Ch. 26, 27, 28 EAQ's
The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to an employee. Which question should the nurse ask before administration of this vaccine? "Are you allergic to chicken?" "Could you be pregnant now?" "Did you ever have influenza?" "Have you ever had hepatitis B?"
"Could you be pregnant now?"
The nurse teaches a 53-yr-old male patient with chronic obstructive pulmonary disease (COPD) how to administer fluticasone by metered-dose inhaler (MDI). Which statement by the patient to the nurse indicates correct understanding of the instructions? "I should not use a spacer device with this inhaler." "I will rinse my mouth each time after I use this inhaler." "I will feel my breathing improve over the next 2 to 3 days." "I should use this inhaler immediately if I have trouble breathing."
"I will rinse my mouth each time after I use this inhaler."
The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? "My liver function will be checked with blood tests every 2 to 3 months." "The medication will decrease the congestion within 3 to 5 minutes after use." "I may develop a serious infection because the medication reduces my immunity." "I will use the medication every day of the season whether I have symptoms or not."
"I will use the medication every day of the season whether I have symptoms or not."
The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? "I need to take this medicine with meals." "The medicine will be prescribed for 10 days." "I will inject this medicine into my upper arm." "The medicine will dissolve the clot in my lung."
"The medicine will be prescribed for 10 days." Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.
The nurse is caring for a group of patients. Which patient is at risk of aspiration? A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields
A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube
Which test result identifies that a patient with asthma is responding to treatment? An increase in CO2 levels A decreased exhaled nitric oxide A decrease in white blood cell count An increase in serum bicarbonate levels
A decreased exhaled nitric oxide Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma and adherence to treatment. An increase in CO2 levels, decreased white blood cell count, and increased serum bicarbonate levels do not indicate a positive response to treatment in a patient with asthma.
The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? A temperature of 101.4°F Heart rate of 120 beats/min Respiratory rate of 20 breaths/min A productive cough with yellow sputum Reports of unable to have a bowel movement for 2 days
A temperature of 101.4°F Heart rate of 120 beats/min A productive cough with yellow sputum
When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? Patient comfort Airway patency Incisional drainage Blood pressure and heart rate
Airway patency
The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? Albuterol Ipratropium bromide Salmeterol (Serevent) Beclomethasone (Qvar)
Albuterol
A patient with a persistent cough is diagnosed with pertussis. What treatment does the nurse anticipate administering to this patient? Antibiotic Corticosteroid Bronchodilator Cough suppressant
Antibiotic
A 45-yr-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma? Anxiety Cyanosis Bradycardia Hypercapnia
Anxiety
A patient is being discharged from the emergency department after being treated for epistaxis. In teaching first aid measures in the event the epistaxis would recur, what measures should the nurse suggest (select all that apply.)? Tilt patient's head backwards. Apply ice compresses to the nose. Tilt head forward while lying down. Pinch the entire soft lower portion of the nose. Partially insert a small gauze pad into the bleeding nostril.
Apply ice compresses to the nose. Pinch the entire soft lower portion of the nose. Partially insert a small gauze pad into the bleeding nostril.
A male patient with chronic obstructive pulmonary disease (COPD) becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? Arterial pH 7.26 PaCO2 50 mm Hg Patient in tripod position Increased sputum expectoration
Arterial pH 7.26
During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply.)? Asbestos exposure Exposure to uranium Chronic interstitial fibrosis History of cigarette smoking Geographic area in which he was born
Asbestos exposure Exposure to uranium History of cigarette smoking Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk but not necessarily where the patient was born.
normal aspartate transaminase is in the range of
10 to 36 U/L
The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 2 mg/mL. Calculate how many milliliters the nurse should use to prepare the patient's dose. _____ mL
2.5 mL
normal albumin is in the rangeof
3.5 to 5.0 g/dL
The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? Basilar crackles Oxygen saturation of 85% Presence of greenish sputum Respiratory rate of 28 breaths/min
Basilar crackles
A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? Pulmonary infarction Pulmonary hypertension Cytomegalovirus (CMV) Bronchiolitis obliterans (BOS)
Bronchiolitis obliterans (BOS)
The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? Humidify the oxygen as able. Administer cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.
Increase fluid intake to 3 L/day if tolerated.
The nurse is evaluating if a patient understands how to safely determine whether a metered-dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler? Place it in water to see if it floats. Keep track of the number of inhalations used. Shake the canister while holding it next to the ear. Check the indicator line on the side of the canister.
Keep track of the number of inhalations used. It is no longer appropriate to see if a canister floats in water or not because this is not an accurate way to determine the remaining inhaler doses. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing it after the number of days when those inhalations have been used (100 puffs/2 puffs each day = 50 days).
The nurse supervises a team including another registered nurse (RN), a licensed practical/vocational nurse (LPN/LVN), and unlicensed assistive personnel (UAP) on a medical unit. The team is caring for many patients with respiratory problems. In what situation should the nurse intervene with teaching for a team member? LPN/LVN obtained a pulse oximetry reading of 94% but did not report it. RN taught the patient about home oxygen safety in preparation for discharge. UAP report to the nurse that the patient is complaining of difficulty breathing. LPN/LVN changed the type of oxygen device based on arterial blood gas results.
LPN/LVN changed the type of oxygen device based on arterial blood gas results.
The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? Coughing Fever, chills Dust allergy Maxillary pain
Maxillary pain
The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? Teach the patient to cough and deep breathe. Take the temperature, pulse, and respiratory rate. Obtain a sputum specimen for culture and Gram stain. Check the patient's oxygen saturation by pulse oximetry.
Obtain a sputum specimen for culture and Gram stain.
During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Pneumococcal Staphylococcus aureus Haemophilus influenzae Bacille-Calmette-Guérin (BCG)
Pneumococcal
The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? Temperature of 98.4°F Oxygen saturation 96% Pulse rate of 72 beats/min Respiratory rate of 18/ breaths/min
Pulse rate of 72 beats/min
An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? Sudden onset of confusion Oral temperature of 102.3oF Coarse crackles in lung bases Clutching chest on inspiration
Sudden onset of confusion
The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a â-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? IV fluids Biofeedback therapy Systemic corticosteroids Pulmonary function testing
Systemic corticosteroids
A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? Oxygen tent Venturi mask Nasal cannula Oxygen-conserving cannula
Venturi mask
a pt has been receiving high-dose corticosteroids and broad-spectrum antibiotics for treatment secondary to a traumatic injury and infection. The nurse plans care for the pt knowing that the pt is most susceptible to a. candidiasis b. aspergillosis c. histoplasmosis d. coccidioidomycosis
a. candidiasis
the nurse identifies a flail chest in a trauma pt when a. multiple rib fractures are determined by x-ray b. a tracheal deviation to the unaffected side is present c. paradoxical chest movement occurs during respiration d. there is a decreased movement of the involved chest wall
c. paradoxical chest movement occurs during respiration
The nurse is teaching a patient how to self-administer ipratropium via a metered-dose inhaler (MDI). Which instruction given by the nurse is most appropriate to help the patient learn the proper inhalation technique? "Avoid shaking the inhaler before use." "Breathe out slowly before positioning the inhaler." "Using a spacer should be avoided for this type of medication." "After taking a puff, hold the breath for 30 seconds before exhaling."
"Breathe out slowly before positioning the inhaler."
The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? "Close lips tightly around the mouthpiece and breathe in deeply and quickly." "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."
"Close lips tightly around the mouthpiece and breathe in deeply and quickly."
The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? "I will seek immediate medical treatment for any upper respiratory infections." "I should continue to do deep breathing and coughing exercises for at least 12 weeks." "I will increase my food intake to 2400 calories a day to keep my immune system well." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."
"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.
The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required? "I will be given amphotericin B to treat the fungus." "I got this fungus because I am immunocompromised." "I need to be isolated from my family and friends so they won't get it." "The effectiveness of my therapy can be monitored with fungal serology titers."
"I need to be isolated from my family and friends so they won't get it."
The nurse teaches a patient with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? "I should avoid using ibuprofen for pain and discomfort." "It is important for me to take my blood pressure medication every day." "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." "If I get a nosebleed, I will lie down flat and raise my feet above my heart."
"If I get a nosebleed, I will lie down flat and raise my feet above my heart."
Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching regarding the use of an ipratropium inhaler? "I can rinse my mouth following the two puffs to get rid of the bad taste." "I should wait at least 1 to 2 minutes between each puff of the inhaler." "Because this medication is not fast acting, I cannot use it in an emergency if my breathing gets worse." "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."
"If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."
A patient has been receiving oxygen per nasal cannula while hospitalized for chronic obstructive pulmonary disease (COPD). The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? "Long-term home oxygen therapy should be used to prevent respiratory failure." "Oxygen will not be needed until or unless you are in the terminal stages of this disease." "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."
"You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia." Long-term oxygen therapy in the home will not be considered until the oxygen saturation is less than or equal to 88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status. PaO2 less than 55 mm Hg will also allow home oxygen therapy to be considered.
normal bilirubin is in the range of
0 to 0.3 mg/dL
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? Water-seal chamber has 5 cm of water. No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site
Chest tube with a loose-fitting dressing If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.
When initially teaching a patient the supraglottic swallow after a radical neck dissection, with which food or fluid should the nurse begin? Cola Applesauce French fries White grape juice
Cola When learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce, decrease the risk of aspiration.
A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? Bilateral erythema of especially large tonsils Temperature 102.2°F, diaphoresis, and chills Contraction of neck muscles during inspiration β-hemolytic streptococcus in the throat culture
Contraction of neck muscles during inspiration Contraction of neck muscles during inspiration indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress. The reddened and enlarged tonsils indicate pharyngitis. The increased temperature, diaphoresis, and chills indicate an infection, which could be β-hemolytic streptococcus or fungal infection, but not an emergency situation for the patient.
A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? Cover the chest wound with a nonporous dressing taped on three sides. Pack the chest wound with sterile saline soaked gauze and tape securely. Stabilize the chest wall with tape and initiate positive pressure ventilation. Apply a pressure dressing over the wound to prevent excessive loss of blood.
Cover the chest wound with a nonporous dressing taped on three sides. The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.
A school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus (select all that apply.)? Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic. Drink noncaffeinated fluids daily. Obtain antibiotic therapy promptly.
Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.
The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters? Apical pulse Daily weight Bowel sounds Deep tendon reflexes
Daily weight
When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections? Smoking causes a hoarse voice. Cough will become nonproductive. Decreased alveolar macrophage function
Decreased alveolar macrophage function
The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with chronic obstructive pulmonary disease (COPD) are successful based on which finding? Absence of dyspnea Improved mental status Effective and productive coughing PaO2 within normal range for the patient
Effective and productive coughing
The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? Allow time to calm the patient. Observe for signs of diaphoresis. Evaluate the use of intercostal muscles. Monitor the patient for bilateral chest expansion.
Evaluate the use of intercostal muscles. The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient. The other options may also occur, but they are not the primary reason for inspecting the chest wall of this patient.
When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers (select all that apply.)? Exercise Allergies Emotional stress Decreased humidity Upper respiratory infections
Exercise Allergies Emotional stress Upper respiratory infections
Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? Acute respiratory failure Secondary respiratory infection Fluid volume excess resulting from cor pulmonale Pulmonary edema caused by left-sided heart failure
Fluid volume excess resulting from cor pulmonale
Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? Supine Lithotomy High Fowler's Reverse Trendelenburg
High Fowler's
When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease? An overproduction of the antiprotease a1-antitrypsin Hyperinflation of alveoli and destruction of alveolar walls Hypertrophy and hyperplasia of goblet cells in the bronchi Collapse and hypoventilation of the terminal respiratory unit
Hyperinflation of alveoli and destruction of alveolar walls In COPD, structural changes include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.
The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? Hypersensitivity to eggs Age older than 80 years History of upper respiratory infections Chronic obstructive pulmonary disease (COPD)
Hypersensitivity to eggs
The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium after noting which assessment finding? Decreased respiratory rate Increased respiratory rate Increased peak flow readings Decreased sputum production
Increased peak flow readings
The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? Hyperresonance on percussion Vesicular breath sounds in all lobes Increased vocal fremitus on palpation Fine crackles in all lobes on auscultation
Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.
When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included? Increasing dyspnea Temperature below 98.6°F Decreased sputum production Unable to drink 3 L of low-sodium fluids
Increasing dyspnea
While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse instruct the patient to do? Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. Use the flow meter each morning after taking medications to evaluate their effectiveness. Increase the doses of the long-term control medication if the peak flow numbers decrease. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.
Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. It is important to keep track of peak flow readings daily, especially when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the flow meter and should be assessed before and after medications to evaluate their effectiveness.
The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? The patient has lung cancer. The incision will be medial sternal or lateral. Chest tubes will not be needed postoperatively. Less discomfort and faster return to normal activity
Less discomfort and faster return to normal activity
The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? Maintain adequate fluid intake. Maintain a 30-degree elevation. Splint the chest when coughing. Maintain a semi-Fowler's position. Instruct patient to cough at end of exhalation.
Maintain adequate fluid intake. Splint the chest when coughing. Instruct patient to cough at end of exhalation. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.
A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? Apply an external splint to the nose. Insert plastic nasal implant surgically. Humidify the air for mouth breathing. Maintain surgical packing in the nose.
Maintain surgical packing in the nose. A goal that is common to nursing and medical management of a patient after rhinoplasty is to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma. Therefore, the nurse helps to keep the nasal packing in the nose. The packing applies direct pressure to oozing blood vessels to stop postoperative bleeding. A medical goal includes realigning the fracture with an external or internal splint. The nurse helps maintain the airway by humidifying inspired air because the nose is unable to do so following surgery because it is swollen and packed with gauze.
A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? Suction the tracheostomy opening. Maintain the airway with a sterile hemostat. Use an Ambu bag and mask to ventilate the patient. Insert the tracheostomy tube obturator into the stoma.
Maintain the airway with a sterile hemostat.
The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? "I will pay less for medication because it will last longer." "More of the medication will get down into my lungs to help my breathing." "Now I will not need to breathe in as deeply when taking the inhaler medications." "This device will make it so much easier and faster to take my inhaled medications."
More of the medication will get down into my lungs to help my breathing."
The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient? Cough reflex Mucociliary clearance Reflex bronchoconstriction Ability to filter particles from the air
Mucociliary clearance
During an assessment of a 45-yr-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? Laryngospasm Pulmonary edema Narrowing of the airway Overdistention of the alveoli
Narrowing of the airway
The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? Obesity Pneumonia Malignancy Cigarette smoking Prolonged air travel
Obesity Malignancy Cigarette smoking Prolonged air travel An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.
A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? Lobectomy surgery is usually needed to drain the abscess. IV antibiotic therapy will be used for a 6-month period of time. Oral antibiotics will be used until there is evidence of improvement. Culture and sensitivity tests are needed for 1 year after resolving the abscess
Oral antibiotics will be used until there is evidence of improvement
When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient? Order fruits and fruit juices to be offered between meals. Order a high-calorie, high-protein diet with six small meals a day. Teach the patient to use frozen meals at home that can be microwaved. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.
Order a high-calorie, high-protein diet with six small meals a day.
The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone after what occurs? Hypertension and pulmonary edema Oropharyngeal candidiasis and hoarseness Elevation of blood glucose and calcium levels Adrenocortical dysfunction and hyperglycemia
Oropharyngeal candidiasis and hoarseness
When teaching the patient with cystic fibrosis about the diet and medications, what is the priority information to be included in the discussion? Fat soluble vitamins and dietary salt should be avoided. Insulin may be needed with a diabetic diet if diabetes mellitus develops. Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.
Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed.
An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? Perform a comprehensive health history with the patient to review prior respiratory problems. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.
Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. Correct Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed.
The nurse teaches pursed-lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? Loosening secretions so that they may be coughed up more easily Promoting maximal inhalation for better oxygenation of the lungs Preventing bronchial collapse and air trapping in the lungs during exhalation Increasing the respiratory rate and giving the patient control of respiratory patterns
Preventing bronchial collapse and air trapping in the lungs during exhalation
A patient is admitted for joint replacement surgery and has a permanent tracheostomy. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Suction the tracheostomy. Check stoma site for skin breakdown. Complete tracheostomy care using sterile technique. Provide oral care with a toothbrush and tonsil suction tube.
Provide oral care with a toothbrush and tonsil suction tube.
A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? Level of consciousness Quality of breath sounds Presence of the gag reflex Tracheostomy cuff pressure
Quality of breath sounds Before performing tracheostomy care, the nurse will auscultate lung sounds to determine the presence of secretions. To prevent aspiration, secretions must be cleared either by coughing or by suctioning before performing tracheostomy cannula care.
The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? Electrolyte levels and daily weights Assessment of speech and swallowing Respiratory rate and oxygen saturation Pain assessment and assessment of mobility
Respiratory rate and oxygen saturation
The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication? Chew a hard candy before the first puff of medication. Rinse the mouth with water before each puff of medication. Ask for a breath mint after the second puff of medication. Rinse the mouth with water after the second puff of medication.
Rinse the mouth with water after the second puff of medication.
he nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Notify the health care provider. Administer a nitroglycerin tablet sublingually. Conduct a thorough assessment of the chest pain. Sit the patient up in bed as tolerated and apply oxygen.
Sit the patient up in bed as tolerated and apply oxygen.
After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum laboratory studies ordered for AM
Sputum culture and sensitivity
Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? Assessing the need for suctioning Suctioning the patient's oropharynx Assessing the patient's swallowing ability Maintaining appropriate cuff inflation pressure
Suctioning the patient's oropharynx
Although a diagnosis of cystic fibrosis (CF) is most often made before age 2 years, an 18-yr-old patient at the student health center with a history of frequent lung and sinus infections has clinical manifestations consistent with undiagnosed CF. Which information would be accurate for the nurse to include when teaching the patient about a scheduled sweat chloride test? "Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF." "The test measures the amount of sodium chloride in your postexercise sweat." "If sweating occurs after an oral dose of pilocarpine, the test result for CP is positive." "If the sweat chloride test result is positive on two occasions, genetic testing will be necessary."
Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF." The diagnostic criteria for CF involve a combination of clinical presentation, sweat chloride testing, and genetic testing to confirm the diagnosis. The sweat chloride test is performed by placing pilocarpine on the skin and carried by a small electric current to stimulate sweat production. This takes about 5 minutes, and the patient feels a slight tingling or warmth. The sweat is collected on filter paper or gauze and then analyzed for sweat chloride concentrations (for about 1 hour). Values above 60 mmol/L for sweat chloride are consistent with the diagnosis of CF. However, a second sweat chloride test is recommended to confirm the diagnosis, unless genetic testing identifies a CF mutation. Genetic testing is used if the results from a sweat chloride test are unclear.
The nurse is caring for a 48-yr-old male patient admitted for exacerbation of chronic obstructive pulmonary disease. The patient develops severe dyspnea at rest, with a change in respiratory rate from 26 breaths/min to 44 breaths/min. Which action by the nurse would be the most appropriate? Have the patient perform huff coughing. Perform chest physiotherapy for 5 minutes. Teach the patient to use pursed-lip breathing. Instruct the patient in diaphragmatic breathing.
Teach the patient to use pursed-lip breathing. Pursed-lip breathing (PLB) prolongs exhalation and prevents bronchiolar collapse and air trapping. PLB is simple and easy to teach and learn. It also gives the patient more control over breathing. Evidence from controlled studies does not support the use of diaphragmatic breathing in patients with COPD. Diaphragmatic breathing results in hyperinflation because of increased fatigue and dyspnea and abdominal paradoxical breathing rather than with normal chest wall motion. Chest physiotherapy (percussion and vibration) is used primarily for patients with excessive bronchial secretions who have difficulty clearing them. Huff coughing is a technique that helps patients with COPD to use a forced expiratory technique to clear secretions.
The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurse's priority action? Test the drainage for the presence of glucose. Suction the nose to maintain airway clearance. Document the findings and continue monitoring. Apply a drip pad and reassure the patient this is normal.
Test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.
The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? Electromyography Intraoral electrolarynx Neck type electrolarynx Transesophageal puncture
Transesophageal puncture The transesophageal puncture provides a fistula between the esophagus and trachea with a one-way valved prosthesis to prevent aspiration from the esophagus to the trachea. Air moves from the lungs and vibrates against the esophagus, and words are formed with the tongue and lips as the air moves out the mouth. The electromyography and both electrolarynx methods produce low-pitched mechanical sounds.
Before discharge, the nurse discusses activity levels with a 61-yr-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? Slightly increase activity over the current level. Swim for 10 min/day, gradually increasing to 30 min/day. Limit exercise to activities of daily living to conserve energy. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.
Walk for 20 min/day, keeping the pulse rate less than 130 beats/min. The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220 - patient's age).
The nurse is caring for a patient with an acute exacerbation of asthma. After initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? Wheezing becomes louder. Cough remains nonproductive. Vesicular breath sounds decrease. Aerosol bronchodilators stimulate coughing.
Wheezing becomes louder. The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Vesicular breath sounds will increase with improved respiratory status. After a severe asthma exacerbation, the cough may be productive and stringy. Coughing after aerosol bronchodilators may indicate a problem with the inhaler or its use.
The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis? Work of breathing Fear of suffocation Effects of medications Anxiety and restlessness
Work of breathing
in evaluating an asthmatic pt's knowledge of self-care, the nurse recognizes that additional instruction is needed when the pt says, a. "I use my corticosteroid inhaler when I feel SOB" b. "I get a flu shot every year and see my HCP if I have an upper respiratory tract infection" c. " I use my inhaler before I visit my aunt who has a cat, but I only visit for a few minutes because of my allergies" d. I walk 30 minutes every day but sometimes I have to use my bronchodilator inhaler before walking to prevent me from getting SOB
a. "I use my corticosteroid inhaler when I feel SOB"
a priority nursing intervention for a pt who has just undergone a chemical pleurodesis for recurrent pleural effusion is a. administering ordered analgesia b. monitoring chest tube drainage c. spending pleural fluid for laboratory analysis d. monitoring the pt's level of consciousness
a. administering ordered analgesia
a pt is concerned that he may have asthma. Of the symptoms that he relates to the nurse, which ones suggest asthma or risk factors for asthma SATA? a. allergic rhinitis b. prolonged inhalation c. history of skin allergies d. cough, especially at night e. gastric reflux or heartburn
a. allergic rhinitis c. history of skin allergies d. cough, especially at night e. gastric reflux or heartburn
when caring for a patient with acute bronchitis, the nurse will prioritize a. auscultating lung sounds b. encouraging fluid restriction c. administering antibiotic therapy d. teaching the pt to avoid cough suppressants
a. auscultating lung sounds
a pt who has bronchiectasis asks the nurse, "what conditions would warrant a call to the clinic?" a. blood clots in the sputum b. sticky sputum on a hot day c. increased SOB after eating a large meal d. production of large amounts of sputum on a daily basis
a. blood clots in the sputum
the best method for determining the risk of aspiration in a patient with a tracheotomy is to a. consult a speech therapist for swallowing assessment b. have the patient drink plain water and assess for coughing c. asses for change of sputum color 48 hours after pt drinks small amount of blue dye d. suction above the cuff after the pt eats or drinks to determine presence of food in trachea
a. consult a speech therapist for swallowing assessment
the nurse notes tidying of the water level in the tube submerged in the water-seal chamber in a pt with closed chest tube drainage. The nurse should a. continue to monitor the pt b. check all connections for a leak in the system c. lower the drainage collector further from the chest d. clamp the tubing at progressively distal points away from the pt until tidaling stops
a. continue to monitor the pt
a plan of care for the pt with COPD could include SATA a. exercise such as walking b. high flow rate of O2 administration c. low-dose chronic oral corticosteroid therapy d. use of peak flow meter to minor progression of COPD e. breathing exercises such as pursed-lip breathing that focus on exhalation
a. exercise such as walking e. breathing exercises such as pursed-lip breathing that focus on exhalation
for which pts with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia SATA? a. pt with seizures b. pt with head injury c. pt who had thoracic surgery d. pt who had myocardial infarction e. pt who is receiving nasogastric tube feeding
a. pt with seizures b. pt with head injury e. pt who is receiving nasogastric tube feeding
the emergency department nurse is caring for its exposed to a chlorine leak from a local factory. The nurse would closely monitor these pt's for a. pulmonary edema b. anaphylactic shock c. respiratory alkalosis d. acute tubular necrosis
a. pulmonary edema
which tx in CF would the nurse expect to implement in the management plan of pts with CF SATA? a. sperm banking b. IV corticosteroids on a chronic basis c. airway clearance techniques (e.g. Acapella) d. GoLYTELY given PRN for severe constipation e. inhaled tobramycin to combat Pseudomonas infection
a. sperm banking c. airway clearance techniques (e.g. Acapella) d. GoLYTELY given PRN for severe constipation
when caring for a pt with a lung abscess, what is the nurse's priority intervention? a. postural drainage b. antibiotic administration c. obtaining a sputum specimen d. pt teaching regarding home care
b. antibiotic administration
the effects of cigarette smoking on the respiratory system include a. hypertrophy of capillaries causing hemoptysis b. hyperplasia of goblet cells and increased production of mucus c. increased proliferation of cilia and decreased clearance of mucus d. proliferation of alveolar macrophages to decrease the risk for infection
b. hyperplasia of goblet cells and increased production of mucus
when planning care for a pt at risk for pulmonary embolism the nurse prioritizes a. maintaining the pt on bed rest b. using sequential compression devices c. encouraging the pt to cough and deep breathe d. teaching the pt how to use the incentive spirometer
b. using sequential compression devices
appropriate discharge teaching for the pt with a permanent tracheostomy after a total laryngectomy for cancer would include SATA? a. encouraging regular exercise such as swimming b. washing around the stoma daily with a moist washcloth c. encouraging participation in post-laryngectomy support group d. providing pictures and hands-on instructions for tracheostomy care e. teaching how to hold breath and trying to gag to promote swallowing reflex
b. washing around the stoma daily with a moist washcloth c. encouraging participation in post-laryngectomy support group d. providing pictures and hands-on instructions for tracheostomy care
a pt is seen a the clinic with fever, muscle aches, sore throat with yellowish exudate, and HA. the nurse anticipates that the interprofessional management will include SATA? a. antiviral agents to treat influenza b. treatment with antibiotics starting ASAP c. a throat culture or rapid strep antigen test d. supportive care, including cool, band liquids e. comprehensive history to determine possible etiology
c. a throat culture or rapid strep antigen test d. supportive care, including cool, band liquids e. comprehensive history to determine possible etiology
which nursing action would be of highest priority when suctioning a pt with a tracheostomy? a. auscultating lung sounds after suctioning is complete b. providing a means of communication for the pt during the procedure c. assessing the pt's o2 sat before, during and after suctioning d. administering pain and/or anti anxiety medication 30 minutes before suctioning
c. assessing the pt's o2 sat before, during and after suctioning
the major advantage of a Venturi man is that it can a. deliver up to 80% O2 b. provide continuous 100% humidity c. deliver a precise concentration of O2 d. be used while a pt eats and sleeps
c. deliver a precise concentration of O2
following a pneumonectomy, an appropriate nursing intervention is a. monitoring chest tube drainage and functioning b. positioning the pt on the unaffected side or back c. doing rang-of-motion exercises on the affected upper limb d. auscultating frequently for lung sounds on the affected side
c. doing rang-of-motion exercises on the affected upper limb
a pt with TB has been admitted to the hospital and is p laced in an airborne infection isolation room. What should the pt be taught SATA? a. expect routine TST to evaluate infection b. visitors will not be allowed while in airborne isolation c. take all medications for full length of time to prevent multidrug-resistant TB d. wear a standard isolation mask if leaving the airborne infection isolation room e. maintain precautions in airborne infection isolation room by oughting into a paper tissue
c. take all medications for full length of time to prevent multidrug-resistant TB d. wear a standard isolation mask if leaving the airborne infection isolation room e. maintain precautions in airborne infection isolation room by oughting into a paper tissue
a patient was seen in the clinic for an episode of epistaxis, which was controlled by placement of anterior nasal packing . During discharge teaching, the nurse instructs the patient o a. use aspirin for pain relief b. remove the packing later that day c. skip the next dose of antihypertsnsion medication d. avoid vigorous nose blowing and strenuous activity
d. avoid vigorous nose blowing and strenuous activity
While in the recovery room, a pt with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? a. notify the physician immediately b. place the pt in the prone position to facilitate drainage c. instill 3 mL of normal saline into the tracheostomy tube to loose secretions d. continue your assessment of the pt, including O2 saturation, RR and breath sounds
d. continue your assessment of the pt, including O2 saturation, RR and breath sounds
a patient with allergic rhinitis reports severe nasal congestion sneezing, and watery, itchy eyes and nose at various times of the year. To teach the patient to control these symptoms, the nurse advises the patient to a. avoid all intralnasal sprays and oral antihistamines b. limit the usage of nasal decongestant spray to 10 days c. use oral decongestants at bedtime to prevent symptoms during the night d. keep a diary of when the allergic reaction occurs and what precipitates it
d. keep a diary of when the allergic reaction occurs and what precipitates it
an appropriate nursing intervention for a pt with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to a. perform postural drainage every hour b. provide analgesics as ordered to promote pt comfort c. administer O2 as prescribed to maintain optimal O2 levels d. teach the pt how to cough effectively to bring secretions to the mouth
d. teach the pt how to cough effectively to bring secretions to the mouth
which guideline would be a part of teaching pt's how to use a metered-dose inhaler MDI? a. after activating the MDI, breath in as quickly as you can b. estimate the amount of remaining medicine in the MDI by floating the canister in water c. disassemble the plastic canister from the inhaler and rinse both pieces under running water every week d. to determine how long the canister will last, divide the total number of puffs in the canister by the puffs needed per day
d. to determine how long the canister will last, divide the total number of puffs in the canister by the puffs needed per day
normal level of alanine transaminase in females is
less than 34 IU/L
A 68-yr-old patient with bronchiectasis has copious thick respiratory secretions. Which intervention should the nurse add to the plan of care for this patient? Use the incentive spirometer for at least 10 breaths every 2 hours. Administer prescribed antibiotics and antitussives on a scheduled basis. Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. Provide nutritional supplements that are high in protein and carbohydrates.
ncrease intake to at least 12 eight-ounce glasses of fluid every 24 hours.
