3 Respiratory Disorders

10. the nurses assesses a mantoux test to be positive when the induration is 10 mm or more when read at what time frame? _______________________________

10. 48-72 hours

23. the nurse screens which of the following pediatric age groups for atypical pneumonia caused by mycoplasma? 1. infancy 2. toddlerhood 3. school age 4. adolescence

23. 3. Mycoplasma pneumoniae is the most common causative agent of pneumonia in school-age children between the ages of 5 and 12 years. viral pneumonia is the most common pneumonia overall and is seen in all age groups. Bacterial pneumonias are more prevalent in children under age 5 years.

5. which of the following statements made by the client indicates to the nurse that the client does not understand how to use cromolyn sodium (intal) and is in need of further instructions? 1. "if i don't feel better in 2 to 3 weeks, i should stop taking the medication." 2. "i will call my doctor if this medication causes severe coughing." 3. "i have to take this medication routinely, even when i feel good." 4. "i do not stop my other medications just because i'm taking this one."

5. 1. cromolyn sodium (intal) is a drug used prophylactically for asthma to inhibit the degranulation of sensitized mast cells that occur after exposure to certain antigens and to prevent histamine release. this drug may take 4 to 8 weeks for optimal effect. it may cause bronchospasm in some individuals. steroids and other drugs are continued along with the cromolyn. if cromolyn is effective, steroids can often be tapered down. Do not stop inhalation or nasal medication abruptly. rapid withdrawal of the drug may precipitate an asthmatic attack.

16. the nurse is admitting a client who complains of fever, chills, chest pain, and dyspnea. the client has a heart rate of 110, respiratory rate of 28, and a nonproductive hacking cough. a chest x-ray confirms a diagnosis of left lower lobe pneumonia. upon auscultation of the left lower lobe, the nurse documents which of the following breath sounds? 1. bronchial 2. bronchovesicular 3. vesicular 4. absent breath sounds

16. 1. in the presence of pneumonia there will be bronchial breath sounds over the area of consolidation. the client may also have crackles in the affected side as a result of fluid in the interstitium and alveoli. absence of breath sounds is not a usual finding and would not likely occur unless there was a serious complication.

16. it is essential that the nurse use humidifiction for an oxygen flow rate of greater than what flow per minute to prevent drying of the mucous membranes? __________

16. 2. it is important to use humidification of greater than a flow rate of 2 to prevent drying of the mucous membranes.

20. the nurse is evaluating the respiratory system of a client who admits to smoking a half pack per day for the last 5 years and 1 pack per day for 10 years prior to that. when evaluating the client's risk of developing a respiratory disease, the nurse calculates that the client has a smoking history of how many packs over the years? 1. 2.5 pack-years 2. 10 pack-years 3. 12.5 pack-years 4. 15 pack-year

20. 3. the standard method for determining pack-year smoking history is to take the number of packs per day times the number of years. the number is recorded as the number of pack-years. (0.50 × 5) + (1.0 × 10) 5 2.5 + 10 5 12.5 packs over the years.

10. a 3-year-old child is brought to the emergency room at night with a harsh cough, hoarseness, and noisy breathing. although the nurse's initial assessment reveals a child who appears comfortable and whose respiratory status is within normal limits, a diagnosis of acute spasmodic laryngitis is made. which of these instructions should the nurse include in the teaching plan? 1. this is an isolated episode and will not recur 2. this illness is usually accompanied by fever 3. stimulating the child may help terminate the episode 4. clinical manifestations may resolve on exposure to cool night air

10. 4. exposure to cool night air or humidity may help relieve the spasm in acute spasmodic laryngitis. the parent should be advised that these attacks may be recurrent. the illness is usually not accompanied by fever. stimulation may aggravate the dyspnea.

2. A client with acute asthma is treated for inspiratory and expiratory wheezes and a decreased forced expiratory volume. which class of prescribed drugs should the nurse administer first to this client? 1. oral steroids 2. bronchodilators 3. inhaled steroids 4. mucolytics

2. 2. the most immediate need of a client with inspiratory and expiratory wheezes and a decreased forced expiratory volume is to dilate the bronchioles and improve air exchange. steroids (inhaled or oral) may follow the emergent treatment to reduce the inflammation, but would not be first-line drugs. mucolytics are not appropriate for the client with asthma, as there is little mucus production associated with asthma.

13. a child in the emergency room is suspected of having epiglottitis. which of the following is the priority to include in this client's plan of care? 1. explain the course of the disease to the parents 2. ensure that the child has a patent airway 3. establish iv access 4. accompany the child to radiology for lateral neck x-ray

13. 2. epiglottitis, or croup syndrome, is a bacterial infection that may lead to a complete airway obstruction. it should be managed in the same way as acute respiratory distress, with maintenance of the airway being the priority. establishing iv access and assisting with x-ray will also be done, but only after the airway has been ensured and trained personnel are available. the nurse should not perform any procedures without additional medical team support. communicating to the parents is important, but only after the client is stabilized.

13. the nurse assesses a college-age client complaining of shortness of breath after jogging and tightness in his chest. upon further questioning, the client denies a sore throat, fever, or productive cough. the nurse notifies the physician that this client's clinical manifestations are most likely related to 1. pneumonia. 2. bronchitis. 3. pneumoconiosis. 4. asthma.

13. 4. the exercise may have induced bronchospasms. lack of fever or productive cough would reduce the possibility of the clinical manifestations representing pneumonia or bronchitis. the occupation as a college student decreases the likelihood of an occupationally related lung disease.

19. which of the following should the nurse include when suctioning a client's tracheostomy? 1. instill sterile saline down the trachea to stimulate a cough, then suction with continuous suctioning 2. insert the catheter until a cough reflex is obtained or until resistance is felt 3. adjust the wall suction to 150 mm hg for the procedure 4. suction the client's mouth before entering the trachea

19. 2. proper suctioning involves inserting the catheter gently until a cough reflex is stimulated or resistance is felt. it is then withdrawn with intermittent suction and a rotating motion using moderate suction pressure (80 to 120 mm hg). nursing research does not support the instillation of saline and the client's risk of aspiration and contamination are increased with this procedure. airway suctioning is a sterile technique. if the client's mouth is to be suctioned it would be the last thing done, after airway suctioning and before discarding.

19. the nurse is instructing a client on the proper use of the pump for nasal spray administration. which of the following statements by the client indicates a need for further instruction? 1. "i should clear my nasal passages gently before using the pump." 2. "i should inhale deeply during administration of the medication." 3. "i should prime the pump if it hasn't been used for more than 24 hours." 4. "i should not inhale during administration of the medication."

19. 9. 2. the client should not inhale during administration, so that the medication can remain in the nasal passages for best absorption. initially, and if not used for more than 7 days, the pump needs to be primed with seven actuations; if not used within 24 hours, prime with two actuations.

20. the nurse is admitting a client who was recently diagnosed with asthma and has been taking a long-acting theophylline (theo-Dur). After reviewing the client's history, the nurse discovered that the client has a manic disorder controlled by lithium (eskalith). which of the following is a priority for the nurse to include in this client's treatment plan? 1. increase the dose of lithium 2. obtain a serum lithium level 3. increase the dose of theophylline 4. obtain a consult for a psychiatric consultation

20. 120. 2. theophylline may reduce the effects of lithium by increasing its rate of excretion. the client may need to have the dose of lithium increased, but not before the client's current serum lithium level is known. there is no indication to increase the theophylline dose. obtaining a serum theophylline level would also be appropriate.

22. which of the following methods should the nurse use to collect a respiratory syncytial virus (rsv) culture that has been ordered on a 6-month-old infant? 1. use a nasopharyngeal swab 2. perform a nasal washing 3. venipuncture 4. gastric lavage

. 22. 2. the nasal washing is identified as the method of choice for collecting the nasal specimen for respiratory syncytial virus (rsv). although sometimes used, a nasopharyngeal swab is not as effective a collection technique. venipuncture and gastric lavage are not used to obtain specimens for rsv determination.

5. the parents of a 10-year-old child ask the nurse what pulmonary function testing is. which of the following is the most appropriate response by the nurse? "pulmonary function testing 1. is an invasive test of pulmonary mechanics." 2. is used to evaluate the severity of a respiratory disease." 3. is used to diagnose specific respiratory diseases 4. does not differentiate between restrictive and obstructive pulmonary disease."

. 5. 2. pulmonary function testing (pft) is used to evaluate the severity of the disease. it is a noninvasive test. pft cannot diagnose specific diseases because different diseases may have the same functional abnormalities. it is used to differentiate between restrictive and obstructive disease.

1. a client was admitted to the intensive care unit 36 hours ago following extensive pulmonary trauma. which clinical manifestation would first alert the nurse that the client is experiencing adult respiratory distress syndrome (aRds)? 1. blood-tinged, frothy sputum 2. dense pulmonary infiltrates with a "whited-out" appearance 3. an increase in respiratory rate 4. increasing hypoxemia

1. 3. adult respiratory distress syndrome usually develops within 24 to 48 hours following an acute catastrophic event in clients with no previous pulmonary disease. in most cases, tachypnea and dyspnea are the first clinical manifestations. blood-tinged, frothy sputum occurs later, after the development of pulmonary edema. the diffuse pulmonary infiltrates, resembling a ground-glass or "whited-out" appearance on a chest x-ray, will appear as aRds progresses, whereas early chest x-rays are often normal. hypoxemia will occur as aRds progresses and the client becomes refractory to oxygen therapy.

1. the nurse informs the parents of an infant that the primary difference between the chest of an infant and that of an adult is that the chest of an infant 1. has a more flattened front-to-back diameter. 2. is a cone-shaped structure. 3. is rounded in shape. 4. consists of cartilage, bone, and muscle.

1. 3. an infant's chest is almost circular in shape; in adults, the anterior-posterior diameter is less than the lateral diameter. the thoracic cavity for both infants and adults is cone-shaped and consists of bone, cartilage, and muscle.

12. the nurse assesses fluctuations in the water seal chamber of a client's closed chest drainage system. the nurse evaluates this finding as indicating 1. the system is functioning properly. 2. an air leak is present. 3. the tubing is kinked. 4. the lung has reexpanded.

12. 1. in a closed drainage chest tube system, fluctuations in the water seal chamber during inhalation and exhalation (called tidaling) is a normal finding until the lung reexpands. if the fluctuations are absent, it may mean that there is an air leak, that the tubing is kinked, or that the lung has reexpanded and the client no longer requires chest drainage.

12. which of the following treatments is the priority for the nurse to administer to a client who has a positive tuberculosis (tb) skin test but has no other evidence of active disease? 1. no treatment and repeat skin test in 6 months 2. isoniazid (inh) for 12 months 3. multidrug therapy for at least 12 months 4. streptomycin for 12 months

12. 2. A positive skin test with no other evidence of disease indicates exposure to the disease. isoniazid (inh) therapy for 12 months is the usual protocol. once a client has a positive skin test, it will always be positive and there is no value in repeating a test. multidrug therapy is used to treat active disease, and streptomycin or Amikacin is often added in the induction phase of treatment

10. After a client diagnosed with pneumonia has an episode of respiratory distress, the client is intubated and placed on a ventilator. the breath sounds are diminished and the chest x-ray shows left lower lobe consolidation. the physician orders respiratory treatments with acetylcysteine (mucomyst). the nurse should monitor the client for which of the following results from this treatment? 1. bronchodilation 2. increased sputum, removed with suctioning 3. Decreased level of consciousness 4. hypotension

10. 2. Acetylcysteine (mucomyst) is a mucolytic agent that breaks down thick secretions and facilitates sputum expectoration. Adverse reactions include nausea and bronchospasm. there is no effect on level of consciousness or vital signs.

11. the nurse has just received orders to provide chest physiotherapy for a client two times per day. the nurse evaluates which schedule to be most therapeutic? 1. 7:00 a.m. and 1:00 p.m. 2. 6:00 a.m. and 4:00 p.m. 3. 9:00 a.m. and 5:00 p.m. 4. 8:00 a.m. and 8:00 p.m.

11. 2. chest physiotherapy and postural drainage are most effective upon first awakening and during the day 1 hour before or 2 to 3 hours after meals. this treatment should always be followed by oral hygiene. all of the other options are most effective either at or shortly after meal times.

2. a mother accompanies her 6-month-old male infant to the emergency room. she is concerned because the infant has not been feeding well. the infant has had a bad cold and cough, although the cough has subsided today. the nurse assessing the infant notes that the infant is very irritable and displays nasal flaring and intercostal retractions. which of the following is the priority intervention for the nurse to take? 1. offer formula because the infant appears hungry 2. suction the infant's nose 3. acknowledge the mother's concern regarding the infant's diminished feeding 4. notify the physician that the infant needs to be seen quickly

2. 4. poor feeding, irritability, nasal flaring, and intercostal retractions are signs of altered respiratory function and respiratory distress in infants. it is important for the nurse to recognize these clinical manifestations in orderto triage the infant, so that the physician sees this child before less ill clients. infant feeding is likely decreased because the infant has air hunger and does not have the energy to feed. suctioning the infant's nose would likely increase hypoxia. although it is important to acknowledge the mother's concern regarding infant feeding, a more appropriate response is to have the physician see the infant as soon as possible.

26. the nurse is preparing to delegate which of the following nursing tasks to a licensed practical nurse? 1. administer morphine iv to a client experiencing a pulmonary embolism 2. monitor a client's chest tube for bubbling 3. assess a client for tactile fremitus 4. perform a sputum culture for a client

26. 4. a licensed practical nurse has the knowledge and skill to perform a sputum culture for client. administering morphine iv to a client, monitoring a chest tube, or assessing a client for tactile fremitus are nursing tasks reserved for a registered nurse

. 22. the nurse is collecting a medication history on a client admitted with asthma who has been taking theophylline. which of the following drugs is a priority for the nurse to notify the physician that the client has also been taking for a urinary tract infection? 1. cephradine (velosef) 2. cephapirin sodium (cefadyl) 3. trimethoprim and sulfamethoxazole (bactrim) 4. ciprofloxacin (cipro)

22. 22. 4. ciprofloxacin (cipro) causes a decrease in theophylline clearance and can elevate serum drug levels, causing theophylline toxicity.

29. the nurse correctly documents moist, lowpitched, gurgling breath sounds as 1. sonorous wheezes. 2. coarse crackles. 3. sibilant wheezes. 4. pleural friction rub.

29. 2. low-pitched gurgling breath sounds are coarse crackles. sonorous wheezes are low-pitched breath sounds. sibilant wheezes are high-pitched musical breath sounds. a pleural friction rub is a creaking sound.

4. while assessing a 13-year-old male following a motor vehicle accident, the nurse notes crepitus over the left lateral rib cage. Based on an understanding of crepitus, the nurse evaluates which of the following to cause the crepitus? 1. palpable vibrations over the chest wall that are produced by voice sounds 2. the transmission of a pleural friction rub through the chest wall 3. remodeling of lung tissue secondary to asthma 4. air escaped from the lungs and trapped in the subcutaneous tissue

4. 4. tactile fremitus is a palpable vibration over the chest wall that is produced by voice sounds. a pleural friction rub is auscultated as a grating sound. remodeling in asthma does not cause crepitus

4. After instructing a client to use a beclomethasone (vanceril) inhaler, which of the following statements by the client indicates to the nurse that the teaching has been successful? 1. "i will limit myself to two cups of coffee per day." 2. "i will take it before bed each night." 3. "i will take it with meals to mask the taste." 4. "i will rinse my mouth after each use."

4. 4. inhaled steroids increase the risk of oral candidiasis and irritation. clients should rinse the mouth out with water or mouthwash after each dose. if other drugs are taken by inhaler at the same time, the steroid should be the last drug given. many may cause nausea, so should not be taken around mealtime. the client should be instructed to follow the schedule of dosing intervals. it is not a one-time-per-day drug. caffeine is not limited and, in fact, has some bronchodilating effect. inhaled steroids are used for maintenance and prophylactic treatment of asthma.

30. when preparing a client to collect a sputum specimen, it would be essential for the nurse to explain which of the following aspects of the procedure? 1. avoid mouth care prior to collecting the specimen 2. breathe deeply followed by coughing up sputum 3. collect the specimen before bedtime 4. Restrict fluids prior to expectorating sputum

30. 2. breathing deeply should be followed by coughing up sputum in the collection process of a sputum specimen. mouth care should be offered prior to collecting a sputum specimen. the specimen should be collected in the morning and fluids encouraged before coughing up the specimen

30. the nurse is caring for a child suspected of having bacterial tracheitis. which of the following is the primary clinical manifestation that the nurse assesses supporting this diagnosis? 1. fever 2. Brassy cough 3. thick purulent tracheal secretions 4. inspiratory stridor

30. 3. Bacterial tracheitis is a bacterial infection involving the mucosa of the upper trachea. although fever, brassy cough, and inspiratory stridor are all clinical manifestations of bacterial tracheitis, the hallmark manifestation diagnostic of the condition is thick, purulent tracheal secretions. if left untreated, these secretions may result in airway obstruction or even respiratory arrest.

6. a 15-month-old infant is seen in a well-child exam. Because the infant's family has recently emigrated from east africa where tuberculosis (tB) is endemic, a mantoux test is performed. no one in the infant's family has currently or has in the past had tuberculosis. the mother brings the infant back to the clinic in 48 hours to have the mantoux test read. according to this infant's risk status and age, which is the smallest amount of induration that the nurse should consider a positive finding? an area of 1. 5 mm induration.] 2. 10 mm induration. 3. 15 mm induration. 4. 20 mm induration.

6. 2. for a child under the age of 4 years and born in an area of the world where tuberculosis is prevalent, a reading of 10 mm induration would be the lowest value that would be considered a positive finding in accordance with current clinical standards. although a 15-mm and 20-mm induration would also be considered positive findings, given the younger age of 15 months, a positive reading would occur at 10 mm.

6. the nurse is aware that the optimal tidal volume for ventilator weaning is what setting? ___________________

6. 3-5 ml/kg.

9. A client with asthma awakens in the middle of the night with an asthma attack. which of the following inhaler medications should the nurse administer first? 1. Albuterol (proventil) 2. triamcinolone acetonide (Azmacort) 3. fluticasone propionate (flovent) 4. cromolyn (intal)

9. 1. the initial treatment for acute asthma is a bronchodilator. steroids such as triamcinolone acetonide (Azmacort) and fluticasone propionate (flovent) may be given after initial bronchospasm is relieved. cromolyn (intal) has no immediate effect and is a prophylactic mast cell inhibitor.

. 7. the nurse selects which of the following inhalation drugs for inflammation? select all that apply: [ ] 1. cortisone (cortone) [ ] 2. belomethasone (beclovent) [ ] 3. Dexamethasone (Decadron) [ ] 4. flunisolide (Aero-bid) [ ] 5. prednisone ( Deltasone) [ ] 6. trriamcinolone (Azmacort)

7. 2. 4. 6. inhaled drugs for inflammation include beclomethasone (beclovent), flunisolide (Aerobid), and triamcinolone (Azmacort). An example of a nasal drug for inflammation is dexamethasone (Decadron). cortisone (cortone) and prednisone (Deltasone) are examples of systemic drugs for inflammation

9. a registered nurse is planning the schedule for the day. which of the following nursing tasks may the nurse delegate to a licensed practical nurse? 1. develop instructions for the client on pursed-lip breathing 2. clarify an order with the physician 3. instruct a client on a bronchoscopy 4. administer a purified protein derivative (ppd) to a client

9. 4. it is not appropriate to assign a licensed practical nurse to develop a teaching plan, teach, or clarify an order with the physician. these are tasks reserved for the registered nurse. an lpn may administer a purified protein derivative to a client.

26. the nurse is preparing to delegate the nursing tasks for the day. which of the following tasks should the nurse delegate to a licensed practical nurse? 1. monitor a client using a decongestant for the effectiveness of the drug 2. Develop a teaching plan for effective coughing techniques for a client taking an expectorant 3. increase the oxygen flow rate to a client receiving oxygen by a simple face mask 4. Administer a nasal spray to a client with rhinitis

. 26. 4. A licensed practical nurse cannot monitor a drug for its effectiveness or develop a teaching plan. these are job functions reserved for a registered nurse. neither a registered nurse nor a licensed practical nurse can increase the oxygen flow rate to a client without a physician's order. once a physician's order is obtained, a registered nurse should increase the flow rate.

27. the nurse took respiratory rates on the following four pediatric clients. which of the following clients should the nurse report as having an abnormal respiratory rate? 1. a 6-month-old infant who has respirations of 45 breaths per minute 2. a 2-year-old child who has respirations of 30 breaths per minute 3. a 10-year-old who has respirations of 28 breaths per minute 4. an 18-year-old who has respirations of 25 breaths per minute

. 27. 4. the respiratory rate of an infant from birth to 6 months is 30 to 50 breaths per minute. children between 6 months and 2 years of age would have respirations from 20 to 30 breaths per minute. children between 3 and 10 years ofage have respirations between 20 and 28 breaths per minute. the respiratory rate of children between 10 and 14 years of age is between 16 and 20 breaths per minute. the respiratory rate of children between16 and 18 years of age would be between 12 and 20 breaths per minute. an 18-year-old who has respirations of 25 breaths per minute is experiencing some degree of respiratory distress and that finding should be reported.

8. A client who has asthma asks the nurse why the preferred route of administration for corticosteroids is inhalation. the appropriate response by the nurse is which of the following? 1. "inhaled medications are easier to take." 2. "the systemic adverse reactions are reduced." 3. "no weaning is required when stopping the drug." 4. "oral care is not required."

. 8. 2. the inhaled glucocorticoids are effective on topical administration, and systemic adverse reactions can be reduced when delivered by this route. instruction is necessary for the client to properly learn the technique of using inhalers. inhaled steroids should not be stopped suddenly, and oral care is necessary after every treatment to reduce oral candidiasis.

1. A client has been receiving intravenous theophylline and the physician writes new orders to discontinue the iv medication and begin an immediate-release oral form of the medication. when should the nurse schedule the first dose of the oral medication to be administered? 1. immediately after stopping the intravenous infusion of theophylline 2. begin 4 to 6 hours after stopping the intravenous infusion of theophylline 3. begin the initial dose at bedtime 4. start the oral dose with the morning medications and breakfast

1. 2. After stopping iv therapy, a period of 4 to 6 hours should elapse before initiating oral therapy. the half-life of the drug is 3 to 15 hours in nonsmoking adults, and 4 to 5 hours in adult heavy smokers. if the oral dose is initiated too soon it could lead to adverse reactions, such as nausea, vomiting, diarrhea, irritability, insomnia, or headache. more serious theophylline toxicity is manifested by cardiac arrhythmias, hypotension and peripheral vascular collapse, tachycardia, hyperglycemia, or seizures. the therapeutic serum level for theophylline is 10 to 20 mcg/ml.

11. which of the following should the nurse include in a plan of care for a 5-year-old child admitted to the hospital with the diagnosis of epiglottitis? 1. perform a throat culture to identify the pathogen 2. administer cough syrup to the child 3. encourage the child to assume a tripod position 4. restrict fluids

11. 3. epiglottitis, also referred to as croup syndrome, is a life-threatening bacterial infection that can lead to a complete airway obstruction. Because of difficulty breathing and swallowing, the child is likely to assume a tripod position. this is characterized by the child sitting upright and leaning forward with chin thrust out, tongue protruding, and mouth open to facilitate breathing and swallowing. a throat culture should not be done, as this could cause additional or complete obstruction. examination of the throat should only occur when emergency tracheostomy or intubation is possible. the onset of epiglottitis is usually abrupt and is more likely preceded by a sore throat than by cold manifestations. it is most common in children between the ages of 2 and 7 years. fluids, antibiotics, and supportive care are included in the treatment plan.

11. the nurse is caring for a client with lung cancer who has an intractable cough and is exhausted from the effort of coughing. which of the following drugs should the nurse administer to this client? 1. rifampin (rifadin) 2. Acetylcysteine (mucomyst) 3. fluticasone (flovent) 4. codeine

11. 4. codeine is a narcotic drug that selectively depresses the cough center in the medulla and inhibits coughing. it is typically used in a dry, nonproductive, intractable cough. it is used with caution in combination with other central nervous system depressants. rifampin (rifadin) is a drug used to treat tuberculosis. Acetylcysteine (mucomyst) is a mucolytic that decreases the viscosity of purulent and nonpurulent secretions and facilitates their removal. fluticasone (flovent) is an inhaled corticosteroid used in the treatment of asthma.

12. a mother calls the medical information line and reports that her 6-year-old child has awakened with a complaint of sore throat and pain on swallowing. she reports that the child was fine when going to bed. the child has a fever of 39.2°c, or 102.5°f, orally and is restless and appears quite sick. which of the following questions is a priority for the nurse to ask to triage this client? 1. "has the child been drooling?" 2. "has the child been exposed to strep throat?" 3. "Did you give the child an antipyretic?" 4. "is the child up to date on immunizations?"

12. 1. clinical manifestations of a sore throat, difficulty swallowing, restlessness, and temperature of 39.2°c, or 102.5°f, orally is suggestive of epiglottitis, which is a medical emergency. confirming that the child is drooling would be additional data to support the nurse's suspicions and assist to direct the parent and child to an emergency department for evaluation and treatment. although asking about strep throat, administration of an antipyretic, and immunizations may be

13. the nurse is developing a medication schedule for a client who is receiving isoniazid (inh). to promote the best absorption, this medication would be administered 1. on an empty stomach. 2. with antacids to relieve stomach upset. 3. with food. 4. 30 minutes after meals.

13. 1. isoniazid (inh) should be taken on an empty stomach, either 1 hour before or 2 hours after meals. Avoid antacids with the medication.

28. the nurse is performing an assessment of the thorax and lungs on a 30-year-old client. which of the following assessments does the nurse evaluate to be a normal adult finding? 1. the thorax is barrel shaped 2. the costal margin is greater than 90° 3. the accessory muscles are used during inspiration and expiration 4. the ribs articulate at a 45° angle with the sternum

28. 4. the thorax is generally slightly elliptical in shape, although the barrel-shaped chest may be normal in the infant and older adult. the costal angle should be less than 90° during exhalation and at rest. no accessory muscles should be used during normal respirations. the ribs should also articulate at a 45° angle with the sternum.

14. which of the following is a priority to include in the instructions given to a client who has bronchitis? 1. avoid cigarette smoking 2. decrease overweight status 3. increase activity 4. avoid malnutrition

14. 1. cigarette smoking is one of the most significant risk factors for developing bronchitis. bronchitis involves the major bronchi and is classified as acute or chronic. acute bronchitis is bronchial airway inflammation related to smoke, irritants, or infection. chronic bronchitis is a component of chronic obstructive pulmonary disease (copd). it usually follows an upper respiratory infection such as rhinitis or sore throat. malnutrition is considered a possible risk factor. obesity or being active in sports is not correlated with bronchitis.

14. which of the following is the priority for the nurse to monitor in a client who has been on a ventilator and on 70% fio2 for the past 72 hours? 1. Atelectasis 2. pulmonary fibrosis 3. expense to client 4. oxygen dependence

14. 2. clients on an fio2 of 50% or greater for 24 to 48 hours have a higher incidence of pulmonary fibrosis and oxygen toxicity. Atelectasis can occur but is generally reversible and therefore not the greatest concern. expense is considered, but treatment requirements for the client take priority. oxygen dependence is related to pulmonary disease.

14. a 4-year-old child with epiglottitis is being transferred via ambulance to the hospital. the parents and child are very fearful. the mother asks if her child can sit in her lap for transport. what is the nurse's best response? 1. "your anxiousness is making your child upset. it is best to leave the child." 2. "riding on your lap would be a dangerous practice and is not recommended." 3. "letting your child ride on your lap may reduce your child's stress." 4. "your child is very anxious so a sedative will be given so your child can sleep."

14. 3. Being allowed to sit on a parent's lap may actually decrease the child's (and parent's) stress and facilitate easier breathing. such a request would need to be approved by the physician and the ambulance personnel. isolating the child from the parents would very likely increase the child's stress and consequently the respiratory dysfunction. this would be counterproductive. sedation would be inappropriate in this situation, as it would further compromise respiratory effort.

15. the nurse is caring for a client who has chronic obstructive lung disease (copD) and pneumonia. After being extubated, which of the following orders should the nurse question? 1. continuation of the current antibiotics 2. o2 per nasal cannula at 6 l/min 3. out of bed with assistance 4. continuation of current nebulizer treatments

15. 2. for a client with chronic obstructive lung disease (copD), there is an insensitivity to high levels of carbon dioxide and therefore an inspiratory drive that is now triggered by low oxygen levels. giving higher concentrations of oxygen (greater than 2 to 3 l/min) can decrease the respiratory rate and depth, leading to oxygen-induced hypoventilation, apnea, and respiratory arrest.

15. the nurse is assessing the respiratory status of a client following a thoracentesis. which finding would indicate further assessment is needed? 1. equal bilateral chest expansion 2. scattered crackles, unchanged from baseline 3. diminished breath sounds on the affected side 4. Respiratory rate of 22 breaths/minute

15. 3. Following a thoracentesis, the nurse assesses breath sounds and vital signs. the nurse particularly looks for signs that may indicate a pneumothorax as a complication from the procedure. signs that may indicate a pneumothorax include increased respiratory rate, dyspnea, retractions, diminished breath sounds, or cyanosis. any of these signs should be reported to the physician immediately. equal bilateral breath sounds are normal findings and a respiratory rate of 22 is slightly elevated and may be due to pain or anxiety. scattered crackles, although not normal, have not changed from baseline and would not represent a complication as a result of the procedure.

15. the father of a child with laryngotracheobronchitis asks the nurse what it is. which of the following statements by the nurse best describes laryngotracheobronchitis? 1. "it is a reactive airway disease characterized by wheezing and cough." 2. "it is a viral illness that results in inflammation of the small airways and production of thick mucus." 3. "it is a bacterial illness that results in serious supraglottic inflammation." 4. "it is a viral illness that results in swelling around the level of the larynx characterized by a barking cough and hoarseness."

15. 4. laryngotracheobronchitis (croup) is a viral illness that results in swelling around the level of the larynx characterized by a barking cough and hoarseness. a reactive airway disease characterized by wheezing and cough is a description of asthma. a viral illness that results in inflammation of the small airways and production of thick mucus is a description of bronchiolitis. a bacterial illness that results in serious supraglottic inflammation is a description of epiglottitis.

29. which of the following nursing interventions should the nurse include in the plan of care for a child with acute spasmodic laryngitis? 1. administer antipyretic 2. provide cold steam in the bedroom from a humidifier 3. avoid exposure to the night air 4. administer corticosteroids

29. 2. acute spasmodic laryngitis is characterized by sudden, brief laryngeal obstructions that occur primarily at night. there is no fever, so antipyretics are not administered. corticosteroids are also not administered. exposure to the night air may terminate the laryngeal spasm. it is appropriate to provide steam from a hot bath or shower or cold steam from a humidifier to relieve mild clinical manifestations.

16. a child with a brassy cough, mild fever, and hoarseness is seen in the emergency department and diagnosed with croup. the physician orders discharge to home with management to include cool-temperature therapy. the nurse preparing discharge teaching notices that the child has developed continuous respiratory stridor. which of the following is the priority nursing intervention? 1. complete discharge instructions, including a review of the clinical manifestations of respiratory distress 2. instruct the parent on how to perform cooltemperature therapy 3. notify the physician of the child's status immediately 4. request that the child follow up with the primary care provider in one week

16. 3. stridor is a high-pitched sound produced by an obstruction of the trachea or larynx that can be heard during inspiration or expiration. stridor even at rest signifies progression of the croup and requires medical management. the physician should be notified immediately. it would be inappropriate to discharge the client in view of the change in status without notifying the physician. instructing the parents on cool-temperature therapy is an appropriate intervention but not the priority.

17. the nurse is preparing to teach a class on the appropriate use of nebulizers and metered dose inhalers. which of the following should the nurse include in the class? 1. metered dose inhalers require a gas flow rate of 6 to 10 l/min 2. nebulizers deliver medication through a face mask or mouthpiece 3. nebulizers deliver doses in puffs 4. metered dose inhalers require refrigeration

17. 2. nebulizers deliver medication through a face mask or mouthpiece, using compressed air or oxygen with a gas flow of 6 to 10 l/min. metered dose inhalers deliver medication via puffs. generally, the standard is 2 puffs per administration, a wait of 2 to 5 minutes between puffs, and no more than 12 puffs in 24 hours for most medications. metered dose inhalers do not require refrigeration.

17. the nurse is preparing a client with empyema for a thoracentesis. which of the following should the nurse have available in the event that the procedure is ineffective? 1. a ventilator 2. a chest tube insertion kit 3. an intubation tray 4. a crash cart

17. 2. with empyema, the fluid to be removed from the pleural space is thick and "puslike." the physician may not be able to withdraw the fluid through needle aspiration and the client may require placement of a chest tube to adequately drain the purulent effusion. a ventilator, intubation tray, or crash cart is not likely to be necessary because there was no indication that the client was unstable.

17. the nurse administers which of the following vaccines to help prevent the development of epiglottitis? 1. Diphtheria/tetanus/acellular pertussis (Dtap) combination vaccine 2. varicella vaccine (varivax) 3. haemophilus influenzae vaccine (hiB) 4. pneumococcal polysaccharide vaccine (prevnar)

17. 3. Haemophilus influenzae is the most common causative organism of epiglottitis. the H. influenzae vaccine may help prevent it. Diphtheria/tetanus/acellular pertussis (Dtap) immunizes against diphtheria, tetanus, and pertussis. varivax immunizes against varicella (chickenpox), and prevnar immunizes against streptococcal pneumonia and to a lesser degree ear infections caused by Streptococcus pneumoniae

18. the nurse selects which of the following types of low flow for oxygen therapy? select all that apply: [ ] 1. venturi mask [ ] 2. Aerosol mask [ ] 3. nasal cannula [ ] 4. nonrebreather mask [ ] 5. transtracheal [ ] 6. simple face mask

18. 18. 3. 4. 6. types of low-flow oxygen therapy include nasal cannula, nonrebreather mask, and simple face mask. types of high-flow oxygen therapy include venturi mask, aerosol mask, and transtracheal.

18. the nurse is caring for a 5-year-old child diagnosed with bronchitis who is otherwise in good health. the child's mother verbalizes to the nurse that she is very upset that thephysician did not prescribe antibiotics. the nurse's response would be based on the understanding that bronchitis is 1. treated by antihistamines, not antibiotics. 2. usually viral in a child under 5 years and not affected by antibiotic therapy. 3. a minor bacterial illness and antibiotics are not recommended because of the risk of developing bacterial resistance. 4. most appropriately controlled by cough syrup administered every 4 hours.

18. 2. laryngotracheobronchitis (croup) is usually caused by a virus, especially in young children. antibiotics are ineffective against viral illnesses. it would be appropriate for the nurse to explain this rationale to the parent as part of client and family education. Bronchitis is not treated with antihistamines. cough suppressants should be used with caution as they may make the child drowsy and may also impede the clearance of secretions. the issue in antibiotic resistance is to treat with an adequate dose of an antibiotic that is active against the offending pathogen, not whether or not to treat.

18. a client is admitted to a burn unit with second- and third-degree burns over 18% of the body. an inhalation injury is also suspected. the nurse should monitor which of the following to determine the extent of carbon monoxide poisoning? 1. pulse oximetry 2. urine myoglobin 3. arterial blood gases 4. serum carboxyhemoglobin levels

18. 4. carbon monoxide binds tightly to hemoglobin to form carboxyhemoglobin. because carbon monoxide binds 200 times greater to hemoglobin than oxygen, there is decreased availability of oxygen to the cells. clients are treated with 100% oxygen. pulse oximetry will read falsely high, as it is a reading of how well the hemoglobin is bound, but not with oxygen. urine myoglobin is indicative of by-products of muscle damage being excreted through the kidneys. arterial blood gas pco2 may falsely represent the client's oxygenation status and is not a measure of carbon monoxide levels.

19. which of the following infection control measures is the priority for the nurse to implement in the care provided to a 5-month-old infant admitted to the hospital with respiratory syncytial virus (rsv) bronchiolitis? 1. hand washing is required by all personnel and visitors having contact with the infant 2. gowns and masks must be worn by all personnel in the infant's room 3. place the infant in a private room 4. visitors are restricted to only the parents of the infant

19. 1. Bronchiolitis is a viral infection causing inflammation of the bronchioles and production of thick mucus that occludes the bronchiole tubes and small airways, impeding expiration. of the infection control measures implemented, consistent hand washing and not touching the nasal mucosa or conjunctivae have been shown to be most important. wearing masks and gowns has not been shown to be of added benefit, although the gowns may help reduce the risk of fomite spread. infants with rsv may be in rooms with children with similar diagnosis or isolated in private rooms, dependent on hospital policy. the advisability of limiting of visitors and staff in an effort to lessen the spread of infection is being studied.

2. a client with a history of asthma presents in the physician's office with complaints of difficulty breathing. while performing the initial assessment, the nurse becomes concerned that the client's respiratory status has worsened based on which of the following? 1. wheezing throughout the lung fields 2. noticeably diminished breath sounds 3. loud wheezing only on expiration 4. mild wheezing on inspiration

2. 2. the severity of wheezing is not a reliable way to determine severity of an asthma attack. some clients with minor attacks may have loud wheezing, whereas others may have severe attacks with mild wheezing. the client with severe asthma attacks may have no audible wheezing because of the decrease in airflow. For wheezing to occur, the client must be able to move air to produce sound. wheezing usually occurs first on exhalation, and as the asthma attack progresses, the client may wheeze during both inspiration and expiration. the significant finding with this assessment is that there are noticeably diminished breath sounds, which means reduced or absence of moving air. this may indicate severe obstruction and respiratory failure.

20. the parents of a 5-month-old infant who has bronchiolitis ask the nurse what changes occur to the lung during the illness. the nurse informs these parents that which of the following lung changes occur? 1. asthma 2. emphysema 3. atelectasis 4. crepitus

20. 2. in bronchiolitis, the bronchioles and small airways become occluded due to inflammation and thick mucus. air becomes trapped behind the occlusions, where it leads to progressive overinflation of the lungs called emphysema. while some infants may manifest asthmalike manifestations, this does not reflect the usual progression of bronchiolitis. atelectasis is a collapse of the lung and is not a normal development in bronchiolitis. crepitus is a crackling sound on palpation caused by the escape of air into the subcutaneous tissue and is also not common in bronchiolitis.

21. a client with pneumonia has a poor appetite, is dyspneic and complains of decreased taste sensation, and is receiving chest physiotherapy treatments and breathing treatments. which of the following actions should the nurse include to improve the client's appetite? 1. provide mouth care before meals 2. provide juice and fluids at the bedside 3. provide three balanced meals each day 4. increase fluid intake to 3 l a day

21. 1. because of the sputum production and expectoration, particularly during and after treatments, the client will have decreased taste sensation. providing oral care after pulmonary treatments and before meals will improve taste and appetite. Fatigue from breathing, activity, and treatments will also decrease energy. providing more frequent small meals (not three large ones), increasing fluid intake, and offering fluids that appeal to the client are appropriate interventions for the client but will not impact appetite.

21. the mother of a 4-month-old diagnosed with respiratory syncytial virus and bronchiolitis tells the nurse the infant has not been feeding well. which of the following physical clinical manifestations indicates to the nurse that the client's condition is deteriorating and the client has become dehydrated? select all that apply: [ ] 1. Bradycardia [ ] 2. oliguria [ ] 3. Decreased respirations [ ] 4. Decreased skin turgor [ ] 5. sunken anterior fontanel [ ] 6. Dry mucous membranes

21. 2. 4. 5. 6. the sunken fontanel is the most specific clinical manifestation indicating that the infant is dehydrated. other clinical manifestations include decreased skin turgor, oliguria, dry mucous membranes, and skin color changes. the infant may also become tachypneic and tachycardic

21. A client questions a prescription for pyridoxine (b6) after being started on the triple-drug therapy for tuberculosis (ethambutol, rifampin, and isoniazid). the nurse explains that pyridoxine will 1. prevent skin rash from the ethambutol. 2. reduce the time the other drugs must be taken. 3. counter the peripheral neuritis of the isoniazid. 4. prevent damage to the eighth cranial nerve from the streptomycin

21.21. 3. pyridoxine (b6) helps counter the peripheral neuritis associated with isoniazid therapy. skin rash is a possible adverse reaction of ethambutol, and clients on streptomycin should be monitored for hearing loss, particularly those with renal insufficiency. the duration of therapy is not shortened by pyridoxine.

22. a client with left-sided heart failure is progressing to pulmonary edema. the nurse assesses the client and reports which of the following manifestations? 1. dry, hacking cough 2. bilateral crackles 3. Fever above 36.8°c or 101.5°F 4. peripheral pitting edema

22. 2. a client with left-sided heart failure and pulmonary edema presents primarily with respiratory symptoms. because of the fluid accumulation in the pulmonary vascular bed, there may be a productive cough with pink, frothy sputum. there is no fever associated with pulmonary edema, and peripheral pitting edema is more associated with right-sided heart failure.

23. A client arrives at the emergency room in status asthmaticus. which of the following is the priority nursing action? 1. Administer aminophylline intravenously as ordered 2. monitor the respiratory status and for signs of hypoxia 3. Administer inhaled bronchodilator therapy as ordered 4. provide emotional support

23. 23. 3. Administering aminophylline intravenously, monitoring the respiratory status and for signs of hypoxia, and providing emotional support are all appropriate interventions, but the initial action should be focused on improving oxygenation (airway, breathing, circulation). An inhalation bronchodilator will act quickly and should be followed by intravenous medications.

23. the nurse is performing a respiratory assessment of a client with pleurisy and compares the assessment findings with the previous day's assessment. currently there is no friction rub, but one was auscultated the previous day. the nurse evaluates this finding as the result of 1. the client taking more shallow breaths. 2. a decreased inflammatory response. 3. the effectiveness of the antibiotics. 4. an accumulation of pleural fluid in the inflamed area.

23. 4. initially a pleural friction rub is auscultated when there is inflammation between the pleural space and visceral pleura. with increasing inflammation, fluid accumulates between the two layers at the inflamed site and reduces the friction. the inflammatory process is still there and would be treated by anti-inflammatory drugs, not necessarily antibiotics (unless there were an infectious process involved). the client should be instructed to take adequately deep breaths for a good assessment of breath sounds and that should be consistent between assessments.

24. the nurse is caring for a client following a cardiac bypass surgery. the nurse notes that in the first hour the chest tube drainage measured 90 ml. during the second hour the drainage dropped to 5 ml. the nurse suspects which of the following? 1. the chest tube may be clotted 2. the lungs have fully inflated 3. the client is recovering normally 4. the physician should be notified

24. 1. the first hour after surgery, chest tube draining may be as high as 100 ml/hour but should taper off over the next several hours. there should not be a sudden significant increase or drop in the amount of drainage. in this case, a sudden drop may indicate that a clot has formed in the tube and the nurse will need to gently work the clot out of the tubing to prevent cardiac tamponade. Further assessment would need to be made before notifying the physician. a chest tube is not "milked" but can be gently manipulated. chest tube drainage is not an indication of lung inflation. chest drainage may taper off to minimal amounts before the tube is withdrawn, but that is based on the fluctuations in the water seal chamber being minimal and an evaluation by chest x-ray.

24. the nurse evaluates which of the following as the appropriate method of improving oxygenation in a client with chronic airway limitation (cAl) who is lethargic, sleeps with the mouth open, is receiving 2 l/minute of oxygen per nasal cannula, and has a pulse oximetry check of 88%? 1. keep the client awake more so deeper breaths can be taken 2. turn the oxygen up to 4 l/minute 3. obtain an order for a face mask and use nasal cannula during meals 4. intubate the client and place the client on a ventilator

24. 3. clients who are mouth breathers may not get the full benefit from nasal cannula administration of oxygen. A face mask may be more effective. face masks are removed for meals and a nasal cannula would be appropriate at that time. the client's oxygenation may improve when awake, but one cannot be kept awake all the time. clients withchronic airway limitation (cAl) should not receive oxygen greater than 2 to 3 l/minute because greater oxygen administration may suppress the respiratory drive.

24. the nurse is teaching a class on sudden infant death syndrome to parents. which of the following should the nurse include in the class? 1. the peak incidence is between 6 and 8 months of age 2. occurrence is most frequent during the summer months 3. Being a low-birth-weight male infant increases the risk 4. every infant under 1 year of age should be tested

24. 3. sudden infant death syndrome is the unexpected death of an apparently healthy infant under the age of 1 year. peak incidence is between 2 and 4 months. it occurs more frequently between the ages of 2 and 4 months and in the winter months. low-birth-weight male infants are at a greater risk than are females. there is no diagnostic test for sudden infant death syndrome.

25. which of the following are adverse reactions of drugs for bronchodilation? select all that apply: [ ] 1. headache [ ] 2. tachycardia [ ] 3. sneezing [ ] 4. back pain [ ] 5. palpitation [ ] 6. Depression

25. 25. 1. 2. 5. Adverse reactions of drugs for bronchodilation include headache, tachycardia, and palpitation. insomnia is an adverse reaction of xanthine derivatives. back pain is an example of leukotriene receptor antagonist adverse reaction. sneezing is an example of adverse decongestant adverse reactions

25. the nurse should monitor a client admitted with a suspected diagnosis of pulmonary emphysema for which of the following clinical manifestations? select all that apply: [ ] 1. copious sputum production [ ] 2. bilateral wheezing [ ] 3. marked weight loss [ ] 4. prolonged inspiratory phase [ ] 5. barrel chest appearance [ ] 6. severe dyspnea

25. 3. 5. 6. clients with pulmonary emphysema typically manifest symptoms of marked weight loss, barrel chest appearance, prolonged expiratory effort, marked dyspnea, and a cough late in the progression of the disease. there is scant mucus production. copious sputum production is characteristic of chronic bronchitis. bilateral wheezing is characteristic of bronchial asthma.

25. which of the following clinical manifestations does the nurse evaluate to be present in a child in the paroxysmal stage of pertussis? select all that apply: [ ] 1. sneezing [ ] 2. low-grade fever [ ] 3. flushed cheeks [ ] 4. waning of paroxysmal coughing [ ] 5. high-pitched crowing [ ] 6. protruding tongue

25. 3. 5. 6. the classic clinical manifestation of pertussis (whooping cough) is the "whoop" or high-pitched crowing sound that is heard at the end of the cough during the paroxysmal stage of the disease. other clinical manifestations found in the paroxysmal stage include flushed cheeks, bulging eyes, and a protruding tongue. sneezing and a low-grade fever are found during the catarrhal stage, when manifestations of an upper respiratory infection occur. a waning of the paroxysmal coughing is characteristic during the convalescent stage.

26. the clinical assignments on a pediatric respiratory unit have been made for the day. which of the following assignments should be questioned? 1. unlicensed assistive personnel are assigned to walk children with croup 2. a licensed practical nurse is assigned to teach a class to parents on sudden infant death syndrome 3. unlicensed assistive personnel are assigned to help children who have cystic fibrosis to eat 4. a licensed practical nurse is assigned to administer a prescribed bronchodilator to a child with asthma

26. 2. unlicensed assistive personnel may help a child walk and eat. a licensed practical nurse may administer a bronchodilator to a child with asthma. it is inappropriate to assign a licensed practical nurse to teach a class on sudden infant death syndrome. a registered nurse should be given responsibility for teaching such a class

27. the nurse is reviewing the normal limits for a head and neck assessment. which of the following findings would indicate the need for additional investigation? 1. a small, discrete, movable lymph node 2. the trachea is to the right of the suprasternal notch 3. a thyroid gland that is not visible or palpable 4. the muscles of the neck are symmetrical

27. 2. the trachea should be midline in the suprasternal notch. it may be normal to feel a small, discrete, movable lymph node. it is clinically insignificant. the thyroid gland should not be visible or palpable and the muscles of the neck should be symmetrical.

28. which of the following should the nurse include in the instructions given to parents of a child with an allergy on methods to reduce allergen exposure? select all that apply: [ ] 1. trim household plants of dead leaves daily [ ] 2. exercise in cool, dry areas [ ] 3. clean moldy areas with 1:10 bleach solution [ ] 4. keep pets in uncarpeted areas [ ] 5. avoid strong odors [ ] 6. maintain laundry water at 37.8°c, or 100°f

28. 3. 4. 5. household plants, strong odors, and exercising in cool, dry areas should be avoided in the plan of care for a child with an allergy. moldy surfaces should be cleaned with a 1:10 bleach solution. pets should be kept in uncarpeted areas that are easy to clean. laundry water should be maintained at 54.4°c, or 130°f.

3. the nurse is admitting a client with asthma who is to be started on theophylline. which of the following questions would be appropriate to ask this client? 1. "Are you a diabetic and taking insulin?" 2. "Do you take cimetidine (tagamet)?" 3. "Do you use aspirin on a daily basis?" 4. "Do you exercise routinely?"

3. 2. cimetidine (tagamet) will decrease theophylline clearance and may increase serum drug levels. the dose may have to be reduced for this client. insulin and aspirin do not affect drug clearance.

3. which of the following should the nurse include in a class on sudden infant death syndrome? select all that apply: [ ] 1. peak incidence is between 6 and 8 months [ ] 2. Being of female gender [ ] 3. Being african american [ ] 4. Being breast-fed infant [ ] 5. Being of low socioeconomic status [ ] 6. have a respiratory disorder

3. 3. 5. 6. male african-american infants who are formula fed have a higher incidence of sudden infant death syndrome. other characteristics include being of low socioeconomic status or having a respiratory disorder. the peak incidence is between 2 and 4 months.

3. a home health nurse is visiting a client with severe chronic obstructive pulmonary disease (copd) who is complaining of increased shortness of air. the client is on home oxygen at 2 l/min via an oxygen concentrator with a respiratory rate of 23 breaths/min. the most appropriate nursing action is to 1. call emergency services to come to the home. 2. reassure the client of being unnecessarily anxious. 3. conduct further assessment of the client's respiratory status. 4. consider increasing the oxygen to 4 l/min during the home visit.

3. 3. Further assessment is the most appropriate nursing action. Remember the nursing process; assessment is the first step. calling for emergency services would be premature. oxygen is not increased without the approval of the physician, and remember that with copd the client's drive to breathe is triggered by low oxygen because of the carbon dioxide retention. For clients with copd, oxygen should not generally be greater than 2 to 3 l/min. Reassurance that the client is unnecessarily anxious is inappropriate.

4. the nurse is admitting a client with suspected tuberculosis (tb) to the acute care unit. the nurse places the client in airborne precautions until a confirmed diagnosis of active tb can be made. which of the following tests is a priority to confirm the diagnosis? 1. chest x-ray that is positive for lung lesions 2. positive purified protein derivative (ppd) test 3. sputum positive for blood (hemoptysis) 4. sputum culture positive for Mycobacterium tuberculosis

4. 4. the most accurate way to diagnose tb is by sputum culture. identifying the presence of tubercle bacilli is essential for a definitive diagnosis. although hemoptysis is associated with more advanced cases of tb, it is not a confirmatory clinical manifestation. a positive ppd indicates exposure to tb, but gives no information about active disease. a chest x-ray with lesions may be present in a number of other diseases, not just tb.

5. a student health nurse is conducting tuberculosis (tb) testing. students who had the purified protein derivative (ppd) test 48 hours ago have returned to have the results read and documented. the nurse determines that the test is positive if which of the following is present? 1. the client complains of itching at the site 2. there is a large area of erythema 3. there is an induration of 10 mm or greater 4. a bruise is present at the site of injection

5. 3. an induration of 10 mm or greater is usually considered a positive result. For immunocompromised and hiv-positive clients, an induration of 5 mm or greater may be considered a positive result. erythema is not a positive reaction. itching or bruising is not indicative of a positive result. Remember, ppd skin tests are read 48 to 72 hours after administration

6. when instructing a client to use a metered dose inhaler, it would be essential for the nurse to include which of the following aspects? instruct the client to 1. hold the breath for 3 seconds after using the inhaler. 2. take a quick deep breath after activating the canister. 3. activate the canister at the beginning of a slow deep breath. 4. place the canister 6 inches in front of an open mouth

6. 3. proper technique for using a metered dose inhaler is to have the client place the canister either in the mouth or 2 inches in front of an open mouth. the canister must be activated at the beginning of a slow deep inspiratory effort. the inhalation is followed by 5 to 10 seconds of breath holding. sequence is then repeated if a second puff is ordered.

7. a client with no history of respiratory disease has a sudden onset of dyspnea, chest pain, and tachycardia. a pulmonary embolism is suspected. the nurse anticipates which set of therapeutic orders to be prescribed for this client? select all that apply: [ ] 1. semi-Fowler's position [ ] 2. oxygen at 2 l/min [ ] 3. high-Fowler's position [ ] 4. morphine sulfate 2 mg intravenously [ ] 5. oxygen at 4 l/min [ ] 6. hydromorphine hydrochloride (dilaudid) 2 mg intramuscular

7. 1. 4. 5. standard therapeutic interventions for a client with a pulmonary embolism include proper positioning, oxygen, and intravenous analgesics. semi-Fowler's position is most appropriate because high-Fowler's position creates extreme flexion of the hips and slows venous return from the legs, which increases the risk of new thrombi. this client has no history of respiratory disease and is not limited to 2 to 3 l/min. therefore, 4 l/min would be appropriate to help relieve dyspnea. intravenous analgesics are prescribed to relieve chest pain. morphine sulfate is the drug of choice and 2 mg is the appropriate intravenous dose. morphine helps reduce pain and anxiety and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.

7. the nurse is caring for a 5-year-old child suspected of having tuberculosis. which of the following is the preferred method of obtaining a sputum specimen for culture and smear from this child? 1. endotracheal suctioning 2. sputum collected by elicited cough 3. sputum collected by early morning gastric washings 4. thoracentesis

7. 3. Because young children are likely to swallow any sputum that is produced by cough, gastric lavage is a more effective method of collecting a sputum sample. it is the preferred method of collecting sputum for culture and smear from a child who is suspected of having tuberculosis. endotracheal suctioning, unless intubated, would not be well tolerated, and thoracentesis is both invasive and impractical on a routine basis.

8. a mother reports that her 15-month-old child has had three colds in three months during the winter while attending day care. the mother inquires whether she should use an over-thecounter antihistamine for this child, because she suspects allergies must be the cause of the frequent colds. which of the following is the nurse's most appropriate intervention? 1. reassure the parent that frequent episodes of nasopharyngitis are common given the child's risk factors 2. notify the physician immediately because this information may be indicative of an immunodeficiency 3. inform the parent that the child might have asthma because of the frequency of upper respiratory infections 4. instruct the parent to use an over-thecounter antihistamine

8. 1. nasopharyngitis occurs more frequently in infants and young children, especially in settings such as a day care center where many children interact in a small space. the most frequent transmission is by human hands, so good hand washing is essential to help prevent continuous colds. the fall and winter months are also prime times for colds. it is unlikely the child is immunosuppressed based on the circumstances and clinical manifestations. the nurse should not suggest that the child has asthma, because it is not in the scope of practice and the diagnosis is not supported by the data collected. it would not be appropriate to make a recommendation concerning over-the-counter antihistamine therapy for a child this young. antihistamines have also been found to be ineffective in treating nasopharyngitis.

8. a client with pulmonary edema is currently receiving 6 l/min of oxygen per nasal cannula. the most recent arterial blood gas (abg) results indicate the following: ph 5 7.30, pco2 5 50 mm hg, po2 5 56 mm hg, hco3 5 24 mm hg. the nurse anticipates that the physician will order which of the following? 1. change nasal cannula to face mask at 6 l/min oxygen 2. add one ampule of sodium bicarbonate to the client's current intravenous fluids 3. change nasal cannula to partial rebreather mask at 8 l/min oxygen 4. intubate the client and place on mechanical ventilation

8. 4. the client is exhibiting respiratory acidosis with severe hypoxemia. intubation and mechanical ventilation are warranted in this situation. changing the oxygen delivery system to a mask would not correct the hypoxemia. changing the oxygen delivery system to partial rebreather mask, even with a slight increase in oxygen, would not correct the significant hypoxia, and the rebreather mask would increase the pco2 retention. adding sodium bicarbonate to the iv fluids treats a clinical manifestation, not the underlying condition of respiratory distress, and sodium bicarbonate will not correct the hypoxemia.

9. a mother reports that her 4-month-old has a cold, but no fever. she reports noisy breathing at night and that the child's nose is very congested. the nurse advises the mother to promote maximum ventilation during sleep. which of the following instructions about positioning would be appropriate for the nurse to include in the instructions? 1. elevate the infant's head on a pillow to open the airway 2. place infant in an upright (90 degrees) position 3. elevate the head of the crib 30 degrees 4. place the infant prone to promote drainage of secretions

9. 3. appropriate positioning is a significant means of easing respiratory efforts in infants and small children. elevation of the head of the crib or maintaining the infant's head at 30 degrees will promote maximum lung expansion. resting an infant's head on a pillow is not recommended, because of the risk of sudden infant death syndrome. positioning an infant at 90 degrees would actually compress the diaphragm and diminish respiratory function. prone positioning of infants is generally not recommended, because of its correlation with sudden infant death syndrome. it should be noted that in the rare case that the infant is experiencing gastroesophageal reflux, positioning the infant prone may be permitted.