Medical Surgical Respiratory Practice Questions - ANSWER KEY!!!

ATI - PN Adult Medical Surgical Nursing (Edition 10.0)

1. A nurse is collecting data on a client following a bronchoscopy. Which of the following

ndings should the nurse report to the provider?

A. Blood-tinged sputum is an expected nding following a bronchoscopy

B. A dry, nonproductive cough is an expected nding following a bronchoscopy

C. A sore throat is an expected nding following a bronchoscopy

D. CORRECT: Laryngospasm's can indicate the client is having di culty

maintaining a patent airway. The nurse should notify the provider immediately

2. A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following
supplies should the nurse ensure are in the clients room? (Select all that apply)

A. CORRECT: Oxygen equipment

B. An incentive spirometer is indicated for a client following thoracic surgery to

promote improved oxygenation and pulmonary function.

C. CORRECT: Pulse oximetry is necessary to monitor oxygen saturation level

during the procedure

D. CORRECT: A sterile dressing is necessary to apply to the puncture site

following the procedure

E. A suture removal kit is needed to remove sutures following surgery

3. A nurse is caring for a client following a thoracentesis. Which of the following

manifestations should the nurse recognize as risks for complications? (Select all that apply)

A. CORRECT: Dyspnea can indicate a pneumothorax or a reaccumulation of

uid. The nurse should notify the provider immediately

B. Localized bloody drainage contained on a dressing is an expected nding

following a thoracentesis

C. CORRECT: Fever can indicate an infection. The nurse should notify the
provider immediately

D. CORRECT: Hypotension can indicate intrathoracic bleeding. The nurse

should notify the provider immediately.

E. The clients report of pain at the puncture site is an expected nding

following a thoracentesis

4. A nurse is collecting data from a client who has a chest tube and drainage system in place.
Which of the following ndings should the nurse expect? (Select all that apply)

A. Continuous bubbling in the water seal chamber indicates an air leak

B. CORRECT: Gentle bubbling in the suction control chamber is an expected

nding as air is being removed

C. CORRECT: A rise and fall of the uid level in the water seal chamber upon
inspiration and expiration indicates that the drainage system is functioning
properly

D. The nurse should cover the sutures at the insertion site with an airtight
dressing

E. The nurse should maintain the drainage system in an upright position below
the level of the clients chest

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5. A nurse is assisting a provider with the removal of a chest tube. Which of the following
actions should the nurse instruct the client to do?

A. The position the client should assume during removal of a chest tube
depends upon the location of the insertion site

B. Use of an incentive spirometer is not indicated during chest tube removal

C. The nurse should instruct the client to breathe normally and remain calm
during the procedure

D. CORRECT: The nurse should instruct the client to take a deep breath,
exhale, and bear down (Valsalva maneuver) as the chest tube is being
removed. This increases intrathoracic pressure and reduces the risk of an air
embolism

6. A nurse is caring for a client who is experiencing respiratory distress. Which of the following
early manifestations of hypoxemia should the nurse recognize? (Select all that apply)

A. Confusion is a late manifestation of hypoxemia

B. CORRECT: Pale skin is an early manifestation of hypoxemia

C. Bradycardia is a late manifestation of hypoxemia

D. Hypotension is a late manifestation of hypoxemia

E. CORRECT: Elevated blood pressure

7. A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which
of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to
the client?

A. A nonrebreather mask delivers an approximated amount of oxygen

B. CORRECT: A Venturi mask incorporates an adapter that allows a precise

amount of oxygen to be delivered

C. A nasal cannula delivers an approximated amount of oxygen

D. A simple face mask delivers an approximated amount of oxygen

8. A nurse is caring for a client who has a new prescription for oxygen therapy of 4 L/min
using a nasal cannula. Which of the following actions should the nurse take?

A. CORRECT: Humidi cation should be provided for ow rates of 3 L/min or

greater

B. The client is able to eat while the nasal cannula is in place

C. The client is able to talk and communicate while the cannula is in place

D. Use water-soluble gel to prevent dry nares

9. A nurse is assisting with the plan of care for a client who has respiratory distress. Which of
the following interventions should the nurse include in the plan? (Select all that apply)

A. The nurse should position the client in a Fowler’s or semi-Fowlers position

B. CORRECT: The nurse should provide emotional support to decrease anxiety

C. CORRECT: The nurse should encourage the client to cough to promote

airway clearance

D. CORRECT: The nurse should perform oral suctioning as necessary to

promote airway clearance

E. The nurse should have the client take deep breaths to promote oxygenation

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 10. A nurse is collecting data from a client who is receiving mechanical ventilation. Which of
the following ndings indicates that the client might have developed an infection?

A. A decrease in blood pressure can indicate an impaired cardiac output

B. An increased abdominal girth can indicate gastric distention

C. CORRECT: A change in color of sputum can be a manifestation of an

infection

D. Absent breath sounds over one lung area can indicate barotrauma

11. A nurse is monitoring a group of clients for increased risk for developing pneumonia.
Which of the following clients should the nurse expect to be at risk? (Select all that apply)

A. CORRECT: The client who has di culty swallowing is at increased risk for
pneumonia due to aspiration

B. CORRECT: The client who has AIDS is immunocompromised, which

increases the risk of opportunistic infections, such as pneumonia

C. The client who has recently been vaccinated in the past few months has a
decreased risk to acquire pneumonia

D. A client who is ambulatory and has received local anesthesia has a

decreased risk to acquire pneumonia

E. CORRECT: Mechanical ventilation is invasive and increases the risk of

pneumonia

F. CORRECT: A client who has myasthenia gravis has generalized weakness

and can have di culty learning airway secretions, which increases the risk of
pneumonia

12. A nurse in a clinic is caring for a client whose partner states the client woke up this
morning, did not recognize him, and did not know where she was. The client reports chills and
chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?

A. CORRECT: The rst action the nurse should take using the nursing process
is to collect data on the client. The data collected will help the nurse assist in
developing a plan of care for the client

B. The nurse should obtain a sputum culture to determine the causative

organism and sensitivity for antibiotic therapy. However, there is another
action the nurse should take rst.

C. The nurse should obtain a complete history from the client to assist the
nurse in determining the plan of care. However, there is another action the
nurse should take rst.

D. The nurse should provide a pneumococcal vaccination to decrease the risk

of pneumonia in the future. However, there is another action the use should
take rst.

13. A nurse is caring for a client who has pneumonia. Data collection ndings include
temperature 37.8° C (100° F), respirations 30/min, blood pressure 130/76 mm Hg, heart rate
100/min, and SaO2 91% on room air. Which of the following actions is the nurses priority?

A. The nurse should administer antibiotics as prescribed to eradicate the

infection. However, there is another action the nurse should take rst.

B. CORRECT: The rst action the nurse should take when using the airway,
breathing, circulation approach to client care is administer oxygen to the
client to reduce hypoxia and improve oxygenation

C. The nurse should obtain a sputum culture as prescribed to determine the

causative organism. The nurse should obtain the sputum culture prior to
administering antibiotics, to ensure accurate results. However, there is
another action the nurse should take rst

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 D. The nurse should administer an antipyretic medication as prescribed for
comfort. However, there is another action the nurse should take rst

14. A nurse in a clinic is collecting data on a client who has sinusitis. Which of the following
techniques should the nurse use to identify manifestations of this disorder?

A. Lung percussion is not an e ective technique to identify manifestations of

sinusitis; it is used to identify pneumonia.

B. Auscultation of the trachea is not an e ective technique to identify

manifestations of sinusitis; it is used to identify bronchitis

C. Inspection of the conjunctiva is not an e ective technique to identify

manifestations of sinusitis; it is used to identify anemia

D. CORRECT: Palpation of the orbital, frontal, and facial areas will elicit a report
of tenderness from a client who has sinusitis

15. A nurse is reinforcing teaching with a client about in uenza. Which of the following client
statements indicates an understanding of the teaching?

A. CORRECT: Hand hygiene decreases the risk of the client spreading in uenza
viruses. The client should wash his hands after blowing his nose to prevent
spreading the virus

B. The client should increase uid intake if in uenza manifestations develop to

maintain hydration and to promote expectoration of mucous

C. In uenza vaccines are administered yearly. The client should receive a

vaccination yearly

D. Cough etiquette includes the client to sneeze into the shoulder or elbow
rather than the hands

16. A nurse is collecting data from a client who is having an acute asthma attach. Which of the
following ndings should indicate to the nurse that the client’s respirations status is declining?
(Select all that apply)

A. Oxygen saturation of 95% is an expected nding and does not indicate

respiratory distress

B. CORRECT: Wheezing is a manifestation of bronchoconstriction and is an

indication that the clients respiratory status is declining

C. CORRECT: Retraction of the sternal muscles is a manifestation of

bronchoconstriction and is an indication that the clients respiratory status is
declining

D. Pink mucous membranes are an expected nding and does not indicate
respiratory distress

E. CORRECT: PVCs are a manifestation of hypoxemia and an indication that

the clients respiratory status is declining

17. A nurse is collecting data from a client who is being admitted to an acute care facility. The
client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when
breathing. Which of the following classes of medications should the nurse expect to
administer?

A. An antibiotic is administered to treat a bacterial infection

B. A beta blocker is administered to treat dysrhythmias, heart disease, or

hypertension

C. An antiviral medication is administered to treat a virus

D. CORRECT: The nurse should expect to administer a beta2 agonist, which

causes dilation of the bronchioles and improves oxygen exchange

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18. A nurse is reinforcing discharge teaching with a client who has a new prescription for
prednisone to treat asthma. Which of the following client statements indicates an
understanding of the teaching?

A. The client should drink plenty of uids while taking prednisone. This
medication can cause the client to have a dry mouth or to become thirsty

B. The client should inform the provider of any black, tarry stools. This
medication can increase bleeding tendency. Black stools is a manifestation
of bleeding

C. CORRECT: The client should take this medication with food. Taking
prednisone on an empty stomach can cause gastrointestinal distress

D. The client should monitor his mouth for canker sores. This medication can
cause bleeding of the gums and soreness in the mouth. It also decreases
immune function

19. A nurse is collecting data from a client who has a history of asthma. Which of the following
factors should the nurse identify as a risk for asthma?

A. Gender is not a risk factor associated with asthma

B. CORRECT: Environmental allergies are a risk factor associated with asthma.

A client who has environmental allergies might have other allergic
manifestations (rhinitis, skin rash)

C. Alcohol use is not a risk factor associated with asthma

D. Race is not a risk factor associated with asthma

20. A nurse is reinforcing teaching with a client on the purpose of taking inhaled albuterol.
Which of the following client statements indicates an understanding of the teaching?

A. A bronchodilator does not decrease the body’s immune response. However,

an anti-in ammatory medication can cause this e ect

B. CORRECT: Inhaled albuterol is a short-acting beta2 agonist used to abort an

ongoing asthma attack or to prevent exercise-induced bronchospasm’s

C. An inhaled bronchodilator does not need to be taken with food. However, an

anti-in ammatory medication can course gastrointestinal distress and
should be taken with food

D. A short-acting inhaled bronchodilator, such as albuterol, has a fast onset to

relieve bronchospasm’s

21. A nurse is reinforcing discharge teaching with a client who has COPD and a new
prescription for albuterol. Which of the following client statements indicates understanding of
the teaching?

A. Anti-in ammatory agents, such as corticosteroids, can cause hyperglycemia

B. Anti-in ammatory agents can decrease the immune response

C. CORRECT: Bronchodilators, such as albuterol, can cause tachycardia

D. Anti-in ammatory agents can cause mouth sores

22. A nurse is preparing to administer a dose of prednisone to a client who has COPD. The
nurse should monitor for which of the following adverse e ects of this medication? (Select all
that apply)

A. CORRECT: The nurse should observe for hypokalemia. This is an adverse

e ect of prednisone

B. Tachycardia is an adverse e ect of bronchodilators

C. CORRECT: The nurse should observe for uid retention. This is an adverse
e ect of prednisone

D. Nausea is an adverse e ect of bronchodilators

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 E. CORRECT: The nurse should monitor for black, tarry stools. This is an
adverse e ect of prednisone

23. A nurse is assisting with the discharge of a client who has COPD. Upon discharge, the
client is concerned that he will never be able to leave his house now that he is on continuous
oxygen. Which of the following is an appropriate response by the nurse?

A. CORRECT: The nurse should inform the client that there are portable oxygen
systems that he can use to leave the house. This should alleviate the clients
anxiety

B. The nurse should tell the client use oxygen at all times to prevent becoming
hypoxic

C. The nurse should encourage the client to return to his daily routine, but
include periods of rest

D. The nurse should encourage the client to return to his daily routine. Home
health services promote a clients independence

24. A nurse is reinforcing teaching with a client about the use of an incentive spirometer.
Which of the following client statements indicates understanding of the teaching?

A. The client should place an adapter on her nger to read the blood oxygen
saturation level while performing a pulse oximetry

B. The client who practices diaphragmatic or abdominal breathing should lie on

her back with knees bent

C. The client who practices diaphragmatic or abdominal breathing should rest

her hand over her abdomen to determine if the breathing is done correctly

D. CORRECT: The client who is using the spirometer should slowly inhale with
her lips forming a seal around the mouthpiece. As the client inhales, the
spirometer indicator will rise. The client should hold her breath for a period
of 2 to 6 seconds to promote lung expansion

25. A nurse is reinforcing teaching with a client about how to perform pursed-lip breathing.
Which of the following should the nurse include in the instructions?

A. The client should inhale deeply through the nose and exhale through the
lips. Exhalation should be longer than inhalation to expel carbon dioxide

B. The client should place her hand on her stomach while performing
diaphragmatic or abdominal breathing. This allows resistance to be met and
services as a guide that the client is inhaling and exhaling correctly

C. CORRECT: The client should take a deep breath in through her nose while
performing pursed-lip breathing. This controls the clients breathing

D. The client should not pu her cheeks upon exhalation. This does not allow
the client to optimally exhale the carbon dioxide from her lungs

26. A home health nurse is reinforcing teaching with a client who has active tuberculosis. The
provider has prescribed isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide
750 mg PO daily, and ethambutol 750 mg PO daily. Which of the following statements indicates
the client understands the teaching? (Select all that apply)

A. The client should not replace one medication for another. It is important that
the client adhere to the multi medication regimen prescribed to treat
tuberculosis

B. CORRECT: The client should wash her hands each time she coughs to
prevent spreading the infection

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 C. CORRECT: The client should wear a mask while in public areas to prevent
speeding the infection

D. The client will need to collect sputum cultures every 2-4 weeks until three
consecutive sputum cultures have come back negative

E. The client should continue to avoid crowded areas if possible and take
preventative measures, such as wearing a mask when going out

27. A use is reinforcing teaching with a client who has tuberculosis. Which of the following
statements should the nurse include in the teaching?

A. The client who has tuberculosis needs to continue taking the multi
medication regiment for 6 - 12 months

B. CORRECT: The client who has tuberculosis needs to provide sputum

samples every 2 - 4 weeks to monitor the e ectiveness of the medication

C. The client who has tuberculosis is often treated in the home setting

D. The client who has tuberculosis needs to wear a mask when in public areas

28. A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed
on a multi medication regimen. Which of the following instructions should the nurse give the
client related to ethambutol?

A. The client who is receiving rifampin should expect to see urine turn a dark
orange

B. The client who is taking ethambutol can have nausea and vomiting but not
weight gain

C. CORRECT: The client who is receiving ethambutol will need to Watch for
visual changes due to optic neuritis, which can result from taking this
medication

D. The client who is taking isoniazid should take vitamin B6 daily and observe
for signs of hepatotoxicity

29. A nurse is preparing to administer isoniazid to a client who has tuberculosis. The nurse
should instruct the client to report which of the following ndings as an adverse e ect of the
medication?

A. Orange urine is an adverse e ect of rifampin

B. Experiencing pain in the joints is an adverse e ect of rifampin

C. CORRECT: Tingling of the hands is an adverse e ect of isoniazid

D. Isoniazid can cause nausea and vomiting, but not constipation

30. A nurse is providing information about tuberculosis to a group of clients at a local

community center. Which of the following manifestations should the nurse include in the
teaching? (Select all that apply)

A. CORRECT: A persistent cough is a manifestation of tuberculosis

B. Weight loss is a manifestation of tuberculosis

C. CORRECT: Fatigue is a manifestation of tuberculosis

D. CORRECT: Night sweats is a manifestation of tuberculosis

E. CORRECT: Purulent sputum is a manifestation of tuberculosis

31. A nurse is caring for a group of clients. Which of the following clients are at risk for a
pulmonary embolism? (Select all that apply)

A. CORRECT: The client who has a BMI of 30 is considered obese and is at

increased risk for a blood clot

B. A client who is postmenopausal has decreased estrogen levels and is not at

risk for developing a pulmonary embolism

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 C. CORRECT: A fractured bone, particularly in a long bone such as the fumes,
increases the risk of fat emboli

D. A client who is a marathon runner has increased blood ow and circulation

of his body, which decreases the risk for developing a pulmonary embolism

E. CORRECT: The client who has turbulent blood ow in the heart, such as
with atrial de brillation, is at increased risk of a blood clot

32. A nurse is collecting data on a client who has a pulmonary embolism. Which of the
following manifestations should the nurse expect to nd? (Select all that apply)

A. The nurse should expect the client to have tachypnea, which is a

manifestation associated with a pulmonary embolism

B. CORRECT: The nurse should expect the client to have a pleural friction rub

C. The nurse should expect the client to have hypotension

D. CORRECT: The nurse should expect the client to have petechiae

E. CORRECT: The nurse should expect the client to have tachycardia

33. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoreses.
The client states she is anxious and is unable to get enough air. Vital signs are heart rate 117/
min, respirations 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg.
Which of the following nursing actions is the priority?

A. The nurse should notify the provider about the condition. However, another
action is the priority

B. The nurse should ensure access to IV heparin as a treatment to prevent

growth of the existing clot and to prevent additional clots from forming.
However, another action is the priority

C. CORRECT: When using the airway, breathing, circulation (ABC) approach to

care, the priority nding is related to the respiratory status. Meeting
oxygenation needs by administering oxygen therapy is the priority action

D. The nurse should obtain a spiral CT scan to detect the presence and
location of the blood clot. However, another action is the priority

34. A nurse is caring for a client who has a pulmonary embolism and a new prescription for
heparin therapy. Which of the following statements by the client should indicate an immediate
concern for the nurse?

A. The nurse should document the clients allergy to morphine to manage the
clients discomfort due to a blood clot. However, another action is priority

B. CORRECT: The greatest risk to the client is the possibility of bleeding from a
peptic ulcer. The priority intervention is to notify the provider of the ndings

C. The nurse should know the clients history of a blood clot to provide
preventative measures. However, another action is the priority

D. The nurse should expect the client who has a pulmonary embolism to report
pain with breathing. However, another action is the priority

35. A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following
factors should the nurse recognize as a contraindication to the therapy?

A. CORRECT: The client who has undergone a major surgical procedure within
the last 3 weeks should not receive thrombolytic therapy because of the risk
of hemorrhage from the surgical site

B. A elevated sedimentation rate does not place the client at risk for
hemorrhage

C. An incident of exercise-induced asthma does not place the client at risk for
hemorrhage, nor is it contraindicated with this type of medication

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 D. An elevated platelet count does not place the client at risk for hemorrhage
when receiving this medication

36. A nurse is collecting data on a client following a gunshot wound to the chest. For which of
the following ndings should the nurse monitor to detect a pneumothorax? (Select all that
apply)

A. CORRECT: The client who has a pneumothorax can experience tachypnea

related to respiratory distress caused by injury

B. CORRECT: The client who has a pneumothorax can experience deviation of

the trachea as tension increases within the chest

C. The client who has a pneumothorax can experience tachycardia related to

respiratory distress and pain

D. The client who has a pneumothorax can experience an increase in the use
of accessory muscles as respiratory distress occurs

E. CORRECT: The client who has a pneumothorax can experience pleuritic

pain related to the in ammation of the pleura of the lung caused by injury

37. A nurse is reviewing the prescriptions for a client who has pneumothorax. Which of the
following actions should the nurse perform rst?

A. A nurse should check the clients pain and administer pain medication.
However, another action is the priority

B. CORRECT: The priority action the nurse should take when using the airway,
breathing, circulation (ABC) approach to client care is to establish and
maintain the clients respiratory function. Obtaining a large-bore IV needle for
decompression is the priority action

C. The nurse can administer benzodiazepine to treat anxiety. However, another

action is the priority

D. The nurse should gather supplies to prepare for chest tube insertion.
However, another action is the priority

38. A nurse is reinforcing discharge instructions for a client who experienced a pneumothorax.
Which of the following statements should the nurse use when teaching the client?

A. Weakness is an expected nding following recovery from a pneumothorax

B. The client should expect a lengthy recovery following a pneumothorax

C. The client should wear a mask if immunosuppressed

D. CORRECT: The client should notify the provider of a productive or persistent

cough. This can indicate need for treatment of a respiratory infection

39. A nurse is collecting data on a client who has a suspected ail chest. Which of the
following ndings should the nurse expect? (Select all that apply)

A. The client will have tachycardia as a manifestation indicative of ail chest

due to inadequate oxygenation

B. CORRECT: The client can have cyanosis as a manifestation indicative of ail

chest due to inadequate oxygenation

C. CORRECT: The client can have hypotension as a manifestation indicative of

ail chest

D. CORRECT: The client can have dyspnea as a manifestation indicative of ail

chest. This is due to injury and the clients inability to e ectively inhale and
exhale

E. CORRECT: The client can have paradoxic chest movement as a

manifestation indicative of ail chest. This is due to injury to the chest and
the inability to inhale and exhale

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40. A nurse is assisting in the care of a client who has ARDs with absent breath sounds in the
lower lobes and dyspnea. Which of the following actins should the nurse take rst?

A. The nurse should obtain a chest X-ray to determine the level of injury to the
lungs. However, there is another action the nurse should take rst

B. The nurse should prepare for chest tube insertion to facilitate lung
expansion and restore normal intrapleural pressure

C. CORRECT: The rst action the nurse should take when using the airway,
breathing, circulation (ABC) approach to client care is to administer oxygen
via high- ow mask to provide the client oxygen to restore optimal breathing

D. The nurse should ensure IV Access to medications. However, there is

another action the nurse should take rst

41. A nurse if reinforcing teaching with a family of a client who has acute respiratory distress
syndrome (ARDs) and is receiving vecuronium. Which of the following statements by a family
member should the nurse identify as understanding of the teaching?

A. Antibiotics treat infection that can be associated with respiratory disorders

B. CORRECT: Vecuronium is a neuromuscular blocking agent given to facilitate

ventilation, especially with ventilator settings that could be painful. It also
helps decrease oxygen consumption

C. Corticosteroids treat in ammation treat in ammation and stabilize the

alveolar-capillary membrane to improve ARDs

D. Benzodiazepines treat anxiety for clients who have respiratory disorders.

They also decrease the body’s demand for oxygen

42. A nurse is reviewing the health records of ve clients. Which of the following clients are at
risk for developing acute respiratory distress syndrome? (Select all that apply)

A. CORRECT: A client who experienced a near-drowning incident is at risk for

developing ARDS due to trauma to the lungs and cerebral edema

B. CORRECT: A client following coronary artery bypass graft surgery is at risk

for developing ARDS due to trauma to the chest

C. Hemoglobin 15.1 mg/dL is within the expected reference range. A client

who has low hemoglobin is at risk for developing ARDS

D. CORRECT: A client who has dysphagia is at risk for developing ARDS due
to di culty swallowing and risk for aspiration

E. CORRECT: A client who experienced a drug overdose is at risk for

developing ARDS due to damage to the central nervous system

43. A nurse is assisting with the plan of care for a client who has severe acute respiratory
distress syndrome (SARS). Which of the following interventions should the nurse recommend?
(Select all that apply)

A. Antibiotics treat bacterial infections and are not e ective for treating SARS,
which is a viral illness

B. CORRECT: Providing supplemental oxygen should be included in the plan of

care for SARS. Oxygen reverses severe hypoxemia

C. There is no e ective antiviral medication against the coronavirus that causes

SARS

D. CORRECT: Administration of bronchodilators should be included in the plan

of care for SARS. Bronchodilators vasodilate the airway

E. CORRECT: Maintaining ventilatory support should be included in the plan of

care for SARS. The client can require intubation to maintain a patent airway

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44. A nurse at a long-term care facility is collecting data from a client who has a history of
asthma and has developed pneumonia. Which of the following ndings indicate the client is
developing respiratory failure? (Select all that apply)

A. CORRECT: The nurse should identify irritability as a nding associated with

respiratory failure, as it results from a lack of oxygen

B. The nurse should expect the client to have pale skin, with possible areas of
cyanosis when experiencing respiratory failure

C. CORRECT: The nurse should expect the client to experience di culty

breathing while lying at when experiencing respiratory failure. The client will
likely be restless and want to sit up to receive the work of breathing

D. A heart rate of 55/min is below the expected reference range. The nurse
should expect the client to be tachycardic when experiencing respiratory
failure

E. CORRECT: The nurse should expect the client to exhibit dyspnea, or

shortness of breath, when experiencing respiratory failure

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