Question

A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer 1

Correct Answers:

CRP
Albumin
PFTS

Rationale :

💁‍♂️The PFTs show mildly decreased FEV1 and FVC with a mild obstructive pattern, which directly correlates with the client’s shortness of breath and impaired pulmonary function.

🔥The CRP of 5.2 mg/L is elevated, demonstrating an inflammatory response that can accompany malignancy or associated pulmonary inflammation.

🥗The albumin of 3.4 g/dL is decreased, which can correlate with the client’s unintentional weight loss and nutritional compromise associated with cancer.

🔬Together, the abnormal PFTs, CRP, and albumin provide findings consistent with the client’s respiratory symptoms and systemic effects of lung malignancy.

📌Core Message

Abnormal pulmonary function, elevated inflammatory markers, and decreased nutritional markers correlate with the respiratory and systemic manifestations associated with lung cancer.

Answer 2

Correct Answers:

Breathing pattern
SpO₂
Expectorate
Weight

Rationale :

🌬️The client has an intermittently labored breathing pattern, which indicates increased work of breathing and possible respiratory compromise.

💨The SpO₂ of 88% on room air represents clinically significant hypoxemia requiring prompt provider notification and intervention.

🩸The presence of blood-streaked sputum represents hemoptysis, an important manifestation associated with pulmonary malignancy that should be reported.

⚖️The client’s unintentional weight loss is an important systemic finding suggesting progression of malignancy or nutritional deterioration.

📌Core Message

Hypoxemia, labored breathing, hemoptysis, and unintentional weight loss are clinically significant abnormalities requiring communication to the healthcare provider.

Answer 3

Correct Answers:

Impaired gas exchange

Rationale :

👉The client has an oxygen saturation of 88% on room air, providing direct evidence of inadequate gas exchange.

🌪️The presence of labored breathing and diminished breath sounds further demonstrates impaired movement of oxygen through the pulmonary system.

🚑According to the airway-breathing-circulation priority framework, an actual problem affecting oxygenation takes precedence over pain, nutrition, or potential infection.

🧠Prompt correction of impaired gas exchange is necessary because prolonged hypoxemia can compromise vital-organ function.

📌Core Message

Impaired gas exchange is prioritized because significant hypoxemia and respiratory difficulty threaten immediate physiological stability.

Answer 4

Correct Answers:

Ambulation
Albuterol
Breathing exercises
Teaching for upcoming surgery

Rationale :

🚶Ambulation promotes pulmonary expansion, mobilizes secretions, and can improve ventilation and functional tolerance when clinically appropriate.

💊Albuterol produces bronchodilation and can improve airflow when the client demonstrates an obstructive respiratory pattern.

🧘Breathing exercises promote improved lung expansion and can decrease the client’s work of breathing while supporting secretion clearance.

🏥Preoperative teaching prepares the client for anticipated surgical treatment and reinforces postoperative pulmonary hygiene, mobility, and respiratory exercises.

📌Core Message

Bronchodilation, mobility, breathing exercises, and surgical preparation support respiratory function and comprehensive management of a client with lung cancer.

Answer 5

Correct Answers:

Accessory muscle use
Respiratory rate
SpO₂

Rationale :

💪A reduction or absence of accessory muscle use demonstrates decreased work of breathing and improved respiratory efficiency.

⏱️A respiratory rate approaching the expected adult range provides an objective indicator that respiratory distress is improving.

💙An increased SpO₂ demonstrates improved oxygenation and pulmonary gas exchange.

💁‍♂️These findings are measurable respiratory outcomes that can be repeatedly assessed to evaluate the client’s response to treatment.

📌Core Message

Improved respiratory status is demonstrated by reduced accessory-muscle use, normalization of respiratory rate, and improved oxygen saturation.

Answer 6

Correct Answers:

Diminished or absent breath sounds over the affected area

Rationale :

💧A pleural effusion involves accumulation of fluid within the pleural space surrounding the lung.

👉The accumulated fluid interferes with transmission of normal breath sounds and limits expansion of the affected lung.

🎧Consequently, auscultation typically reveals diminished or absent breath sounds over the area containing pleural fluid.

📉Larger amounts of pleural fluid can produce more pronounced decreases in ventilation and corresponding respiratory symptoms.

📌Core Message

Pleural fluid reduces lung expansion and sound transmission, producing diminished or absent breath sounds over the affected region.

Answer 7

Correct Answers:

Semi-Fowler's

Rationale :

🛏️A postoperative pneumonectomy client benefits from Semi-Fowler’s positioning because elevation of the head promotes lung expansion and ventilation.

🤙Following removal of one lung, maximizing function of the remaining functional lung tissue is essential for adequate oxygenation.

🌬️An elevated position decreases pressure against the diaphragm and facilitates more effective respiratory excursion.

⚕️The nurse should also closely monitor the client for respiratory distress and mediastinal complications after pneumonectomy.

📌Core Message

Semi-Fowler’s positioning promotes ventilation and expansion of the remaining functional lung after pneumonectomy.

Answer 8

Correct Answers:

Clean the client's sutures every 8 hr.
Suction the client's mouth away from the surgical side.
Provide humidified air for the client.
Ensure suction equipment is immediately available at the bedside.

Rationale :

🧼Regular suture and incision care helps maintain cleanliness and allows assessment for infection or wound complications after laryngectomy.

🧹When oral suctioning is needed, directing suction away from the surgical site helps prevent trauma or disruption of the suture line.

💦Providing humidified air prevents drying and thickening of airway secretions because inspired air no longer passes through the normal upper-airway humidification system.

🚨Keeping suction equipment immediately available is essential because retained secretions can obstruct the client’s new airway and stoma.

📌Core Message

Following laryngectomy, priority care protects the stoma and surgical site while maintaining humidification and immediate access to suction for airway clearance.

Answer 9

Correct Answers:

Perform venipuncture for blood draws to monitor coagulation studies.
Administer anticoagulant injections and monitor for signs of bleeding.
Assist the client with ambulation and report any complaints of sudden chest pain or dyspnea.
Monitor the client's oxygen saturation and respiratory status every 2 hours.

Rationale :

💉A properly trained LPN can perform venipuncture and collect ordered specimens for coagulation monitoring, subject to institutional scope and policy.

🩸An LPN can administer prescribed anticoagulant injections and collect/report findings such as observable bleeding manifestations for a stable client.

🚶A nursing assistant can assist with ambulation and must promptly report new chest pain, dyspnea, or other abnormal symptoms to the licensed nurse.

📟Routine measurement of oxygen saturation and collection of respiratory data can be delegated appropriately, while the RN remains responsible for interpretation, comprehensive assessment, and clinical decision-making.

📌Core Message

Appropriate delegation assigns routine procedures, established medication administration, mobility assistance, and data collection to qualified personnel while reserving teaching and complex clinical judgment for the RN.

Answer 10

Correct Answers:

Assess for airway obstruction and perform suctioning if needed to clear secretions.

Rationale :

💁‍♂️A sudden increase in peak airway pressure commonly indicates increased resistance caused by secretions, mucus plugging, coughing, bronchospasm, or tubing obstruction.

🔍Because the client is showing respiratory distress, the nurse should immediately evaluate whether an airway obstruction is preventing effective ventilation.

🧹If retained secretions are present, appropriate endotracheal suctioning can restore airway patency and reduce peak pressures.

🚨Maintaining a patent airway takes priority because unresolved obstruction can quickly lead to hypoxemia and inadequate ventilation.

📌Core Message

Sudden high peak airway pressure with respiratory distress requires immediate evaluation and correction of possible airway obstruction or retained secretions.

Test	Value	Reference Range
WBC	8.2 x 10³/μL	4.0 - 11.0 x 10³/μL
Hgb	11.5 g/dL	12.0 - 16.0 g/dL (female)
Hct	36%	36 - 48% (female)
Platelets	242 x 10³/μL	150 - 400 x 10³/μL

Test	Value	Reference Range
BUN	19 mg/dL	7 - 20 mg/dL
Creatinine	1.0 mg/dL	0.6 - 1.2 mg/dL
Glucose	97 mg/dL	70 - 100 mg/dL (fasting)
Albumin	3.4 g/dL	3.5 - 5.0 g/dL

Study	Findings
Chest X-ray	3.7 cm spiculated mass in left upper lobe; mild hilar enlargement
CT Chest	Confirmed mass, suspected regional lymph node involvement; no distant metastases detected

Test	Result / Interpretation
Sputum Cytology	Positive for malignant epithelial cells consistent with non-small cell lung cancer
Bronchoscopy	Mass visualized in left upper lobe; biopsy obtained
PFTs	Mildly decreased FEV1 and FVC; mild obstructive pattern

Test	Value	Reference Range
WBC	8.2 x 10³/μL	4.0 - 11.0 x 10³/μL
Hgb	11.5 g/dL	12.0 - 16.0 g/dL (female)
Hct	36%	36 - 48% (female)
Platelets	242 x 10³/μL	150 - 400 x 10³/μL

1 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

2 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

3 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

4 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

5 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

6 :
A nurse is assessing a client with a pleural effusion. Which finding would the nurse expect?

7 :
A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

8 :
A nurse is caring for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take? (Select all that apply)

9 :
A nurse is delegating tasks to a licensed practical nurse (LPN) and nursing assistant (NA) for a client diagnosed with a pulmonary embolism (PE) who is receiving anticoagulation therapy and oxygen. Which of the following tasks are appropriate to delegate to the LPN and NA? Select all that apply.

10 :
A nurse is caring for a patient on mechanical ventilation who suddenly develops increased peak airway pressures and visible signs of respiratory distress. After assessing the patient and ventilator settings, what is the nurse's priority action?

1 : A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

2 : A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

3 : A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

4 : A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

5 : A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

Answer Options

6 : A nurse is assessing a client with a pleural effusion. Which finding would the nurse expect?

7 : A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

8 : A nurse is caring for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take? (Select all that apply)

10 : A nurse is caring for a patient on mechanical ventilation who suddenly develops increased peak airway pressures and visible signs of respiratory distress. After assessing the patient and ventilator settings, what is the nurse's priority action?

1 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

2 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

3 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

4 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

5 :
A 59-year-old female client presents to the clinic with complaints of persistent cough, shortness of breath, and chest pain for two weeks.

6 :
A nurse is assessing a client with a pleural effusion. Which finding would the nurse expect?

7 :
A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

8 :
A nurse is caring for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take? (Select all that apply)

10 :
A nurse is caring for a patient on mechanical ventilation who suddenly develops increased peak airway pressures and visible signs of respiratory distress. After assessing the patient and ventilator settings, what is the nurse's priority action?