Deck 15: Oxygenation

Question 1

The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function. Which laboratory finding would be most significant for this client?

A)Hemoglobin level 14 g/dL
B)Oxygen saturation 96%
C)Serum sodium 140 mg/dL
D)Blood pH 7.32

Answer 1

Blood pH 7.32

Question 2

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations are the direct result of altered perfusion? Select all that apply.

A)Bounding pulse
B)Pink nail beds
C)Cyanosis
D)Confusion
E)Wheezing

Answer 2

Cyanosis
Confusion

Question 3

The nurse is providing care to a client with arterial blood gas analysis as follows: PaO₂ of 82, PaCO₂ of 49, HCO₃ of 26, and pH of 7.31. Which assessment by the nurse is correct?

A)Respiratory acidosis
B)Respiratory alkalosis
C)Metabolic alkalosis
D)Metabolic acidosis

Answer 3

Respiratory acidosis

Question 4

Which clinical manifestation does the nurse correctly attribute to hypoxia in a client with acute respiratory distress syndrome (ARDS)?

A)Fluid imbalance
B)Hypertension
C)Bradycardia
D)Dyspnea

Question 5

The nurse is providing care to a client admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS). When educating the client's family, what should the nurse say is the expected progression of the disease process?

A)Initiation of ARDS
B)Onset of pulmonary edema
C)End-stage ARDS
D)Alveolar collapse

Question 6

While performing nasotracheal suctioning, the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse's hand to remove the suction catheter. Which actions by the nurse are appropriate? Select all that apply.

A)Remove the suction catheter
B)Lower the head of the bed
C)Decrease the suction pressure
D)Apply restraints to the client's arms and legs
E)Hyperoxygenate the client

Question 7

The nurse is providing care for a client admitted during an acute exacerbation of asthma. Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client?

A)Inhaled short-acting beta-agonists
B)Oral corticosteroids
C)Inhaled long-acting beta-agonists
D)Oral anticholinergics

Question 8

The nurse is providing care to a client with sepsis due to a severely infected leg wound. The client states that he is having trouble breathing. Upon assessment, the nurse notes dyspnea, a respiratory rate of 32, the use of accessory muscles to breathe, and rales and rhonchi upon auscultation of the lungs. The nurse recognizes these findings as characteristic of what condition?

A)Allergic response from antibiotic therapy
B)Deep vein thrombosis
C)Acute respiratory distress syndrome
D)Anemia

Question 9

The structure of the respiratory system that serves as the site of gas exchange is the

A)macrophage.
B)bronchi.
C)alveoli.
D)bronchiole.

Question 10

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothorax. Which interventions are appropriate for this client? Select all that apply.

A)Elevate head of the bed
B)Administer a high rate of oxygen by nasal cannula
C)Prepare for a chest tube insertion
D)Administer prescribed antihypertensive medications
E)Administer intravenous caffeine per order

Question 11

When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate to the nurse?

A)Narrow bronchi
B)Narrow trachea passages
C)Blocked large airway passages
D)Inflamed pleural surfaces

Question 12

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this client?

A)Risk for Infection
B)Impaired Spontaneous Ventilation
C)Risk for Acute Confusion
D)Decreased Cardiac Output

Question 13

A client with chronic obstructive pulmonary disease (COPD)is prescribed oxygen 24% 2 L/min. Which is the best method to administer oxygen to this client?

A)Face mask
B)Nasal cannula
C)Nonrebreather mask
D)Venturi mask

Question 14

The nurse is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.

A)Excessive rapid breathing
B)Chest pain
C)Rapid breathing at rest
D)Shallow breathing
E)Cyanosis

Question 15

Vaccinations can help promote healthy oxygenation by

A)reducing the transmission of preventable diseases.
B)increasing the exchange of oxygen for carbon dioxide in the lungs.
C)promoting adequate blood circulation to organs and tissues.
D)preventing all respiratory infections.

Question 16

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention?

A)The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler.
B)The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.
C)The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds.
D)The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

Question 17

Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply.

A)Encouraging deep breathing exercises
B)Assisting with positioning
C)Providing suctioning
D)Prescribing bronchodilators
E)Monitoring activity intolerance

Question 18

The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply.

A)Increased CO₂
B)Vasoconstriction
C)Decreased O₂
D)Decreased intracranial pressure (ICP)
E)Increased pulse rate

Question 19

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate?

A)Encourage strenuous activity.
B)Consult a dietitian for low-calorie meals.
C)Space periods of activity with periods of rest.
D)Encourage dependence with activities of daily living.

Question 20

The nurse assigned to the newborn nursery is conducting shift assessments. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate?

A)Notify the healthcare provider of this assessment finding.
B)Obtain an arterial blood gas for further respiratory assessment.
C)Begin monitoring the respiratory rate every 5 minutes.
D)Continue to monitor the newborn per facility policy.

Question 21

The nurse is instructing a client who is prescribed ipratropium bromide (Atrovent)for asthma. Which should be included in this client's teaching? Select all that apply.

A)Take no more than the prescribed number of doses each day.
B)Rinse the mouth after taking this medication.
C)Take on an empty stomach.
D)Take with meals or a full glass of water.
E)Use hard candy or drink extra fluids to help with a dry mouth.

Question 22

The nurse is providing care to a client with ARDS who has a tracheostomy. The nurse will monitor the client for complications related to the loss of which protective mechanism?

A)The ability to cough
B)Filtration and humidification of inspired air
C)Decrease in oxygen-carrying capacity of the trachea
D)The sneeze reflex initiated by irritants in the nasal passages

Question 23

The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings should the nurse identify as signs that the client has progressed to respiratory failure? Select all that apply.

A)Retractions and fatigue
B)Tachycardia and tachypnea
C)Inaudible breath sounds
D)Diffuse wheezing and the use of accessory muscles when inhaling
E)Reduced wheezing and an ineffective cough

Question 24

A client receiving treatment for acute respiratory distress syndrome (ARDS)is demonstrating anxiety related to having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select all that apply.

A)Explain about care areas specifically designed for long-term ventilatory support.
B)Dim the lights and reduce distracting noise, such as the television.
C)Instruct that intubation and ventilation are temporary measures.
D)Encourage family visits and participation in care.
E)Remain with the client as much as possible.

Question 25

The nurse working on a pediatric unit is caring for a client newly diagnosed with asthma. Which assessment data indicate impending respiratory failure and the need for immediate intervention? Select all that apply.

A)Shallow respirations
B)Slightly diminished breath sounds
C)Decreased wheezing
D)Increased crackles
E)Increased respiratory rate

Question 26

The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? Select all that apply.

A)Sepsis
B)Viral pneumonia
C)Drug overdose
D)Near drowning in saltwater
E)Fractured humerus

Question 27

The nurse is caring for a client admitted with septic shock. Which early clinical manifestation might indicate the development of ARDS?

A)Intercostal retractions
B)Cyanosis
C)Tachypnea
D)Tachycardia

Question 28

A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate?

A)Ineffective Airway Clearance
B)Impaired Tissue Perfusion
C)Ineffective Breathing Pattern
D)Activity Intolerance

Question 29

A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching?

A)"We'll be sure to use the fireplace often to keep the house warm in the winter."
B)"We will replace the carpet in our child's bedroom with tile."
C)"We'll keep the plants in our child's room dusted."
D)"We're glad the dog can continue to sleep in our child's room."

Question 30

The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). The client is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a decrease of cardiac output secondary to positive pressure ventilation?

A)Blood pressure increases from 88/58 mmHg to 90/60 mmHg
B)Urine output decreases from 30 mL/hr to 25 mL/hr
C)Heart rate drops from 108 bpm to 104 bpm
D)Oxygen saturation increases from 82% to 90%

Question 31

The nurse is caring for a woman who is 32 weeks pregnant and requires mechanical ventilation for ARDS. In addition to standard nursing interventions for adult clients with ARDS, what special interventions need to be implemented for this client?

A)Inducing labor
B)Administering nitric oxide and corticosteroids
C)Providing nutritional support
D)Fetal monitoring

Question 32

A client asks why asthma medication is needed even though the client's last attack was several months ago. Which response by the nurse is appropriate?

A)"The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack."
B)"The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him."
C)"The medication is still needed to decrease inflammation in your airways and help prevent an attack."
D)"The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it."

Question 33

The nurse instructs a client with asthma on bronchodilator therapy. Which statement indicates client understanding of how the drug works?

A)"The medication widens the airways by causing airway muscle contraction."
B)"The medication widens the airways by causing airway muscle relaxation."
C)"The medication widens the airways by decreasing histamine production."
D)"The medication widens the airways by decreasing mucus production."

Question 34

Friends of a client hospitalized with asthma would like to bring the client a gift. Which gift should the nurse recommend for this client?

A)A basket of flowers
B)A stuffed animal
C)Fruit and candy
D)A book

Question 35

A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygenation?

A)Oxygen via a nasal cannula
B)Mechanical ventilation
C)Oxygen via a face mask
D)Oxygen via a Venturi mask

Question 36

The nurse is planning care for a young adolescent client diagnosed with asthma. Which evidence-based age-appropriate interventions will the nurse include in the plan of care? Select all that apply.

A)Referring to a peer-led support group
B)Teaching the parents how to administer maintenance medication prior to teaching the client
C)Assessing peer support when planning care
D)Collaborating with teachers for support in the school setting
E)Telling the client to avoid medication while at school

Question 37

The client with ARDS who is likely to have the poorest outcome is

A)a Hispanic male with pneumonia.
B)an African American male with sepsis.
C)a Caucasian female with sepsis.
D)an African American female with chest trauma.

Question 38

A client with acute respiratory distress syndrome (ARDS)is being weaned from ventilatory support. Which nursing actions are appropriate for this client? Select all that apply.

A)Increase percentage of oxygen being provided through the ventilator.
B)Place in the Fowler position.
C)Provide morning care during the weaning procedures.
D)Begin weaning procedures in the morning.
E)Medicate with morphine for pain as needed.

Question 39

Which data supports the nurse's assessment that a newborn with acute respiratory distress syndrome (ARDS)is improving?

A)Increased PaCO₂
B)Oxygen saturation of 92%
C)Pulmonary vascular resistance increases
D)Thick secretions from the respiratory tract

Question 40

One primary method for preventing ARDS in hospitalized clients is

A)performing postural drainage for clients with respiratory congestion.
B)elevating the head of the bed for clients who are ingesting food.
C)providing smoking cessation literature to clients who smoke.
D)administering oxygen as ordered by the healthcare provider.

Question 41

The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The client speaks very little English and is a smoker. Which action would be the most beneficial for this client?

A)Have the adult child of the client translate during the assessment process
B)Encourage aerobic activity
C)Encourage the client to write down questions prior to seeing the healthcare provider
D)Obtain educational materials about smoking cessation written in Spanish.

Question 42

The nurse is providing care to a client with asthma. When developing the client's plan of care, which intervention would be most appropriate to promote effective gas exchange?

A)Provide adequate rest periods
B)Reduce excessive stimuli
C)Assist with activities of daily living
D)Place in Fowler position

Question 43

The nurse is collecting a health history for a 12-month-old child. The child lives in a home where both parents smoke, and the child has had respiratory syncytial virus twice since birth. The child's older sister was recently diagnosed with asthma. The nurse understands that this child's risk of developing asthma later in life is

A)above average.
B)average.
C)below average.
D)well below average.

Question 44

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD)after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this client?

A)Tachycardia
B)Cough
C)Barrel chest
D)Wheezing

Question 45

The nurse caring for a client diagnosed with chronic obstructive pulmonary disease (COPD)is educating the client on effective coughing techniques. Which statement made by the client indicates a need for further teaching?

A)"I should inhale by sniffing."
B)"I should exhale sharply with a 'huff."'
C)"I should limit my fluid intake to 1-1.5 quarts daily."
D)"I should cough twice and then rest."

Question 46

The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD). Which conditions will you include when you teach the client's family about the types of COPD?

A)Asthma and bronchitis
B)Asthma and emphysema
C)Bronchitis and emphysema
D)Emphysema and atelectasis

Question 47

The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD)who has a breathing rate of 32 per minute, elevated blood pressure, and fatigue. Which nursing diagnosis is the priority for this client?

A)Ineffective Coping
B)Ineffective Airway Clearance
C)Anxiety
D)Ineffective Breathing Pattern

Question 48

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse select to address the client's ineffective breathing pattern? Select all that apply.

A)Instruct in pursed-lip breathing
B)Teach visualization and meditation
C)Deep breathing and coughing every hour
D)Instruct in abdominal breathing
E)Provide oxygen 2 liters nasal cannula.

Question 49

The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD). Which medication does the nurse anticipate to decrease this client's risk for developing a respiratory infection?

A)A broad-spectrum antibiotic
B)A bronchodilator
C)A corticosteroid
D)An influenza vaccine

Question 50

The nurse is reviewing discharge instructions with a client who is newly diagnosed with asthma. Which client statement indicates a need for further teaching?

A)"I need to rinse my mouth after every use of my inhaler."
B)"I need to take my Singulair at least 1 hour before I eat."
C)"When inhaling two different medications, I should use the bronchodilator last."
D)"Because I am on theophylline, I will need to have therapeutic blood levels drawn."

Question 51

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse select to meet nutritional needs? Select all that apply.

A)Encourage a diet high in protein and fats.
B)Keep snacks to a minimum.
C)Provide frequent small meals with between-meal supplements.
D)Encourage carbohydrate-rich foods to provide needed calories for energy.
E)Suggest the client eat three meals per day to maintain energy needs.

Question 52

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which factors in the client's history support the current diagnosis? Select all that apply.

A)Working in an industrial environment
B)Working in an office setting with air conditioning
C)History of asthma
D)Current cigarette smoking
E)Playing golf several times a week

Question 53

Which of the following triggers can stimulate an acute asthma attack? Select all that apply.

A)Stress
B)Animal dander
C)Loud noises
D)Exercise
E)Bright lights

Question 54

Which assessment finding by the nurse supports the diagnosis that a client is in the early stages of chronic obstructive pulmonary disease (COPD)?

A)Dysrhythmias
B)Cyanotic nail beds
C)Clubbing of the fingers
D)Cough in the morning producing clear sputum

Question 55

A client diagnosed with chronic obstructive pulmonary disease (COPD)has a pulse oximetry reading of 93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35 bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which order does the nurse question for this client?

A)Antibiotic therapy
B)Nonsteroidal anti-inflammatory agents (NSAIDs)
C)Oxygen by nasal cannula at 3-4 liters/minute
D)Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents

Question 56

The pathophysiologic stimulus that initiates asthma is

A)bronchoconstriction.
B)inflammation in the airways.
C)airway edema.
D)mucus secretion.

Question 57

The nurse is caring for a 72-year-old client who has presented to the emergency department for the third time in 8 months with acute asthma exacerbations. The client states that he has trouble holding his inhaler, and sometimes he forgets to take his medication. He is also worried because he thinks his new drugs are adversely interacting with medications for his other conditions. What nursing diagnosis is appropriate for this client?

A)Deficient Knowledge
B)Ineffective Health Management
C)Risk for Aspiration
D)Ineffective Coping

Question 58

The nurse is evaluating care provided to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which observation would indicate that care provided to this client has been effective?

A)Client conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading.
B)Client needs assistance with morning care and meals due to shortness of breath.
C)Client states family members are discussing admission to a nursing home for continuing care.
D)Client leaves hospital unit to smoke outside four times a day.

Question 59

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). When planning care for this client, which interventions are appropriate to enhance the client's breathing pattern? Select all that apply.

A)Provide adequate rest periods.
B)Assist with activities of daily living (ADLs).
C)Educate on relaxation techniques.
D)Educate on pursed-lip breathing.
E)Administer a cough suppressant.

Question 60

What is one genetic cause of COPD?

A)Alpha-1 antitrypsin deficiency
B)A defect in the CFTR gene
C)A mutation in the superoxide dismutase 1 gene
D)Mutations in the human leukocyte antigen

Question 61

The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV)/bronchiolitis wants to know which factors contribute to the risk of contracting RSV. Which response by the nurse is appropriate?

A)"There is a higher risk in children who are being breastfed."
B)"There is no way to avoid the illness."
C)"There is a higher risk in children who are exposed to secondary cigarette smoke."
D)"It is seen more frequently in children who do not attend daycare."

Question 62

The nurse is developing a plan of care for a toddler diagnosed with respiratory syncytial virus (RSV). Which intervention is inappropriate for this client?

A)Offer small, frequent meals.
B)Encourage to ambulate frequently.
C)Encourage oral intake.
D)Monitor intake and output.

Question 63

The nurse is planning care for a child with respiratory syncytial virus (RSV)bronchiolitis. Which interventions should the nurse include in the child's plan of care to address the nursing diagnosis Impaired Gas Exchange? Select all that apply.

A)Weigh daily.
B)Monitor vital signs and pulse oximetry.
C)Administer oxygen as prescribed.
D)Weigh diapers.
E)Provide frequent rest periods.

Question 64

The nurse is caring for an 18-month-old client who is newly diagnosed with cystic fibrosis. The client is currently hospitalized due to a Pseudomonas aeruginosa infection in the lungs. The client's vital signs are: P 138, R 43, T 101.3°F, BP 86/40, SpO? 88%. The client is coughing up thick, green mucus. What independent nursing intervention can the nurse implement to improve the client's oxygenation?

A)Administration of CFTR modulators
B)Percussion and postural drainage
C)Nutritional counseling
D)Teaching the client to cough into a tissue

Question 65

The mother of a 5-month-old baby, who attends daycare, is concerned because the child has developed a runny nose, cough, and low-grade fever over the last few days. These symptoms are consistent with which condition?

A)Meningitis
B)Respiratory syncytial virus (RSV)bronchiolitis
C)Bronchitis
D)The common cold

Question 66

The nurse working in the emergency department (ED)is assessing an infant client. Which findings does the nurse anticipate in a child diagnosed with respiratory syncytial virus (RSV)? Select all that apply.

A)Rhinorrhea
B)Irritability
C)Grunting
D)Bradypnea
E)Tachypnea

Question 67

The nurse is providing teaching to the client who is pregnant and has cystic fibrosis. The nurse should explain that the client is at increased risk for which condition?

A)Emergency delivery
B)Gestational diabetes
C)Placenta previa
D)Spontaneous abortion

Question 68

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV). What should the nurse stress as the best way to prevent RSV?

A)Hand washing
B)Monitoring temperature
C)Administering antibiotics
D)Limiting fluid intake

Question 69

A 7-year-old client is hospitalized due to complications related to cystic fibrosis. The nurse is responsible for administering medications and performing chest physical therapy. In which order should the nurse perform these actions?

A)Place the client in a position for postural drainage
B)Administer inhaled albuterol
C)Administer inhaled hypertonic saline
D)Perform percussion on the client's back and chest
E)Administer oxygen by nasal cannula

Question 70

An infant with respiratory syncytial virus (RSV)bronchiolitis is prescribed intubation to maintain an adequate airway. Who will the nurse collaborate with to maintain the endotracheal tube and ventilation?

A)An advanced practice nurse
B)The primary healthcare provider
C)A respiratory therapist
D)A play therapist

Question 71

Which prevention strategies would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus (RSV)bronchiolitis? Select all that apply.

A)Do not smoke, and avoid all secondhand smoke around the child.
B)Practice frequent hand washing.
C)Encourage physical activity and play.
D)Consider alternatives to sending the child to daycare.
E)Ensure an adequate nutritional intake.

Question 72

The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial virus (RSV). Which nursing diagnosis would be most appropriate for the infant?

A)Acute Pain
B)Ineffective Tissue Perfusion
C)Activity Intolerance
D)Decreased Cardiac Output

Question 73

What is the best way nurses can help clients reduce the risk of COPD?

A)Providing smoking cessation resources
B)Encouraging clients to receive vaccinations
C)Referring clients to a nutritionist
D)Providing references to local fitness facilities

Question 74

Which population should the nurse assigned to care for pediatric clients recognize as having the highest risk of hospitalization due to RSV?

A)Alaskan Native infants
B)African American infants
C)Native American infants
D)Asian American infants

Question 75

For couples in which both individuals carry one defective CF gene, any offspring from the couple has a ________ percent chance of inheriting two abnormal genes and developing cystic fibrosis.

A)100
B)75
C)50
D)25

Question 76

Besides the respiratory system, which system would be critical for the nurse to assess in a client recently diagnosed with cystic fibrosis?

A)Nervous system
B)Gastrointestinal system
C)Musculoskeletal system
D)Urinary system

Question 77

The nurse observes a toddler, admitted with possible respiratory syncytial virus (RSV)bronchiolitis, grunting with expiration. Which action by the nurse is appropriate?

A)Assist the child to clear the nasal passages.
B)Limit fluids.
C)Suction the airway to relieve the obstruction.
D)Lay the child on his back.

Question 78

A 15-year-old client with cystic fibrosis asks why she has not started her menstrual period yet. Which response by the nurse is correct?

A)"Usually girls with cystic fibrosis start menstruating earlier than their peers."
B)"It is normal for girls with cystic fibrosis to start their period at age 16. Just be patient."
C)"Some girls with cystic fibrosis do not experience menstruation due to nutritional problems."
D)"Because secretions are thicker in people with cystic fibrosis, your period will be very heavy once it starts."

Question 79

The ion that cannot be regulated properly in clients with cystic fibrosis is

A)chloride.
B)sodium.
C)calcium.
D)potassium.

Question 80

The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV)bronchiolitis. Which assessment finding indicates that treatment has been effective?

A)Client ingesting small amounts of clear fluids when encouraged
B)Client resting in bed with limited interest in play or activities
C)Client respiratory rate within normal limits for age
D)Client coughing copious amounts of green sputum and requires occasional suctioning