Q2 Respiratory

A nurse is caring for a client who is complaining of chest pain after a motor vehicle collision. What finding would cause the most concern?

• Equal rise of chest wall

• Bruising on ribs

• Pain on inspiration

• The ribs do not appear to be moving together

A nurse is caring for a client with a chest tube who reports increasing shortness of breath. What is the priority action?

• Increase suction

• Reposition the client

• Check for occlusions in the tubing

• Administer oxygen

A nurse is caring for a client being mechanically ventilated. The high-pressure alarm sounds, with no obvious cause. What is the priority intervention?

• Suction the client

• Call the provider

• Manually ventilate the client with the ambu-bag

• Silence the alarm

A client with a history of hemorrhagic stroke has a massive pulmonary embolism and is hypotensive. What is the best treatment option?

• Thrombolytics

• Heparin drip

• IVC filter

• Pulmonary embolectomy

The nurse is caring for a client with ARDS who becomes hypotensive. What is the most likely cause?

• Increased cardiac output due to hypoxia

• Cardiac tamponade

• Hypovolemia due to fluid leaking into the interstitial spaces

• Left ventricular failure

A client with ARDS is intubated and receiving oxygen at 40% (FiO2 0.4). What is the priority lab value to report to the healthcare provider?

• PaO2, 85

• PaO2, 72

• PaO2, 62

• HCO3, 26

What actions should the nurse take when caring for a client receiving mechanical ventilation?

• Check the ventilator settings throughout the shift

• Ensure there is a manual resuscitation bag at the bedside

• Assess the client’s respiratory status every two hours

• Collaborate with the respiratory therapist

A client was involved in a motor vehicle accident 36 hours ago. The nurse monitors frequently to assess for which high-risk complication?

• Pneumothorax

• Cardiac tamponade

• Acute respiratory distress syndrome (ARDS)

• Aspiration pneumonia

The family of a client with ARDS asks if their loved one is going to die. What is the best way to address their concerns?

• We can’t predict that.

• They are getting the best care.

• Support the family and help them understand the realistic expectation of the client’s chance of survival

• Please talk to the physician.

A client has an oral endotracheal tube (ETT) placed. What is the nurse’s first responsibility immediately following placement?

• Tape the tube securely

• Assess for bilateral breath sounds

• Check for end-tidal CO2

• Order chest x-ray