A nurse in the emergency department is caring for a female client who reports shortness of breath and pain in the chest. The client states she began taking oral contraceptives 3 weeks ago and that she smokes. Her vital signs are: heart rate 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Arterial blood gas results are: pH 7.50, PaCO₂ 29 mm Hg, PaO₂ 60 mm Hg, HCO₃⁻ 20 mEq/L, and SaO₂ 86%. Which of the following is the priority nursing intervention?

Administer oxygen via face mask

Prepare for mechanical ventilation

Prepare to administer a sedative

Assess for indications of pulmonary embolism

Answer and Explanation

The Correct Answer is A

Rationale:
A. The ABGs show respiratory alkalosis (pH 7.50, PaCO₂ 29) with hypoxemia (PaO₂ 60, SaO₂ 86%). The priority is to administer oxygen via face mask to correct hypoxemia.
B. Mechanical ventilation may be needed if oxygen therapy is ineffective, but it is not the first action.
C. A sedative is not appropriate because the hyperventilation is compensatory for impaired oxygenation.
D. Assessing for pulmonary embolism is important (risk factors: oral contraceptives, smoking, sudden dyspnea), but ensuring oxygenation takes priority in the immediate situation.

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Correct Answer is D

Explanation

Rationale:
A. Ambulation helps with lung expansion but does not directly thin secretions.
B. Incentive spirometer use improves ventilation and prevents atelectasis but does not specifically thin secretions.
C. Coughing and deep breathing help mobilize secretions once loosened, but they do not thin them.
D. Increasing fluid intake hydrates the respiratory tract and helps thin secretions, making them easier to expectorate — this is the most effective action.

A. weight gain B. high-grade fever C. Flushed cheeks D. Night sweats E. Blood in the sputum

Correct Answer is ["D","E"]

Explanation

Rationale:
A. Weight gain is not expected. Clients with pulmonary TB typically experience weight loss due to chronic infection and decreased appetite.
B. High-grade fever is not typical. TB usually causes a low-grade fever, especially in the afternoon.
C. Flushed cheeks are not a characteristic manifestation of TB. The client may appear pale and fatigued instead.
D. Night sweats are a classic symptom of TB due to the body’s response to chronic infection.
E. Blood in the sputum (hemoptysis) is a hallmark sign of pulmonary TB due to lung tissue damage and cavitation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Correct Answer is D

Explanation

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply)

Correct Answer is ["D","E"]

Explanation

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications?

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

Which of the following are the most common manifestations of COPD? (Select all that apply.)

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is short of breath. When reviewing the client's arterial blood gases (ABGS), which of the following conditions should the nurse anticipate the client to be experiencing?

A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance?

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

Which of the following symptoms is a common indication of active tuberculosis (TB) infection?

Which of the following statements is true regarding the use of long-acting and short-acting inhalers for asthma management?