Exam 2

Which assessment finding does the nurse interpret that is associated most closely with lung disease? A.Cough B.Dyspnea C.Chest pain D.Sputum production

A.Cough

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.

A. Document your findings as normal.

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? A. Intermittent bubbling may be noted in the water seal chamber. B.200 cc of drainage per hour is expected during recovery of a pneumothorax. C.The chest tube is positioned at the patient's chest level to facilitate drainage. D.All of these options are appropriate findings.

A. Intermittent bubbling may be noted in the water seal chamber.

Three days later, the provider prepares to discharge the patient on warfarin (Coumadin). Which teaching points do you include about this therapy? (Select all that apply.) A."Be sure to have follow-up INR laboratory tests done." B."Report any bruising or bleeding to your provider." C."Consume lots of foods that are rich in vitamin K, such as green leafy vegetables." D."Use a soft toothbrush to brush your teeth and an electric razor to shave your legs."

A."Be sure to have follow-up INR laboratory tests done." B."Report any bruising or bleeding to your provider." D."Use a soft toothbrush to brush your teeth and an electric razor to shave your legs."

A patient with COPD presents for a routine follow up. The patient smokes 1 PPD. Which statement by the patient causes the nurse to suspect an increase in dyspnea? A."I bought a new pillow so I could prop myself up at night to sleep." B."I have a productive cough in the morning." C."I have gained weight since I was here last." D."The patient is well groomed and is sitting in a tripod position."

A."I bought a new pillow so I could prop myself up at night to sleep."

A nursing student is teaching a 72-year-old patient about the importance of the pneumonia vaccination. Which teaching requires intervention by the nurse? (Select all that apply.) ● A."You will only need one vaccine called Pneumovax." B."You will need two vaccines to prevent pneumonia." C."If you have had the Prevnar vaccine, then you will not need the Pneumovax vaccine." D."Since you are over 64 years old, only the flu vaccine is suggested." E."You will receive the Prevnar vaccine about a year after the Pneumovax vaccine."

A."You will only need one vaccine called Pneumovax." C."If you have had the Prevnar vaccine, then you will not need the Pneumovax vaccine." D."Since you are over 64 years old, only the flu vaccine is suggested."

A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action? A.Administer the rescue drugs. B.Take the patient's vital signs. C.Notify the patient's prescriber. D.Repeat the PEF reading to verify the results.

A.Administer the rescue drugs

After morning care, the student nurse is to perform tracheostomy care under the RN's supervision. Which instructions does the RN give the student nurse? (Select all that apply.) A.Create a sterile field. B.Change trach ties if soiled. C.Remove old dressings and excess secretions. D.Suction the tracheostomy tube after the trach care. E.Clean the inner cannula with full-strength hydrogen peroxide.

A.Create a sterile field. B.Change trach ties if soiled. C.Remove old dressings and excess secretions.

While in the treatment room, the patient says she needs to use the bathroom. The nurse delegates this task to the unlicensed assistive personnel (UAP). What is the best approach for the nursing assistant to take? A.Place the patient on a bedpan and stay with her until she is finished. B.Ambulate her into the hall bathroom on room air and stand outside the door until she is done. C.Ask the provider for an indwelling catheter because of her shortness of breath when she ambulates. D.Tell her to try to wait until the shortness of breath subsides.

A.Place the patient on a bedpan and stay with her until she is finished.

The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.) A.Weight loss B.Nasal mask to deliver BiPAP C.A change in sleeping position D.Medication to increase daytime sleepiness

A.Weight loss B.Nasal mask to deliver BiPAP C.A change in sleeping

The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.) A.Weight loss B.Nasal mask to deliver C-PAP C.A change in sleeping position D.Medication to increase daytime sleepiness E.Position-fixing device that prevents tongue subluxation

A.Weight loss B.Nasal mask to deliver C-PAP C.A change in sleeping position E.Position-fixing device that prevents tongue subluxation

The nurse immediately checks on the patient and finds that she appears anxious and her vital signs are as follows: -Blood pressure: 128/84 -Heart rate: 114 (sinus tachycardia) -Respiratory rate: 24 and labored -Temperature: 99.4° F (axillary) -O2 saturation: 91% on 40% O2 via trach collar Which of these findings are cause for concern?

ANS: The BP is within normal range and only slightly elevated. The temperature is only slightly elevated. Her heart rate is elevated; the nurse should check the patient's medications to see if she is on a bronchodilator or other medication that could cause her heart rate to increase. The priority concern is the increased respiratory rate and the decreased oxygen saturation despite the 40% oxygen setting.

A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse? A."I should limit my alcohol consumption." B."I should eat more green leafy vegetables like spinach." C."I should take the medication at the same time every day." D."I should make a doctor's appointment for weekly blood draws."

B."I should eat more green leafy vegetables like spinach."

A patient with a history of chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. Which nursing intervention is most appropriate? A.Do not administer oxygen. B.Administer oxygen via Venturi mask. C.Use nasal cannula to administer high flow oxygen. D.Administer oxygen at 6L per simple face mask.

B.Administer oxygen via Venturi mask.

A patient with a history of chronic obstructive pulmonary disease is admitted with shortness of breath. Which nursing intervention is most appropriate? A.Do not administer oxygen. B.Administer oxygen via Venturi mask. C.Use nasal cannula to administer high flow oxygen. D.Administer oxygen at 6L per simple face mask.

B.Administer oxygen via Venturi mask.

Based on the patient's vital signs, what is the appropriate nursing action? -Blood pressure: 128/84 -Heart rate: 114 (sinus tachycardia) -Respiratory rate: 24 and labored -Temperature: 99.4° F (axillary) -O2 saturation: 91% on 40% O2 via trach collar A.Inform the provider of abnormal vital signs. B.Complete an assessment of airway and respiratory status. C.Provide patient teaching regarding relaxation techniques. D.Notify the Rapid Response Team for extra assistance.

B.Complete an assessment of airway and respiratory status.

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A.Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B.Gather supplies needed which will include a petroleum gauze dressing per physician preference. C.Place the patient in Semi-Fowler's position. D.Have the patient take a deep breath, exhale, and bear down during removal of the tube. E.Pre-medicate prior to removal as ordered by the physician.

B.Gather supplies needed which will include a petroleum gauze dressing per physician preference. C.Place the patient in Semi-Fowler's position. D.Have the patient take a deep breath, exhale, and bear down during removal of the tube. E.Pre-medicate prior to removal as ordered by the physician.

After consulting with the provider, the following orders are received: Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol 650mg every 4 hour for temperature above 101º F Cefazolin (Ancef) 1 g IVP every 8 hour Which of the provider's orders should the nurse implement first? A.IV fluids 1000 mL .9 NS at 60 mL/hr B.Oxygen at 2 L per nasal cannula C.Blood cultures and urinalysis D.Cefazolin (Ancef) 1 g IVP every 8 hour

B.Oxygen at 2 L per nasal cannula

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A.Stay with the patient and monitor their vital signs while another nurse notifies the physician. B.Place a sterile dressing over the site and tape it on three sides and notify the physician. C.Attempt to re-insert the tube. D.Keep the site open to air and notify the physician.

B.Place a sterile dressing over the site and tape it on three sides and notify the physician.

A patient is brought to the ED with respiratory depression. The patient has a history of COPD. What acid-base imbalance is most likely? A.Metabolic alkalosis B.Respiratory acidosis C.Metabolic acidosis and respiratory acidosis D.Metabolic alkalosis and respiratory alkalosis

B.Respiratory acidosis

The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows: BG—239 BP—138/88 HR—128 RR—36 O2 saturation—88% (room air) Temperature—101.6º F Which vital sign or test result requires the nurse's immediate attention? A.Blood pressure B.Respiratory rate C.Temperature Blood glucose

B.Respiratory rate

The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows: BG—239 mg/dL BP—138/88 mm Hg HR—128 RR—36 breaths/min O2 saturation—88% (room air) Temperature—101.6º F Which vital sign or test result requires the nurse's immediate attention? A.Blood pressure B.Respiratory rate C.Temperature D.Blood glucose

B.Respiratory rate

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A.This is an expected finding. B.The lung may have re-expanded or there is a kink in the system. C.The system is broken and needs to be replaced. D.There is an air leak in the tubing.

B.The lung may have re-expanded or there is a kink in the system.

The nurse understands that which of the following is the most common symptom of pneumonia in the older adult patient? A.Fever B.Cough C.Confusion D.Weakness

C.Confusion

The nurse understands that which of the following is the most common symptom of pneumonia in the older adult patient?* A.Fever B.Cough C.Confusion Weakness

C.Confusion

The nurse is reviewing the standing orders for a patient who was admitted for evaluation of chest pain. The patient has a history of chronic obstructive pulmonary disease (COPD) and his laboratory results and assessment reveal that he has mild respiratory acidosis. The nurse would question which order? A.Encourage oral fluids B.Keep head of bed elevated C.Oxygen therapy at 4 L/min as needed D.Bedrest with bathroom privileges only

C.Oxygen therapy at 4 L/min as needed

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding. A.Reposition the patient because the tubing is kinked B.Continue to monitor the drainage system C.Increase the suction to the bubbling stops D.Check the drainage system for an air leak.

D.Check the drainage system for an air leak.

Which assessment finding for an older adult patient does the nurse ascribe to the natural aging process? A.Tightening of the vocal cords B.Decrease in residual volume C.Decrease in the anteroposterior diameter D.Decrease in respiratory muscle strength

D.Decrease in respiratory muscle strength

The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A.Place the patient in supine position and clamp the tubing. B.Notify the physician immediately. C.Disconnect the drainage system and get a new one. D.Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

D.Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

The nurse is evaluating the laboratory work of a patient who has uncontrolled metabolic acidosis. Which outcome would result from this condition? A.pH 7.40 B.O2 98% C.Bicarbonate 38 mEq/L D.Serum potassium 5.7 mEq/L

D.Serum potassium 5.7 mEq/L

As the assessment is completed, the nurse observes that the patient has a large amount of thick secretions visible in the trach. What is the priority nursing action? A.Add pulmonary toileting to daily interventions. B.Instruct the NA to sit with the patient until she is calmer. C.Call the respiratory therapist for a stat bronchodilator treatment. D.Suction the artificial airway and remove the secretions.

D.Suction the artificial airway and remove the secretions.

Two hours later, the patient is admitted to the medical unit where she is started on a continuous IV heparin weight-based protocol. Which finding indicates that the heparin infusion is therapeutic? A.INR is less than 1 B.INR is between 2 and 3 C.aPTT is the same as the control D.aPTT is 1.5 to 2.5 times the control

D.aPTT is 1.5 to 2.5 times the control

Rau Kuohui, a 50-year-old female, was shot in the right side of her chest. She is currently in the progressive care unit. Her arterial blood gases are as follows: pH 7.30 Pao2 88 mmHg Paco2 50 mmHg Bicarbonate 26 mEq/L 1.Does Ms. Kuohui have an acid-base imbalance? If so, what type of imbalance?

Yes, she has respiratory acidosis. Rationale: The patient's pH is low (acidotic condition), Pao2 is low (respiratory depression), Paco2 is high (respiratory etiology - retention of carbon dioxide), bicarbonate and lactate are normal. These findings indicate respiratory acidosis.

The nurse instructs a patient on the steps needed to obtain a peak expiratory flow rate. In which order would these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." a) 4, 2, 1, 3, 5, 6, 7 b) 3, 4, 1, 2, 5, 7, 6 c) 2, 1, 3, 4, 5, 6, 7 d) 1, 3, 2, 5, 6, 7, 4

a) 4, 2, 1, 3, 5, 6, 7

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? Select all that apply. a.Sit upright in the bed or in a chair. b.Inhale as deeply and quickly as possible. c.Hold the device in a downward position. d.Place the mouthpiece in your mouth and seal your lips tightly around it. e.After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

a.Sit upright in the bed or in a chair. d.Place the mouthpiece in your mouth and seal your lips tightly around it. e.After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. a.Sitting up and leaning on a table b.Standing and leaning against a wall c.Lying supine with the feet elevated d.Sitting up with the elbows resting on knees e.Lying on the back in a low Fowler's position

a.Sitting up and leaning on a table b.Standing and leaning against a wall d.Sitting up with the elbows resting on knees

The nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure? a.16% b.21% c.30% d.40%

b.21%

The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process? a.Osmosis b.Diffusion c.Ionization d.Active transport

b.Diffusion

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? a.Low cardiac output secondary to cor pulmonale b.Gas exchange alteration related to ventilation-perfusion mismatch c.Altered breathing pattern secondary to increased work of breathing d.Inability to clear the airway related to inability to expectorate sputum

b.Gas exchange alteration related to ventilation-perfusion mismatch

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? a.Increase to 3 L/min and titrate until the SpO2 is 95%. b.Increase to 3 L/min and titrate until the SpO2 is 88%. c.Place the client on a nonrebreather mask on 100% FiO2. d.Maintain at 2 L/min and call respiratory therapy for a breathing treatment.

b.Increase to 3 L/min and titrate until the SpO2 is 88%.

A nurse answers a call light and finds a patient anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a.Assess the patient's lung sounds. b.Notify the Rapid Response Team. c.Provide reassurance to the patient. d.Take a full set of vital signs.

b.Notify the Rapid Response Team.

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? a.pH, 7.40; PaO2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L b.pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L c.pH, 7.47; PaO2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L d.pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

b.pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? u a.Dry cough b.Hematuria c.Bronchospasm d.Blood-streaked sputum

c.Bronchospasm

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? a.Restrict fluid b.Placing a pillow under knees c.Encouraging range of motion exercises d.Applying a heating pad to lower extremities

c.Encouraging range of motion exercises

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? a.Cyanosis b.Hyperinflated chest c.Rapid, shallow respirations d.Coarse crackles auscultated bilaterally

c.Rapid, shallow respirations

A nurse cares for a patient who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take? a.Ambulate the patient in the hallway to promote deep breathing. b.Auscultate the patient's anterior and posterior lung fields. c.Encourage the patient to take shallow breaths to help with the pain. d.Administer pain medication and encourage the patient to take deep breaths.

d.Administer pain medication and encourage the patient to take deep breaths.

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur? a.The client will lose consciousness. b.The client's sodium and chloride levels will rise. c.The client will complain of facial numbness and tingling. d.The client's arterial blood gas results will reflect acidosis.

d.The client's arterial blood gas results will reflect acidosis.

A nurse cares for a patient who has a chest tube. When would this patient be at highest risk for developing a pneumothorax? a.When the insertion site becomes red and warm to the touch b.When the tube drainage decreases and becomes sanguineous c.When the patient experiences pain at the insertion site d.When the tube becomes disconnected from the drainage system

d.When the tube becomes disconnected from the drainage system