The client, who is Hispanic, had a radical neck dissection to treat a large facial tumor. Which initial action by the nurse would best determine if the client has an altered body image from the procedure?

While performing tracheostomy care for the client who experienced facial trauma, the nurse discovers that more air is needed to inflate the cuff to maintain a seal. Which complication related to the tracheostomy should the nurse further explore?

The client is experiencing vocal cord paralysis after extubation from prolonged ET intubation. Which symptom should prompt the nurse to conclude that only one vocal cord is affected?

The nurse identifies the nursing problem of ineffective airway clearance for the postoperative client following an open thoracotomy. Which priority intervention best addresses this nursing problem?

The nurse is assisting the client with arm and shoulder exercises on the client’s first postoperative day following a right—sided thoracotomy. The client reports pain with the exercises and wants to know why they must be performed. Which explanation should the nurse provide to the client?

The nurse is caring for the client with a left-sided chest tube attached to a wet suction chest tube system. Which observation by the nurse would require immediate intervention?

The nurse is caring for the client who sustained multiple injuries and chest trauma in an MVA. The client has developed ARDS, and the HCP requests that the family be updated about this. Which information should the nurse plan to discuss with the family?

The nurse is assessing the client who just arrived by ambulance following an MVA. Which assessment finding should the nurse associate with a possible pulmonary contusion?

The nurse assesses the client brought to the ED via ambulance after a motorcycle crash. The client has paradoxical chest movement with respirations, multiple bruises across the chest and torso, crepitus, and tachypnea. What should the nurse do next?

The client hospitalized with severe pneumonia asks the nurse, “Why do I need to spit in this sputum specimen container?” Which response is most appropriate?

The client with CF is visiting with the nurse in preparation for leaving home for college. Which client statement should the nurse clarify?

The nurse is assessing the client post-hemilaryngectomy and radical neck dissection for treatment of cancer. Which finding should the nurse expect due to the surgical procedure?

The nurse is evaluating discharge teaching that has been completed for the client following total laryngectomy. Which client statement should the nurse correct?

The nurse includes a referral to a dietitian in the plan of care for the client following total laryngectomy. Which should be the nurse’s primary rationale for initiating a nutritional referral?

On the third postoperative day following a total laryngectomy, the client’s spouse asks when the client will be able to eat. Which response by the nurse is correct?

The nurse is caring for the client requiring positive pressure mechanical ventilation. The client has been resisting the ventilator-assisted breaths, and the client’s BP has been steadily decreasing. Which intervention should the nurse implement?

The nurse begins to hear high-pressure alarms in the room of the client requiring respiratory assistance with a ventilator. Which is the best action by the nurse?

The nurse is helping the client newly diagnosed with obstructive sleep apnea to apply a CPAP mask at bedtime. When asked by the client about the purpose of CPAP, what should be the nurse’s best response?

The client newly diagnosed with asthma is preparing for discharge. Which point should the nurse emphasize during the client’s teaching?

The nurse is assessing the lung sounds of the client with pneumonia who is having pain during inspiration and expiration. Which information about lung sounds should the nurse document when hearing loud grating sounds over the lung fields?

The nurse is providing teaching to the client with COPD about the purpose of pursed-lip breathing. Which explanation is most appropriate?

The client with interstitial pulmonary disease is experiencing dyspnea and fatigue. Which recommendation by the nurse will be most helpful to this client?

During the immediate postoperative period, the nurse obtains two sets of VS that are WNL for the client who had a total laryngectomy and a tracheostomy placement for cancer treatment. Which is the nurse’s priority action at this time?

In consulting with the HCP, the nurse learns that the client admitted with a possible PE has a ventilation/ perfusion quotient (V/Q) mismatch as shown on a V/Q scan. Which action should be taken by the nurse?

The client with asthma has pronounced wheezing and signs of a possible impending asthma attack. Which intervention should the nurse implement first?

The nurse is assessing the client with chronic bronchitis. Which finding should the nurse expect?

The nurse is developing a plan of care for the client admitted with a cough, fever, dyspnea, and a diagnosis of pneumonia. Which is the best intervention to include in the client’s plan of care to prevent atelectasis?

The nurse observes for early signs of ARDS in the client being treated for smoke inhalation. Which early signs indicate the possible onset of ARDS in this client?

The NA is providing information to the nurse about clients receiving care from the NA. After receiving this report, which client should the nurse attend to first?

The client telephones the clinic after having 3 days of symptoms that strongly suggest influenza. What should the nurse advise?

The client telephones the clinic after having 3 days of symptoms that strongly suggest influenza. What should the nurse advise?

The home health nurse is visiting the client whose chronic bronchitis has recently worsened due to not following previous instructions. Which instruction should the nurse reinforce?

The nurse is caring for the client in an ED who has five fractured ribs from blunt chest trauma. The client is rating pain at 9 out of 10 on a 0 to 10 scale. When contacting the HCP, the nurse should advocate for which pain management option?

The client with COPD is in the third postoperative day following right-sided thoracotomy. During the day shift, the client required 10 L of oxygen by mask to keep oxygen saturation levels greater than 88%. Which action should be taken by the evening shift nurse?

The nurse is caring for a group of clients. Which cheat should the nurse identify as being at the greatest risk for developing bronchiolitis obliterans organizing pneumonia (BOOP)?

The client, hospitalized with a lower respiratory tract infection, has a history of mild liver disease and asthma. Which prescription by an HCP should the nurse question?

The nurse assesses the client who recently had a lower lobectomy for lung cancer. Findings include dyspnea with respirations at 45 breaths per minute, hypotension, Sao2 at 86% on 10 L close-fitting oxygen mask, trachea deviated slightly to the left, and the right side of the client’s chest not expanding. Which action should be taken by the nurse first?

The nurse and client are updating the client’s asthma action plan. Which information should be updated on the action plan?

The client who had an open thoracotomy for removal of a large tumor received fluid resuscitation during surgery due to an extensive blood loss. Upon postoperative assessment, the nurse finds that the client is cyanotic and dyspneic and has pink, frothy secretions drooling from the client’s mouth. Which intervention should the nurse implement immediately?

The nurse is caring for the client whose condition has progressed from an acute lung injury from near-drowning to ARDS. Which intervention should the nurse question with the HCP?