Module 2 Week 6 Respiratory & Cardio V1

The nurse is preparing a client for a bronchoscopy procedure. Which of the following nursing actions should the nurse implement before the procedure? (Select all that apply.). Maintain NPO (nothing by mouth) status as prescribed. Encourage the client to drink a glass of water with pre-procedure medications. Establish intravenous (IV) access. Remove dentures and eyeglasses. Advise the client to swallow any excess local anesthetic spray to maximize its effectiveness. Assess coagulation studies results.

A nurse is caring for a client who has just returned from a bronchoscopy. For each nursing intervention listed below, select whether it is Appropriate or Not Appropriate post-procedure. Monitor for signs of complications such as hemorrhage, bronchospasm, or pneumothorax. Assess for the return of the gag reflex. Monitor respiratory status, particularly if sedation was administered. Maintain NPO status until the gag reflex returns. Encourage the client to drink fluids immediately after the procedure. Administer cough suppressants to reduce post-procedure coughing. Obtain written consent for the procedure. Warm saline gargles and lozenges may be helpful for a sore throat.

A nurse is caring for a client who sustained multiple rib fractures following a motor vehicle accident. The client is experiencing severe pain, shallow respirations, and increasing respiratory distress. Which of the following interventions should the nurse prioritize?. Administer pain medication as prescribed to maintain adequate ventilatory status. Monitor for increased respiratory distress. Place the client in Fowler's position. Prepare the client for an intercostal nerve block as prescribed if the pain is severe.

A nurse is assessing a client suspected of having a pneumothorax. Which of the following assessment findings are associated with pneumothorax? (Select all that apply.). Diminished or absent breath sounds on the affected side. Tracheal deviation to the unaffected side. Sudden onset of sharp chest pain and dyspnea. Hyperresonance on percussion over the affected area. Paradoxical chest movement. Crackles in bilateral lung fields. Pink, frothy sputum. Jugular vein distention (JVD).

A nurse is caring for a client experiencing acute asthma exacerbation. On assessment, the nurse observes wheezing, shortness of breath, tachypnea, and use of accessory muscles for breathing. Which of the following interventions should the nurse implement first?. Administer bronchodilators. Position the client with the head elevated 30 degrees. Administer 6L of oxygen via oxygen mask. Educate the client on possible triggers and measures to prevent episodes.

A nurse is providing care for a client with chronic obstructive pulmonary disease (COPD) who is experiencing increased shortness of breath. Which of the following interventions are appropriate and not appropriate?. Encourage pursed-lip breathing. Administer high-flow oxygen therapy. Administer bronchodilators as prescribed. Provide low-flow oxygen therapy. Encourage bed rest with minimal activity. Position the client in a high-Fowler's position. Monitor oxygen saturation. Restrict fluid intake. Administer sedatives for anxiety. Advise the client to avoid all physical activity.

A nurse is reviewing the arterial blood gas (ABG) results of a client with chronic obstructive pulmonary disease (COPD). The results are as follows: pH: 7.32 PaCO2: 55 mmHg HCO3: 28 mEq/L PaO2: 65 mmHg Which of the following is the correct interpretation of these results?. Uncompensated Metabolic Acidosis. Partially Compensated Respiratory Acidosis. Partially Compensated Metabolic Alkalosis. Uncompensated Respiratory Alkalosis.

A nurse is assessing a client diagnosed with a pleural effusion. Which of the following findings would the nurse expect to note upon assessment?. Hyperresonance on percussion of the affected lung. Decreased breath sounds over the affected area. Increased tactile fremitus over the affected lung. Tracheal deviation toward the affected side.

A nurse is reviewing the results of a tuberculin skin test (TST) for multiple clients. Which of the following classifications indicate a positive reaction for tuberculosis exposure? (Select all that apply.). An induration of 5 mm or greater in an HIV-positive client. An induration of 10 mm or greater in a recent immigrant from a high-prevalence country. An induration of 15 mm or greater in a healthy individual with no known risk factors. An induration of 3 mm in a healthcare worker exposed to a TB-positive patient. An induration of 8 mm in a client with diabetes mellitus. A red, erythematous area of 12 mm without palpable induration in an immunocompromised client. An induration of 7 mm in a client with no known risk factors.

A 68-year-old client is admitted to the emergency department with sudden onset of dyspnea and pleuritic chest pain. The client appears diaphoretic, confused, and is using accessory muscles to breathe. Which of the following nursing interventions should the nurse implement first?. Activate the rapid response team. Administer 2L of oxygen via nasal cannula. Prepare for thrombolytic therapy or emergency embolectomy. Monitor vital signs and cardiac rhythm continuously.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Ventricular Fibrillation. Atrial Fibrillation. Supraventricular Tachycardia. Ventricular Tachycardia.

A nurse is monitoring a client experiencing premature ventricular contractions (PVCs). Which of the following findings should prompt the nurse to notify the primary healthcare provider (PHCP) or cardiologist? (Select all that apply.). The client reports chest pain. The PVCs increase in frequency. The client's blood pressure is 159/95. Multifocal PVCs are observed on the ECG. The PVCs occur on the T wave (R-on-T phenomenon). The PVCs occur sporadically without any pattern. PVCs occur in runs of ventricular tachycardia.

A nurse is reviewing an ECG strip (See Exhibit). The nurse correctly identifies this rhythm as: Ventricular Tachycardia. Normal Sinus Rhythm. Sinus Bradycardia. Atrial Fibrillation.

A nurse is assessing a client diagnosed with a pleural effusion who reports worsening shortness of breath, decreased breath sounds on auscultation, and mild tachypnea. Which of the following interventions should the nurse perform first?. Encourage coughing and deep breathing. Assess oxygen saturation and administer oxygen therapy. Position the client in a high Fowler's position. Prepare the client for thoracentesis.

A nurse is caring for a client who is postoperative day 1 following cardiac surgery. Which of the following interventions should the nurse include in the client's care plan to prevent complications? (Select all that apply.). Encourage the use of an incentive spirometer once per shift. Assess for signs of cardiac tamponade, including muffled heart sounds and hypotension. Encourage the client to remain on strict bed rest for the first 72 hours. Monitor the client's chest tube output, reporting drainage greater than 70 mL/hr. Instruct the client to perform deep breathing and splint the chest incision with a pillow. Limit fluid intake to 500 mL/day to prevent fluid overload. Monitor for atrial fibrillation or other arrhythmias using continuous telemetry.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Ventricular Tachycardia. Normal Sinus Rhythm. Sinus Bradycardia. Atrial Fibrillation.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Asystole. Ventricular Fibrillation. Ventricular Tachycardia. Atrial Fibrillation.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Sinus Bradycardia. First Degree AV Block. Normal Sinus Rhythm. Second Degree Type I heart block.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Third degree heart block. Second Degree Type II heart block. First Degree AV Block. Second Degree Type I heart block.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Third degree heart block. Second Degree Type II heart block. First Degree AV Block. Second Degree Type I heart block.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Third degree heart block. Second Degree Type II heart block. First Degree AV Block. Second Degree Type I heart block.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Third degree heart block. Second Degree Type II heart block. First Degree AV Block. Second Degree Type I heart block.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Ventricular Tachycardia. Supraventricular Tachycardia. Multifocal Premature Ventricular Contraction. Unifocal Premature Ventricular Contraction.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Ventricular Tachycardia. Supraventricular Tachycardia. Multifocal Premature Ventricular Contraction. Unifocal Premature Ventricular Contraction.

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Ventricular Tachycardia. Supraventricular Tachycardia. Premature Ventricular Contraction (Bigeminy). Premature Ventricular Contraction (Trigeminy).

A nurse is reviewing an ECG strip (see exhibit). The nurse correctly identifies this rhythm as: Ventricular Tachycardia. Supraventricular Tachycardia. Premature Ventricular Contraction (Bigeminy). Multifocal Ventricular Contraction.

A nurse is assessing a client who was recently diagnosed with Second Degree Type II Heart Block (Mobitz II). The client suddenly becomes diaphoretic, confused, and develops a systolic blood pressure of 78 mmHg. The cardiac monitor shows a ventricular rate of 38 bpm with consistently dropped QRS complexes. Which of the following interventions should the nurse perform first?. Administer a fluid bolus to improve blood pressure. Initiate transcutaneous pacing immediately. Administer atropine to increase the heart rate. Obtain a 12-lead ECG to further assess conduction abnormalities.

A nurse in the emergency department witnesses a client suddenly collapse. The cardiac monitor displays ventricular fibrillation (VF), and the client is unresponsive, pulseless, and not breathing. Which action should the nurse take first?. Administer epinephrine 1 mg IV push. Defibrillate the client immediately. Begin chest compressions at a rate of 100-120 per minute. Obtain a 12-lead ECG to confirm the rhythm.