution
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Goggles or face shield not needed
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Nasal cannula
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Portable or wall suction machine with tubing and collection receptacle
Question 4
Question
Appropriate follow-up evaluation of a client after suctioning does not include which of the following assessments?
Answer
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Assessment of vital signs
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Only document findings abnormal in the client record; the doctor will see the results when rounds on the client are done
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Compare findings to previous assessment data
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Chart appearance if secretions
Question 5
Question
While suctioning a client in ICU, the nurse notices that the activity brings about deep breathing and coughing maneuvers by the client. This is considered a good action because:
Answer
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Deep breathing oxygenates the lungs, and coughing loosens and moves secretions in the lungs.
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Deep breathing has no effect on the lungs or the ability of the client to cough.
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Deep breathing is impossible to perform when one has a respiratory disease, and coughing is a reflex action.
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Deep breathing allows secretions to build up in the lungs, and coughing helps to determine their location.
Question 6
Question
An appropriate nursing responsibility in caring for clients with chest drainage systems would be:
Answer
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Evaluating respiratory rate every four hours after the tube is inserted
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Not filling the water seal area of the unit
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Never using clamps with the drainage tubing
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Monitoring the patency and integrity of the drainage system
Question 7
Question
Which client is most at risk for developing an upper respiratory infection?
Answer
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A 20-year-old healthy adult
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A 3-year-old in preschool
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A 50-year-old non-smoker
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A 13-year-old with a broken leg
Question 8
Question
The nurse is providing wellness teaching to a group of seniors in the community. Which action is not appropriate to follow in promoting healthy breathing?
Answer
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Making sure furnaces, ovens, and wood stoves are correctly ventilated
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Eliminating or reduce the use of household pesticides and irritating chemical substances
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Providing for rest periods during the day
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Sitting straight and standing erect to permit full lung expansion
Question 9
Question
Which clinical signs are indicative of hypoxia? Select all that apply.
Answer
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rapid pulse
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cyanosis
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deep, rapid breaths
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flaring of nostrils
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mouth breathing
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substernal or intercostal retractions
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