HESI: Breathing Patterns
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1. After determining priority
nursing diagnoses, what step
should the nurse take next in
developing plan of care?
A) determine the need for
client teaching
B) reassess Josh for any
changes
C) Implement the priority
nursing actions
D) establish goals and expected
outcomes
2. After further conversation with
Josh's mother, the nurse needs
to leave the the room to assess
another client.
Which action by the nurse
demonstrates the use of trust in
the nurse-client relationship?
A) Teaching Josh and his mother
how to read the oximeter.
B) Returning to the room at the
time promised
C) Offering the mother
reassurance that Josh is stable.
D) Providing a phone so that
Josh's mother can call home.
3. After nurse repositions the
finger clip and O2 sat: 97%.
Despite normal reading, Josh's
mother appears
worried/nervous "He's never
been sick. I am so scared."
To encourage the mother to
share more about her feelings,
how should nurse respond?
A) "Josh will be just fine. You
don't need to worry."
B) "I worried just like you when
my son was sick."
C) "Perhaps you would rather
wait outside."
D) "It sounds like this has been a
very frightening experience for
you."
Establish goals and
expected outcomes-
Rationale: after analysis of
data to prioritize nursing
diagnoses, the nurse
should establish nursing
care goals and expected
outcomes.
Returning to the room
time as promised-
Rationale: trust and
rapport is important to
develop during the
orientation stage so the
client has the most
optimal outcome
"It sounds like this has
been a very frightening
experience for you." --
this open-ended statement
acknowledges the difficult
situation the mother is
experiencing and
encourages further
discussion.
Rationale: This open-
ended statement
acknowledges the difficult
situation the mother is
experiencing and
encourages further
discussion.
4. After receiving O2 for a
short while, Josh is much
less dyspneic. The nurse
notes that the O2 sat:
97%. 15 min later, O2 sat
alarm indicates reading
changed to 80%. What
immediate action(s)
should nurse implement?
(Select all that apply).
A) reposition the finger
clip and obtain another
reading.
B) assess Josh for signs
and symptoms of
respiratory distress.
C) Encourage Josh to
begin coughing and deep
breathing.
D) Increase the oxygen
flow 3-4L/min.
E) Notify the healthcare
provider immediately.
5. Because of Josh's
dyspnea, the nurse is
concerned he may need
to receive O2. To
determine the need for
application of a nasal
cannula, which
assessment is most
important or the nurse to
perform?
A) Measure oxygen
saturation
B) Auscultate breath
sounds
C) Measure capillary refill
D) Observe chest
excursion
-Reposition the finger clip and
obtain another reading-since he
is not in distress (reapply to
confirm sudden drop in O2 sat)
-Assess Josh for S/S resp
distress-priority
-Encourage Josh to begin
coughing and deep breathing-
coughing helps to clear mucous
from airway which will allow for
max lung expansion
Rationale: Since Josh is not in any
distress, the nurse should first
reapply the clip and obtain
another reading to confirm the
sudden drop in oxygentation.
Assessment for signs and
symptoms of respiratory distress
is a priority. Coughing helps
clear mucous from airway which
will allow for optimal lung
expansion.
Measure O2 saturaion-
Rationale: Oxygen saturation
provides important data about
the percentage of hemoglobin
that is saturate with oxygen- a
valuable reflection for the client's
overall oxygenation.
6. HCP determines Josh has respiratory "A large first dose 10. The liquid cough syrup is labeles as Reduce the
tract infection and prescribes oral allows the medication an antitussive. The nurse explains this frequency of the
abx and oral liquid cough syrup. to start working medication should have what effect? cough-
Josh's mother obtains meds at faster."
pharmacy and shows them to the A) Liquefy the respiratory secretions Rationale:
nurse. The prescription for abx Rationale: A large first B) Reduce the frequency of the antitussives are used
reads, "Take 2 pills for 1st dose, dose, called a cough to reduce the
followed by 1 pill every 12 hours." loading dose, is often C) Decrease any pain with coughing frequency of a
The mother asks the nurse if this used to achieve a D) Prevent nausea due to the sputum cough. This may be
"seems right." therapeutic level desirable for Josh at
How should the nurse respond? more rapidly in the night, to allow him
bloodstream. to sleep
A) "this sounds like a mistake. Take 1
11. The med label states, "Take 2 tsp 10 mL
pill with each dose."
every 4hrs as needed." The nurse
B) "2 pills every 12 hours is the usual
gives Josh some medication cups and Rationale: 1 tsp = 5
dose."
teaches him and his mother how to ml
C) "Let me contact the pharmacist to
pour medication into the cup. To what
clarify these directions."
level should the medication be
D) "A large first dose allows the
poured?
medication to start working faster."
7. In assessing Josh's breath sounds, Breathe deeply A) 5 ml
the nurse should ask him to perform through the mouth- B) 10 ml
which action? C) 20 ml
Rationale: Josh should D) 30 ml
A) Hold his breath for 15 seconds be instructed to
12. The nurse assesses Josh's vital signs. Place a hand on
B) Repeat the phrase, "Ninety-nine" breath slowly and
His respiration are rapid and shallow. Josh's chest and
C) cough deeply after each breath deeply through a
What is the best technique for the count the hand
D) Breath deeply through the mouth slightly opened
nurse to use to asses Josh's motion-
mouth to allow best
respirations accurately?
auscultation of breath
Rationale: This
sounds.
A) Observe chest expansion for 15 technique allows the
8. Josh and his mother return to HCP Lung apices- seconds and multiply by 4. nurse to observe
office 1 week later, after Josh B) Encourage Josh to breath as and count the chest
completed course of abx therapy. In Rationale: An deeply and slowly as possible. movement, even
assessing Josh's breath sounds, accepted method for C) Watch for nasal flaring and count when respirations
where should nurse listen first? lung auscultation is to the air exchanges with each are shallow
begin at the top of movement.
A) lung bases the chest, comparing D) Place a hand on Josh's chest and
B) lung apices one side of the chest count the hand motion.
C) Aortic site to the other, moving
13. Nurse auscultates vesicular breath Record presence of
D) pulmonic site downward in a
sounds in the peripheral lung fields. clear breath sounds-
systematic method,
What action should nurse take?
finishing at the lung
Rationale: vesicular
base.
A) Record the presence of clear breath sounds are a
9. Josh's respiratory rate is 36. Tachypnea- breath sounds normal finding in
How should the nurse describe B) Tell Josh's mother that his lungs are peripheral lung
Josh's respiratory pattern? Rationale: rapid sill congested fields
respiratory rate, which C) Assist Josh to cough to clear his
A) Eupnea is consistent with his lungs and listen again.
B) Bradypnea rate of 36. Normal RR D) Notify the HCP of the abnormal
C) Tachypnea for a school-aged lung sounds
D) Orthopnea child is 16-30
breaths/min.
14. Nurse measures O2 sat: 88% and
capillary refill at 1sec. Breath
sounds are absent in base and
coarse bilaterally throughout rest
of the lung fields. Nurse applies a
nasal cannula and administers O2
at 2L/min.
When applying nasal cannula, it is
most important for nurse to
provide what instructions?
A) Make sure the cannula tubing
stays snugly around the ears and
under the chin.
B) remind client and family that
oxygen is combustible and must
be kept 10 feet away from open
flames.
C) make sure the humidifier always
contains some water.
D) keep some type of padding
around the ears and over the
cheekbones.
15. The nurse plans to measure Josh's
O2 saturation w/spring-
tension finger clip. While nurse
explains procedure, Josh asks if it
will hurt. Which response is best
for nurse to provide?
A) "yes, but the pain will only last
a very short time."
B) "No, you will not even know the
clip is on your finger."
C)"The clip feels like squeezing
your finger with your other hand."
D) "you seem to be worried about
experiencing pain."
16. The patient care technician is
planning to transport sputum to
the lab. What instructions should
nurse provide?
A) Wear clean gloves to carry the
specimen to the lab.
B) Place the specimen cup in a
biohazard bag for transport.
C) Don gloves and a gown for the
best protection.
D) Wash your hands after carrying
the cup to the lab.
Remind client and 17.
family that O2 is
combustible and must
be kept 10ft from open
flames-
Rationale: Oxygen
supports combustion
and is essential to
ensure client safety
during oxygen
administration.
18.
"The clip feels like
squeezing your finger
with your other hand"--
Rationale: This is an
honest response to
Josh's question
regarding pain and one
that places the
sensation he will feel in
a context he can
understand.
Place specimen cup in 19.
biohazard bag for
transport
Rationale: this protects
person transporting
specimen, as well as
the lab personnel
receiving the specimen
Since Josh has a productive
cough, HCP requests sputum
specimen be optained and sent
to lab for culture and sensitivity.
In assisting Josh to obtain a
sputum specimen, what action
should nurse take?
A) Instruct Josh to cough deeply
from the chest and spit into the
specimen cup.
B) Gently wipe a sterile-tipped
applicator along the back of the
oropharynx.
C) Insert a soft-tipped catheter
through the nares to suction
secretions.
D) Use a hard-tipped Yankauer
catheter device to remove oral
secretions.
To achieve the desired outcome,
nurse has initiated the
prescribed O2 therapy. After
applying nasal cannula, nurse
plans to attach a disposal sensor
pad to meausure the O2 sat
continuously. What action should
nurse implement prior to
applying the sensor?
A) determine is Josh has latex
allergy.
B) clean the site with an iodine
solution.
C) "Milk" the capillary blood flow
of the site.
D) Apply gauze padding to
protect the skin.
To measure capillary refill, the
nurse must perform which
action?
A) Count josh's radial pulse
B) Compress Josh's nailbed
C) Obtain a healthcare provider's
prescription
D) Elevate the extremity to be
assessed
Instruct Josh to cough
deeply from chest and
spit into speciment cup-
Rationale: this technique
is the least invasive and
will provide sputum
rather than mucus. Client
who is alert, able to
follow instructions and
has productive cough
can obtain a specimen
without invasive catheter.
Determine if Josh has a
latex allergy-disposable
pads may be made of
latex-
Rationale: The
disposable sensor pads
may be made of latex. If
they are, the nurse
should confirm that the
client does not have a
latex sensitivity or
allergy.
Compress Josh's nailbed-
Rationale: to measure
capillary refill, the nurse
should first compress the
client's nailbed and then
observe the return of
normal color to the
nailbed.
20. Upon further observation the
nurse describes Josh's
sputum as "Tenacious." To
what does this refer?
A) Color
B) Odor
C) Frequency
D) Consistency
21. Upon returning to the room,
the nurse asseses Josh's
cough. Which documentation
is subjective data?
A) Client's respiration are
36/min.
B) Client appears to be very
anxious
C) Client's mother is present
in the room
D) Client reports that he is
coughing a lot.
22. Which assessment finding
further supports diagnosis?
A) Restlessness & fatigue
B) skin is warm and flushed
C) Complaints of being
thirsty
D) BP of 102/62
23. Which documentation best
reflects nurse's objective
assessment?
A) Client reports that he has
been coughing up large
amounts of sputum.
B) Frequent deep cough,
producing small amounts of
pale yellow sputum.
C) Client seems anxous and
short of breath, as he has a
constant productive cough.
D) Cough is frequent, and
the client produces some
yellow sputum when he
coughs.
Consistency- 24. Which nursing Impaired gas exhcange-Normal (95-
diagnosis is most 100%)-
Rationale: sputum w/ thick relevant to Josh's
consistency may be current status? Rationale: normal saturation is 95-100%.
described as "tenacious" Joshs O2 saturation is well below
(sticking together) A) Excess fluid normal, indicating that his gas
volume exchange is impaired.
B) Impaired
spontaneous
ventilation
Client reports that he is
C) Impaired gas
coughing a lot
exchange
D) Decreased
Rationale: Subjective data is
cardiac output
the information reported by
the client 25. Which outcome Client's O2 saturation will be >95% on
statement should room air-
nurse use for Josh's
plan of care? Rationale: the client-cented outcome
statement describes the desired
A) The client will outcome in measurable terms
receive O2 at
2L/min per nasal
cannula.
Restlessness and fatigue-
B) The clients O2
saturation will be
Rationale: These are
monitored
indications of hypoxia.
continuously.
Restlessness is an early sign
C) the clients O2
of hypoxia that is often
saturation will be
missed.
>95% on room air.
D) The clients
Frequent deep cough, respiratory
producing SMALL amounts function will be
of PALE YELLOW sputum- stable.
26. Which serum lab WBC 6,000/mm3-
Rationale: objective report-
value confirms
w/documentation of
resolution of Josh's Rationale: This is a normal value for a
thorough description of the
infection? child, confirming the resolution of the
cough and sputum
infection. Infection generally causes an
produced.
A) RBC 4.5 elevation in the WBC's.
million/mm3
B) WBC 6,000/mm3
C) hemoglobin at
12 g/dl
D) Hematocrit at
40%