The Adult Client With Res

Nclex RN 5th edition[Type text] Practice Questions Chapter 58: Respiratory System
The Adult Client with Respiratory Disorder pg 762

Practice Questions
652. An emergency department nurse is assessing a client who has sustained a blunt
injury to the chest wall. Which of these signs would indicate the presence of a
pneumothorax in this client?
1. A low respiratory rate
2. Diminished breath sounds
3. The presence of a barrel chest
4. A sucking sound at the site of injury
ANSWER: 2
Rationale: This client has sustained a blunt or a closed chest injury. Basic symptoms of
a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax
may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous
emphysema. Hyperresonance also may occur on the affected side. A sucking sound at
the site of injury would be noted with an open chest injury.
Test-Taking Strategy: Use the process of elimination and note the strategic word blunt
in the question. This will assist in eliminating option 4, sucking chest wound injury.
Knowing that in a respiratory injury increased respirations will occur will assist you in
eliminating option 1. Option 3 can be eliminated because a barrel chest is a
characteristic finding in a client with chronic obstructive pulmonary disease.
Review the signs of pneumothorax if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing ProcessAssessment
Content Area: Adult HealthRespiratory
Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patient -
centered collaborative care (6th ed., p. 699). St. Louis: Saunders.
653. A nurse is caring for a client hospitalized with acute exacerbation of chronic
obstructive pulmonary disease. Which of the following would the nurse expect to note
on assessment of this client?
1. Hypocapnia
2. A hyperinflated chest noted on the chest x-ray
3. Increased oxygen saturation with exercise
4. A widened diaphragmnoted on the chest x-ray
ANSWER: 2
Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD)
include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation
with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a
hyperinflated chest and a flattened diaphragm if the disease is advanced.
Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because in
the client with COPD, hypercapnia would be noted. Next, eliminate option 3 because
oxygen desaturation rather than saturation would occur. From the remaining options,
reading carefully will assist in directing you to option 2. If you are unfamiliar with the
manifestations associated with COPD, review this content.

centered collaborative care (6th ed., pp. 623, 627). St. Louis: Saunders.
654. A nurse instructs a client to use the pursed-lip method of breathing and the client
asks the nurse about the purpose of this type of breathing. The nurse responds,
knowing that the primary purpose of pursed-lip breathing is to:
1. Promote oxygen intake.
2. Strengthen the diaphragm.
3. Strengthen the intercostal muscles.
4. Promote carbon dioxide elimination.
ANSWER: 4
Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive
lung disease. This type of breathing allows better expiration by increasing airway
pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not
the purposes of this type of breathing.
Test-Taking Strategy: Visualize the use of this procedure to assist you in answering
correctly. Knowledge regarding the respiratory conditions in which this type of breathing
is helpful also will assist in directing you to option 4. Reviewthe purpose of this
breathing technique if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Integrated Process: Teaching and Learning
References: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patient-
centered collaborative care (6th ed., pp. 630631). St. Louis: Saunders. Potter, P., &
Perry, A. (2009) Fundamentals of nursing (7th ed., pp. 960, 963). St. Louis: Mosby.
655. The low-pressure alarm sounds on a ventilator. A nurse assesses the client and
then attempts to determine the cause of the alarm. The nurse is unsuccessful in
determining the cause of the alarm and takes what initial action?
1. Administers oxygen
2. Checks the clients vital signs
3. Ventilates the client manually
4. Starts cardiopulmonary resuscitation
ANSWER: 3
Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain
the problem, the client is disconnected from the ventilator and manual resuscitation is
used to support respirations until the problem can be corrected. No reason is given to
begin cardiopulmonary resuscitation. Checking vital signs is not the initial action.
Although oxygen is helpful, it will not provide ventilation to the client.
Test-Taking Strategy: Read the question carefully, and note that the subject relates to
adequate ventilation of the client. Also note that the nurse is unsuccessful in
determining the cause of the alarm. This will direct you to option 3. If you
are unfamiliar with the management of ventilators and alarms, review this content.
Level of Cognitive Ability: Applying
Integrated Process: Nursing ProcessImplementation
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 1643). St. Louis: Saunders.
656. A nurse is caring for a client after a bronchoscopy and biopsy. Which of the
following signs, if noted in the client, should be reported immediately to the physician?
1. Dry cough
2. Hematuria
3. Bronchospasm
4. Blood-streaked sputum
ANSWER: 3
Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is
expected for several hours. Frank blood indicates hemorrhage. A dry cough may be
expected. The client should be assessed for signs of complications, which would
include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension,
tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first because
it is unrelated to the procedure. Next, eliminate option 1 because a dry cough may be
expected. Noting that a biopsy has been performed will assist in eliminating
option 4, because blood-streaked sputum would be expected. Note that option 3, the
correct option, relates to the airway. If you had difficulty with this question, review
postprocedure care following bronchoscopy with biopsy.
Reference: Chernecky, C., & Berger, B. (2008). Laboratory tests and diagnostic
procedures (5th ed., p. 262). St. Louis: Saunders.
657. A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning,
the nurse must limit the suctioning time to a maximum of:
1. 1 minute
2. 5 seconds
3. 10 seconds
4. 30 seconds
ANSWER: 3
Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the
pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia.
The nurse must preoxygenate the client before suctioning and limit the suctioning pass
to 10 seconds.
Test-Taking Strategy: Use the process of elimination. Recall that during suctioning, the
clients airway is blocked; therefore you should be able to eliminate options 1 and 4
easily. From the remaining options, eliminate option 2 because of the short time frame.
Five seconds does not seem reasonable to achieve removal of secretions. Review the
procedure for suctioning if you had difficulty with this question.
658. A nurse is suctioning fluids from a client through an endotracheal tube. During the
suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing.
Which of the following is the appropriate nursing intervention?
1. Continue to suction.
2. Notify the physician immediately.
3. Stop the procedure and reoxygenate the client.
4. Ensure that the suction is limited to 15 seconds.
ANSWER: 3
Rationale: During suctioning, the nurse should monitor the client closely for side
effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate
resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal
coughing. If side effects develop, especially cardiac irregularities, the procedure is
stopped and the client is reoxygenated.
Test-Taking Strategy: Use the process of elimination, recalling that suctioning can
cause cardiac irregularities. Noting the strategic words heart rate is decreasing should
direct you to option 3. If you had difficulty with this question, review
the complications and interventions associated with suctioning
procedures.
management for positive outcomes (8th ed., pp. 1647, 1799). St. Louis: Saunders.
659. A nurse is assessing the respiratory status of a client who has suffered a fractured
rib. The nurse would expect to note which of the following?
1. Slow deep respirations
2. Rapid deep respirations
3. Paradoxical respirations
4. Pain, especially with inspiration
ANSWER: 4
Rationale: Rib fractures are a common injury, especially in the older client, and result
from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness
localized at the fracture site and exacerbated by inspiration and palpation, shallow
respirations, splinting or guarding the chest protectively to minimize chest movement,
and possible bruising at the fracture site. Paradoxical respirations are seen with flail
chest.
Test-Taking Strategy: Use the process of elimination. Focusing on the anatomical
location of the injury will direct you to option 4. Review the assessment findings in rib
fractures if you had difficulty with this question.
management for positive outcomes (8th ed., pp. 16581659). St. Louis: Saunders.
660. A client with a chest injury has suffered flail chest. A nurse assesses the client for
which most distinctive sign of flail chest?
1. Cyanosis
2. Hypotension
3. Paradoxical chest movement
4. Dyspnea, especially on exhalation
ANSWER: 3
Rationale: Flail chest results from multiple rib fractures. This results in a floating
section of ribs. Because this section is unattached to the rest of the bony rib cage, this
segment results in paradoxical chest movement. This means that the force of inspiration
pulls the fractured segment inward, while the rest of the chest expands. Similarly, during
exhalation, the segment balloons outward while the rest of the chest moves inward. This
is a characteristic sign of flail chest.
Test-Taking Strategy: Use the process of elimination, focusing on the strategic words
most distinctive. Cyanosis and hypotension occur with many different disorders, so
eliminate options 1 and 2 first. From the remaining options, choose paradoxical chest
movement over dyspnea on exhalation by remembering that a flail chest has broken rib
segments that move independently of the rest of the rib cage. Review the assessment
findings in flail chest if you had difficulty with this question.
661. A client has been admitted with chest trauma after a motor vehicle accident and
has undergone subsequent intubation. A nurse checks the client when the high -
pressure alarm on the ventilator sounds, and notes that the client has absence of
breath sounds in the right upper lobe of the lung. The nurse immediately assesses for
other signs of:
1. Right pneumothorax
2. Pulmonary embolism
3. Displaced endotracheal tube
4. Acute respiratory distress syndrome
ANSWER: 1
Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain
with respiration, asymmetrical chest expansion, and diminished or absent breath sound
sairway pressure because of resistance to lung inflation. Acute respiratory distress
syndrome and pulmonary embolism are not characterized by absent breath sounds. An
endotracheal tube that is inserted too far can cause absent breath sounds, but the lack
of breath sounds most likely would be on the left side because of the degree of
curvature of the right and left main stem bronchi.
Test-Taking Strategy: Use the process of elimination. Focus on the symptoms
presented in the question and note the relationship between right upper lobe and right
pneumothorax in option 1. Review the manifestations associated with pneumothorax
if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patient-
centered collaborative care (6th ed., pp. 569, 698699). St. Louis: Saunders.
662. A nurse is assessing a client with multiple trauma who is at risk for developing
acute respiratory distress syndrome. The nurse assesses forwhich earliest sign of acute
respiratory distress syndrome?
1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate
ANSWER: 4
Rationale: The earliest detectable sign of acute respiratory distress syndrome is an
increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to
the body. This is followed by increasing dyspnea, air hunger, retraction of accessory
muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory
crackles or diffuse coarse crackles.
Test-Taking Strategy: Use the process of elimination, noting the strategic word
earliest. Eliminate option 3 first because intercostal retraction is a later sign of
respiratory distress. Of the remaining options, recall that adventitious breath sounds
(options 1 and 2) would occur later than an increased respiratory rate. Review the early
signs of acute respiratory distress syndrome if you had difficulty with this question.

663. A nurse is assessing a client with chronic airflow limitation and notes that the client
has a barrel chest. The nurse interprets that this client has which of the following forms
of chronic airflow limitation?
1. Emphysema
2. Bronchial asthma
3. Chronic obstructive bronchitis
4. Bronchial asthma and bronchitis
ANSWER: 1
Rationale: The client with emphysema has hyperinflation of the alveoli and flattening of
the diaphragm. These lead to increased anteroposterior diameter, referred to as barrel
chest. The client also has dyspnea with prolonged expiration and has hyperresonant
lungs to percussion.
Test-Taking Strategy: Use the process of elimination. Recall that the barrel chest is a
result of long-term hyperinflation of the lungs and air trapping. Knowing that a barrel
chest occurs in emphysema will direct you to option 1. Review the characteristics of
emphysema if you had difficulty with this question.
Reference: Copstead-Kirkhorn, L., & Banasik, J. (2010). Pathophysiology (4th ed., p.
553). St. Louis: Mosby.
664. A nurse has conducted discharge teaching with a client diagnosed with
tuberculosis. The client has been taking medication for 1 weeks. The nurse evaluates
that the client has understood the information if the client makes which of the following
statements?
1. I need to continue drug therapy for 2 months.
2. I cant shop at the mall for the next 6 months.
3. I can return to work if a sputum culture comes back negative.
4. I should not be contagious after 2 to 3 weeks of medication therapy.
ANSWER: 4
Rationale: The client is continued on medication therapy for 6 to 12 months, depending
on the situation. The client generally is considered not to be contagious after 2 to 3
weeks of medication therapy. The client is instructed to wear a mask if there will be
exposure to crowds until the medication is effective in preventing transmission. The
client is allowed to return to work when the results of three sputum cultures are
negative.
Test-Taking Strategy: Use the process of elimination. Knowing that the medication
therapy lasts for at least 6 months helps you eliminate option 1 first. Knowing that three
sputum cultures must be negative helps you to eliminate option 3 next. From the
remaining options, recalling that the client is not contagious after 2 to 3 weeks of
therapy will direct you to option 4. If you had difficulty with this question, review the
infectious period of tuberculosis.
Level of Cognitive Ability: Evaluating
Integrated Process: Nursing ProcessEvaluation
centered collaborative care (6th ed., pp. 672673). St. Louis: Saunders.
665. A nurse is preparing to give a bed bath to an immobilized client with tuberculosis.
The nurse should wear which of the following items when performing this care?
1. Surgical mask and gloves
2. Particulate respirator, gown, and gloves
3. Particulate respirator and protective eyewear
4. Surgical mask, gown, and protective eyewear
ANSWER: 2
Rationale: The nurse who is in contact with a client with tuberculosis should wear an
individually fitted particulate respirator. The nurse also would wear gloves as per
standard precautions. The nurse wears a gown when the possibility exists that the
clothing could become contaminated, such aswhen giving a bed bath.
Test-Taking Strategy: Use the process of elimination. Knowing that the nurse should
wear a particulate respirator eliminates options 1 and 4. Knowledge of basic standard
precautions directs you to option 2 from the remaining options. Review precautions
related to the care of a client with tuberculosis if you had difficulty with this question.
Client Needs: Safe and Effective Care Environment
References: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patient -
centered collaborative care (6th ed., pp. 670, 672). St. Louis: Saunders. Perry, A., &
Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 185). St. Louis: Mosby.
666. A client has experienced pulmonary embolism. A nurse assesses for which
symptom, which is most commonly reported?
1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken
ANSWER: 3
Rationale: The most common initial symptom in pulmonary embolism is chest pain that
is sudden in onset. The next most commonly reported symptom is dyspnea, which is
accompanied by an increased respiratory rate. Other typical symptoms of pulmonary
embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.
Test-Taking Strategy: Use the process of elimination. Because pulmonary embolism
does not result from an infectious process or an allergic reaction, eliminate options 1
and 2 first. To select between options 3 and 4, look at them closely. Option
4 states dyspnea when deep breaths are taken. Although dyspnea commonly occurs
with pulmonary embolism, dyspnea is not associated only with deep breathing.
Therefore eliminate option 4. Review the signs of pulmonary embolism
if you had difficulty with this question.
Reference: Swearingen, P. (2008). All-in-one care planning resource: Medical-surgical,
pediatric, maternity, & psychiatric nursing care plans (2nd ed., p. 137). St. Louis: Mosby.
667. A client who is human immunodeficiency virus positive has had a Mantoux skin
test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse
interprets the results as:
1. Positive
2. Negative
3. Inconclusive
4. Indicating the need for repeat testing
ANSWER: 1
Rationale: The client with human immunodeficiency virus (HIV) infection is considered
to have positive results on Mantoux skin testing with an area larger than 5 mm of
induration. The client without HIV is positive with an induration larger than 10 mm. The
client with HIV is immunosuppressed, making a smaller area of induration positive for
this type of client. It is possible for the client infected with HIV to have false-negative
readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect
interpretations.
Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first
because they are comparable or alike. From the remaining options, recalling that the
client with HIV is immunosuppressed will assist in determining the interpretation of the
area of induration. Review results of tuberculosis skin testing in an immunosuppressed
client if you had difficulty with this question.
Integrated Process: Nursing ProcessAnalysis
668. A client with acquired immunodeficiency syndrome has histoplasmosis. A nurse

assesses the client for which of the following signs and symptoms?
1. Dyspnea
2. Headache
3. Weight gain
4. Hypothermia
ANSWER: 1
Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the
client with acquired immunodeficiency syndrome (AIDS). The infection begins as a
respiratory infection and can progress to disseminated infection. Typical signs and
symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the clients
lymph nodes, liver, and spleen may occur as well.
Test-Taking Strategy: Use the process of elimination. Recalling that histoplasmosis is
an infectious process will help you eliminate option 4. Because the client has AIDS and
another infection, weight gain is an unlikely symptom and can be eliminated next.
Knowing that histoplasmosis begins as a respiratory infection helps you choose
dyspnea over headache as the correct option. Review the signs of histoplasmosis if
you had difficulty with this question.
669. A nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The
nurse concludes that the client understands the information if the client reports which of
the following early signs of exacerbation?
1. Fever
2. Fatigue
3. Weight loss
4. Shortness of breath
ANSWER: 4
Rationale: Dry cough and dyspnea are typical signs and symptoms of pulmonary
sarcoidosis. Others include night sweats, fever, weight loss, and skin nodules.
Test-Taking Strategy: Use the process of elimination and note the strategic word early.
Because sarcoidosis is a pulmonary problem, eliminate options 1 and 3 first. Select
option 4 over option 2 because the shortness of breath (and impaired ventilation)
appears first and would cause the fatigue as a secondary symptom. Review the early
signs of exacerbation in sarcoidosis if you had difficulty with this
question.
Level of Cognitive Ability: Evaluating
Integrated Process: Nursing ProcessEvaluation
670. A nurse is taking the history of a client with silicosis. The nurse assesses whether
the client wears which of the following items during periods of exposure to silica
particles?
1. Mask
2. Gown
3. Gloves
4. Eye protection
ANSWER: 1
Rationale: Silicosis results from chronic, excessive inhalation of particles of free
crystalline silica dust. The client should wear a mask to limit inhalation of this substance,
which can cause restrictive lung disease after years of exposure. Options 2, 3, and 4
are not necessary.
Test-Taking Strategy: Use the process of elimination. Recalling that exposure to silica
dust causes the illness and that the dust is inhaled into the respiratory tract will direct
you to option 1. If you had difficulty with this question, review the protective measures
associated with silicosis.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care (6th ed., p. 640). St. Louis: Saunders.
Potter, P., & Perry, A. (2009) Fundamentals of nursing (7th ed., pp. 662663). St. Louis:
Mosby.
671. An oxygen delivery system is prescribed for a client with chronic obstructive
pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery
system would the nurse anticipate to be prescribed?
1. Face tent
2. Venturi mask
3. Aerosol mask
4. Tracheostomy collar
ANSWER: 2
Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the
best oxygen delivery system for the client with chronic airflow limitation because it
delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy
collar are also high-flow oxygen delivery systems but most often are used to administer
high humidity.
Test-Taking Strategy: Use the process of elimination and note the strategic words
precise oxygen concentration. Eliminate options 1, 3, and 4 because they are
comparable or alike in that they are used to provide high humidity. Review the various
types of oxygen delivery systems if you had difficulty with this question.
Integrated Process: Nursing ProcessPlanning
Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patient-

672. A nurse is instructing a hospitalized client with a diagnosis of emphysema about

measures that will enhance the effectiveness of breathing during dyspneic periods.
Which of the following positions will the nurse instruct the client to assume?
1. Sitting up in bed
2. Side-lying in bed
3. Sitting in a recliner chair
4. Sitting on the side of the bed and leaning on an overbed table
ANSWER: 4
Rationale: Positions that will assist the client with emphysema with breathing include
sitting up and leaning on an overbed table, sitting up and resting the elbows on the
knees, and standing and leaning against the wall.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first
because they are comparable or alike. Next, eliminate option 2 because this position will
not enhance breathing. If you had difficulty with this question, review the positions that
will decrease the work of breathing in a client with emphysema.
673. A community health nurse is conducting an educational session with community

members regarding tuberculosis. The nurse tells the group that one of the first
symptoms associated with tuberculosis is:
1. Dyspnea
2. Chest pain
3. A bloody, productive cough
4. A cough with the expectoration of mucoid sputum
ANSWER: 4
Rationale: One of the first pulmonary symptoms of tuberculosis is a slight cough with
the expectoration of mucoid sputum. Options 1, 2, and 3 are late symptoms and signify
cavitation and extensive lung involvement. Test-Taking Strategy: Use the process of
elimination and note the strategic word first in the question. Next focusing on the
diagnosis should direct you to option 4. If you are unfamiliar with the signs associated
with tuberculosis, review this content.
References: Copstead-Kirkhorn, L., & Banasik, J. (2010). Pathophysiology (4th ed., pp.
586587). St. Louis: Mosby.
Swearingen, P. (2008). All-in-one care planning resource: Medical-surgical, pediatric,

maternity, & psychiatric nursing care plans (2nd ed., p. 143). St. Louis: Mosby.
674. A nurse performs an admission assessment on a client with a diagnosis of

tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this
diagnosis?
1. Chest x-ray
2. Bronchoscopy
3. Sputum culture
4. Tuberculin skin test
ANSWER: 3
Rationale: Tuberculosis is definitively diagnosed through culture and isolation of
Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin
skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and
histological evidence of granulomatous disease on biopsy.
Test-Taking Strategy: Note the strategic word confirm in the question. Confirmation is
made by identifying M. tuberculosis. If you had difficulty with this question, review the
diagnostic procedures related to tuberculosis.
collaborative care (6th ed., p. 669). St. Louis: Saunders.
Alternate Item Format:

Multiple Response
675. The nurse is preparing a list of home care instructions for the client who has been
hospitalized and treated for tuberculosis. Of the following instructions, which will the
nurse include on the list? Select all that apply.
1. Activities should be resumed gradually.
2. Avoid contact with other individuals, except family members, for at least 6 months.
3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
4. Respiratory isolation is not necessary because family members already have been
exposed.
5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic
bags.
6. When one sputum culture is negative, the client is no longer considered infectious
and usually can return to former employment.
ANSWER: 1, 3, 4, 5
Rationale: The nurse should provide the client and family with information about
tuberculosis and allay concerns about the contagious aspect of the infection. Instruct
the client to follow the medication regimen exactly as prescribed and always to have a
supply of the medication on hand. Advise the client of the side effects of the medication
and ways of minimizing them to ensure compliance. Reassure the client that after 2 to 3
weeks of medication therapy, it is unlikely that the client will infect anyone. Inform the
client that activities should be resumed gradually and about the need for adequate
nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote
healing and prevent recurrence of infection. Inform the client and family that respiratory
isolation is not necessary because family members already have been exposed. Instruct
the client about thorough hand washing and to cover the mouth and nose when
coughing or sneezing and to put used tissues into plastic bags. Inform the client that a
sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When
the results of three sputum cultures are negative, the client is no longer considered
infectious and can usually return to former employment.
Test-Taking Strategy: Knowledge regarding the pathophysiology, transmission, and
treatment of tuberculosis is needed to answer this question. Read each option carefully
to answer correctly. Review home care instructions for the client with tuberculosis if you
had difficulty with this question.
management for positive outcomes (8th ed., p. 1608). St. Louis: Saunders.
collaborative care (6th ed., pp. 670, 672). St. Louis: Saunders.

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Nclex RN 5th edition[Type text] Practice Questions Chapter 58: Respiratory System

The Adult Client with Respiratory Disorder pg 762

Level of Cognitive Ability: Analyzing

Content Area: Adult HealthRespiratory

668. A client with acquired immunodeficiency syndrome has histoplasmosis. A nurse

Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patient-

672. A nurse is instructing a hospitalized client with a diagnosis of emphysema about

673. A community health nurse is conducting an educational session with community

Swearingen, P. (2008). All-in-one care planning resource: Medical-surgical, pediatric,

674. A nurse performs an admission assessment on a client with a diagnosis of

Alternate Item Format:

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