Med-Surg Respiratory
C
A patient diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35 bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which prescription does the nurse question for this patient? A) Antibiotic therapy B) Nonsteroidal anti-inflammatory agents C) Oxygen by nasal cannula at 3-4 liters/minute D) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents
C
A patient with asthma presents with which symptoms? A) Cough, elevated blood pressure. B) Decreased respirations, fatigue. C) Increased respirations, wheezes. D) Increased sputum, decreases respirations.
C
An older adult patient is admitted with pneumonia. Which manifestation is unexpected during the nurse's initial assessment? A) Lethargy B) Hemoptysis C) Increased appetite D) Increased respirations
D
Friends of a patient hospitalized with asthma would like to bring the patient a gift. Which gift would the nurse recommend for this patient? A) A basket of flowers B) A stuffed animal C) Fruit and candy D) A book
A, B, C & D
The nurse is caring for a client admitted with COPD who is having difficulty breathing. Which actions can the nurse take to provide support? (Select all that apply.) A) Place client in semi-Fowler's position B) Provide bronchodilators, if ordered C) Offer small, frequent meals D) Encourage smoking cessation E) Wean from oxygen
C
The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care? A) The client has no signs of respiratory distress. B) The client shows an improved respiratory pattern. C) The client demonstrates intolerance to activity. D) The client participates in establishing goals.
A, C & D
The nurse is planning care for a young adolescent patient diagnosed with asthma. Which evidence-based age-appropriate interventions will the nurse include in the plan of care? (Select all that apply.) A) Referring to a peer-led support group B) Teaching the parents how to administer maintenance medication prior to teaching the patient C) Assessing peer-support when planning care D) Collaborating with teachers for support in the school setting E) Telling the patient to avoid medication while at school
C
The nurse is providing care to a patient admitted after experiencing an acute asthma attack. Which assessment findings indicate the need for immediate intervention by the nurse? A) Retractions and fatigue B) Tachycardia and tachypnea C) Inaudible breath sounds D) Diffuse wheezing and the use of accessory muscles when inhaling
A
Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD? A) "I need to get an influenza vaccine each year, even when there is a shortage." B) "I need to get a vaccine for pneumonia each year with my influenza shot." C) "If I reduce my cigarettes to 6 a day, I won't have difficulty breathing." D) "I need to restrict my drinking liquids to keep from having so much phlegm."
D
During an acute asthma attack, the nurse should expect which finding? A) Increased peak flow reading B) Increased incentive spirometer reading C) Client able to breathe comfortably D) Wheezing on auscultation
B
The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this diagnosis? A) Wheezing B) Hemoptysis C) Grey sputum D) Slightly whitish sputum
C
The nurse is preparing to assess an older adult patient admitted with tuberculosis. Which manifestations does the nurse anticipate for this patient? A) Night sweats B) Swollen lymph nodes C) Cough D) Hemoptysis
D
An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB). The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most appropriate response by the nurse? A) "Different medication is used in the second PPD." B) "The treatment for TB is six months of medication, and we want to make sure the first results of the first PPD were accurate." C) "The first PPD was not interpreted in the correct time frame of 48-72 hours." D) "There is an increased risk for a false-negative response for people who work in long-term care facilities. The two-step is recommended to accurately screen for TB."
A
During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which diagnosis presents with this assessment finding? A) Pneumonia B) Cystic fibrosis C) Bronchospasm D) Interstitial edema
B
The nurse working on a pediatric unit is caring for a patient newly diagnosed with asthma. Which assessment data indicates exhaustion and the need for immediate intervention? A) Slightly diminished breath sounds B) Decreased wheezing C) Increased crackles D) Increased respiratory rate
C
What is the primary difference between emphysema and chronic bronchitis? A) Chronic bronchitis predominantly affects the large airways. B) Emphysema predominantly affects the large airways. C) Emphysema predominantly affects the alveoli. D) Chronic bronchitis predominantly affects the alveoli.
D
Which assessment finding supports the nurse's suspicion that a patient is experiencing chronic obstructive pulmonary disease (COPD)? A) Dysrhythmias B) Cyanotic nail beds C) Clubbing of the fingers D) Cough in the morning producing clear sputum
A
Which instruction should the nurse provide to a client who has just received a PPD? A) Return to the clinic in 48-72 hours to have the test read. B) Take antiviral medication as prescribed. C) Massage the subcutaneous injection site. D) There may be a very small amount of bleeding on the forearm.
B
The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client? A) Daily inhaled corticosteroids. B) Use of a "rescue inhaler." C) Use of systemic steroids. D) Leukotriene agonists.
C
The client with emphysema comes to the emergency department with difficulty breathing. What assessment finding should the nurse anticipate? A) Excess mucous production B) Barrel shaped chest C) Hypoventilation D) Blueish skin tones
B
The nurse is caring for a patient who is admitted to the unit with tuberculosis (TB). The patient is placed in isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most appropriate? A) Single-door room with positive air flow (air flows out of the room.) B) Isolation room with an anteroom and negative air flow (air flows into the room.) C) Isolation room with an anteroom and normal airflow D) Single-door room with normal airflow
C
Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen? A) "I will take Singulair, a leukotriene, every day to prevent allergic asthma attacks." B) "I need to use my Intal, cromolyn inhaler, 15 minutes before I begin my exercise." C) "I need to take oral glucocorticoids every day to prevent my asthma attacks." D) "If I have an asthma attack, I need to use my albuterol, a beta2 agonist, inhaler."
C
The nurse is reviewing discharge instructions with a patient who is newly diagnosed with asthma. Which patient statement indicates a need for further teaching? A) "I need to rinse my mouth after every use of my inhaler." B) "I need to take my Singulair at least one hour before I eat." C) "I can resume my ephedra when I return home." D) "Because I am on theophylline, I will need to have therapeutic blood levels drawn."
D & E
A client has diminished breath sounds after receiving an albuterol nebulizer treatment for asthma. What are the nurse's priority actions? (Select all that apply.) A) Obtain a 12-lead ECG. B) Request a beta blocker. C) Document the finding. D) Notify the healthcare provider. E) Provide mechanical ventilation, if ordered.
C, D & E
A client, newly diagnosed with asthma, has recovered from an acute attack. The nurse analyzes possible triggers in the environment. Which triggers could have caused the exacerbation? (Select all that apply.) A) Client walking in hallway two times today B) Gift basket in room containing boxed food items C) Fellow staff nurse in hallway wearing perfume D) Flower arrangement on client's bedside table E) Visitor who smells of cigarette smoke
C
A nurse is caring for a patient with tuberculosis (TB) who is taking Rifampin for treatment of the disease. Which nursing intervention is most appropriate for this patient? A) Administer the medication with meals to reduce gastrointestinal side effects B) Record a baseline visual examination before initiating therapy C) Administer the medication on an empty stomach D) Administer the medication by deep intramuscular injection into a large muscle mass
B
A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching? A) "We'll be sure to use the fireplace often to keep the house warm in the winter." B) "We will replace the carpet in our child's bedroom with tile." C) "We'll keep the plants in our child's room dusted." D) "We're glad the dog can continue to sleep in our child's room."
A
An adolescent patient is brought to the emergency department (ED) with fatigue, weight loss, a dry cough, and night sweats. The family just recently immigrated to the United States. Based on this data, for which potential risk should the nurse include when planning care for this patient? A) Pneumothorax B) Pneumonia C) Renal failure D) Septicemia
C
An older adult patient diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate? A) Ineffective Airway Clearance B) Impaired Tissue Perfusion C) Ineffective Breathing Pattern D) Activity Intolerance
A, C & E
The nurse is caring for a client with a diagnosis of active tuberculosis. Which symptoms does the nurse expect this client to exhibit? (Select all that apply.) A) Fever B) Abdominal rigidity C) Abnormal breathing sounds D) Hypothermia E) Decreased oxygen saturation
B
The 56-year-old client diagnosed with TB is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? A) "I will take my medication for the full three weeks prescribed." B) "I must stay on the medication for months if I am to get well." C) "I can be around my friends because I have started taking antibiotics." D) "I should get a TB skin test every 3 months to determine if I am well."
B
The nurse understands that the priority intervention with the patient with TB is which of the following? A) Antibiotic administration. B) Initiation of isolation. C) TB test. D) Chest x-ray.
C
Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD? A) Clubbing of the client's fingers. B) Infrequent respiratory infections. C) Chronic sputum production. D) Non-productive hacking cough.
D
Which diagnostic test should the nurse anticipate the HCP ordering to rule out the diagnosis of asthma in clients diagnosed with COPD? A) A bronchoscopy. B) An immunoglobuin E. C) An arterial blood gas. D) A bronchodilator reversibility test.
D
Which diagnostic test should the nurse anticipate the HCP ordering to rule out the diagnosis of asthma in clients diagnosed with COPD? A) A bronchoscopy. B) An immunoglobulin E. C) An arterial blood gas. D) A bronchodilator reversibility test.
B
Which intervention should the emergency department nurse implement first for the client admitted for an acute asthma attack? A) Administer glucocorticoids intravenously. B) Administer oxygen 5 L per nasal cannula. C) Establish and maintain a 20-gauge saline lock. D) Assess breath sounds every 15 minutes.
B, C & E
Which nursing actions are appropriate when caring for a client diagnosed with tuberculosis? (Select all that apply.) A) Place on droplet precautions. B) Humidify oxygen when administered. C) Request dietary consult. D) Offer family members N95 masks. E) Medication teaching.
A, B, C, D & E
Which nursing interventions should the nurse implement for the client who has a respiratory disorder? (Select all that apply.) A) Administer oxygen via a nasal cannula. B) Assess the client's lung sounds. C) Encourage the client to cough and deep breathe. D) Monitor the client's pulse oximeter reading. E) Increase the client's fluid intake.
A
Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD? A) The client demonstrates the corret way to pursed-lip breathe. B) The client lists 3 signs/symptoms to report to the HCP. C) The client will drink at least 2,500 mL of water daily. D) The client will be able to ambulate 100 feet with dyspnea.
C
Which referral is most appropriate for a client diagnosed with end-stage COPD? A) The Asthma Foundation of America. B) The American Cancer Society. C) The American Lung Association. D) The American Heart Association.
D
Which statement indicates to the nurse the client diagnosed with asthma understands the teaching regarding mast cell stabilizer medications? A) "I should take two puffs when I begin to have an asthma attack." B) "I must taper off the medications and not stop taking them abruptly." C) "These drugs will be most effective if taken at bedtime." D) "These drugs are not good at the time of an attack."
D
Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required? A) "I should contact my health-care provider if my sputum changes color or amount." B) "I will take my bronchodilator regularly to prevent having bronchospasms." C) "This metered-dose inhaler gives a precise amount of medication with each dose." D) "I need to return to the HCP to have my blood drawn with my annual physical."
A, B & C
The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? (Select all that apply) A) Nursing. B) Pharmacy. C) Social work. D) Occupational therapy. E) Speech therapy.
B
The charge nurse for a medical-surgical unit is notified that a patient with tuberculosis (TB) is being transported to the unit. Which nursing action for infection prevention is the most appropriate in this circumstance? A) Stock the patient's supply cart at the beginning of each shift B) Wear a respirator mask and gown when caring for the patient C) Perform hand hygiene only after leaving the room D) Test all staff members for TB immediately
C
The nurse is providing care to a patient diagnosed with chronic obstruction pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this patient? A) Tachycardia B) Cough C) Barrel chest D) Wheezing
D
The nurse is providing care to a patient newly diagnosed with asthma. When developing the patient's plan of care, which intervention would be most appropriate to promote airway clearance? A) Provide adequate rest periods B) Reduce excessive stimuli C) Assist with activities of daily living D) Place in Fowler position
C
The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient's diagnosis? A) Cough reflex B) Filtration of air C) Alveolar macrophages D) Mucociliary clearance system
A, B, C & D
A client comes to the clinic with a 5-year history of COPD. The nurse provides a focused assessment. What should be included? (Select all that apply.) A) Cough B) Sputum C) Confusion D) Use of accessory muscles E) Bowel sounds
D
A nurse is caring for an older adult patient admitted to the hospital with pneumonia. The patient asks the nurse what can be done to decrease the risk for developing pneumonia in the future. Which response by the nurse is inappropriate? A) "You should avoid alcohol." B) "You can start by not smoking." C) "You can get the pneumonia vaccination, which may help to decrease your risk in the future." D) "You should drink a yogurt drink once a day that is supplemented with L. casei immunitas cultures."
C
A patient asks why asthma medication is needed even though the patient's last attack was several months ago. Which response by the nurse is appropriate? A) "The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack." B) "The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him." C) "The medication is still needed to decrease inflammation in your airways and help prevent an attack." D) "The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it."
A
The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). A nursing diagnosis for this patient is Imbalanced Nutrition: Less than Body Requirements. Which intervention is appropriate for this nursing diagnosis? A) Encourage a diet high in protein and fats B) Keep snacks to a minimum C) Encourage carbohydrate-rich foods to provide needed calories for energy D) Suggest the patient eat three meals per day to maintain energy needs
A
The charge nurse is making rounds. Which client should the nurse assess first? A) The 29-year-old client diagnosed with reactive airway disease who is complaining the nurse caring for him was rude. B) The 76-year-old client diagnosed with heart failure who has 2+ edema of the lower extremities. C) The 15-year-old client diagnosed with diabetic ketoacidosis after a bout with the flu who has a blood glucose reading of 189 mg/dL. D) The 62-year-old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at 2 liters per minute.
A
The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? A) Assist the client into a sitting position at 90 degrees. B) Administer oxygen at 6 LPM via nasal cannula. C) Monitor vital signs with the client sitting upright. D) Notify the health-care provider about the client's status.
B
The client diagnosed with asthma is admitted to the mergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client? A) Complete blood count. B) Pulmonary function test. C) Allergy skin testing. D) Drug cortisol level.
C
The client diagnosed with community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? A) Administer the ordered oral antibiotic immediately (STAT). B) Order the meal tray to be delivered as soon as possible. C) Obtain a sputum specimen for culture and sensitivity. D) Have the UAP weight the client.
C
The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching? A) Take 2 puffs on the rescue inhaler and wait 5 minutes before exercise. B) Warm-up exercises will increase the potential for developing the asthma attacks. C) Use the bronchodilator inhaler immediately prior to beginning to exercise. D) Increase dietary intake of food high in MSG.
B
The client diagnosed with restrictive airway disease has been prescribed a glucocorticoid inhaled medicaiton. Which information should the nurse teach regarding this medication? A) Do not abruptly stop taking this medication; it must be tapered off. B) Immediately rinse the mouth following administration of the drug. C) Hold the medication in the mouth for 15 seconds before swallowing. D) Take the medication immediately when an attack starts.
A
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client? A) Pleuritic chest discomfort and anxiety. B) Asymmetrical chest expansion and pallor. C) Leukopenia and CRT <3 seconds. D) Substernal chest pain and diaphoresis.
D
The client is admitted with a diagnosis of rule-out TB. Which type of isolation procedures should the nurse implement? A) Standard Precautions. B) Contact Precautions. C) Droplet Precautions. D) Airborne Precautions.
C
The correct statement about the prevalence of pneumonia is which of the following? A) Pneumonia is no longer a major health problem. B) The prevealence of pneumonia is increasing dramatically. C) The prevalence and mortality are highest in persons older than 65 years. D) The frequency has not devlined, but mortality has declined.
C
The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? A) The 65-year-old client diagnosed with TB who has a sputum specimen to be sent to the laboratory. B) The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. C) The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. D) The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.
C
The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active TB. Which statement indicates the need for radiological evaluation instead of skin testing? A) The client's first skin test indicates a purple flat area at the site of injection. B) The client's second skin test indicates a red area measuring 4 mm. C) The client's previous skin test was read as positive. D) The client has never shown a reaction to the tuberculin medication.
A, B & E
The nurse and a licensed practical nurse (LPN) are caring for 5 clients on a medical unit. Which clients would the nurse assign to the LPN? (Select all that apply.) A) The 32-year-old female diagnosed with exercise-induced asthma who has a forced vital capacity of 1000 mL. B) The 45-year-old male with adult-onset asthma who is complaining of difficulty completing all of the ADLs at one time. C) The 92-year-old client diagnosed with respiratory difficulty who is beginning to be confused and keeps climbing out of bed. D) 6-year-old client diagnosed with intrinsic asthma who is scheduled for discharge and the mother needs teaching about the medications. E) The 20-year-old client diagnosed with asthma who has a pulse oximetry reading of 95% and wants to sleep all the time.
A, D & E
The nurse caring for a homeless patient at risk for tuberculosis (TB) will include which symptoms of the disease when educating the patient? (Select all that apply.) A) Fatigue B) Low-grade morning fever C) Productive cough that later turns to a dry, hacking cough D) Weight loss E) Night sweats
A
The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which observation would indicate that care provided to this patient has been effective? A) Patient conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading. B) Patient needs assistance with morning care and meals due to shortness of breath. C) Patient states family members are discussing admission to a nursing home for continuing care. D) Patient leaves hospital unit to smoke outside four times a day.
A
The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a patient with pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the nurse include in this patient's plan of care? A) Perform chest percussion every four hours and prn B) Administer the pneumococcal vaccine prior to discharge C) Limit fluid intake to 1,000 mL per day D) Provide the patient with smoking cessation education
A, B, C, D & E
The nurse encourages a client with COPD to eliminate risk factors for exacerbation. What is considered a risk factor? (Select all that apply.) A) Chemicals B) Dust C) Air pollutants D) Secondhand smoke E) Cigarette smoking
D
The nurse in an inner city clinic is providing a health screening for a homeless patient with a history of drug abuse. The patient has a chronic nonproductive cough. For which should the nurse expect to screen this patient? A) Herpes zoster B) Sickle cell disease C) Sick sinus syndrome D) Tuberculosis
B
The nurse instructs a patient with asthma on bronchodilator therapy. Which statement indicates patient understanding? A) "The medication widens the airways because it acts on the parasympathetic nervous system." B) "The medication widens the airways because it stimulates the fight-or-flight response of the nervous system." C) "The medication widens the airways because it decreases the production of histamine that narrows the airways." D) "The medication widens the airways because it decreases the production of mucous that narrows the airways."
A
The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client? A) Confusion and lethargy. B) High fever and chills. C) Frothy sputum and edema. D) Bradypnea and JVD.
B
The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? A) Large amounts of thick white sputum. B) Oxygen flowmeter set on 8 liters. C) Use of accessory muscles during inspiration. D) Presence of a barrel chest and dyspnea.
D
The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain? A) Number of years the client has smoked. B) Risk factors for complications. C) Ability to administer inhaled medication. D) Willingness to modify lifestyle.
A, B & C
The nurse is caring for a patient who develops a fever and productive cough after having an appendectomy. Which prescriptions should the nurse expect from the health-care provider for this health problem? (Select all that apply.) A) Sputum cultures B) Antibiotics C) Chest physiotherapy D) Bronchial washing for culture E) Isolation precautions
D
The nurse is caring for a patient who is receiving multiple drugs for treatment of tuberculosis. The nurse teaches the patient the rationale for the multiple-drug treatment and evaluates learning as effective when the patient makes which statement? A) "Multiple drugs are necessary to develop immunity to tuberculosis." B) "Multiple drugs are necessary because I became infected from an immigrant." C) "Multiple drugs will be required as long as I am contagious." D) "Multiple drugs are necessary because of the risk of resistance."
B
The nurse is caring for an older adult patient who is hospitalized with a second episode of pneumonia in the past 18 months. The patient has expressed frustration to the nurse and states, "I never got sick when I was younger. Why is this happening?" Which response by the nurse is most appropriate? A) "As you grow older, your immune system just quits working." B) "As you grow older, there is a decrease in the immune response, which puts you at greater risk for developing an infection." C) "As you grow older, there in an overall increase in the speed and strength of your immune response." D) "As you grow older, there is an increase in the number of B cells in the circulation, which hinders the immune response."
D
The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? A) The client's pulse ox reading is 92%. B) The client's arterial blood gas level is 74. C) The client has SOB when walking to the bathroom. D) The client's sputum is rusty colored.
A, B & E
The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? (Select all that apply.) A) Place the client on oxygen delivered by nasal cannula. B) Plan for periods of rest during activities of daily living. C) Place the client on a fluid restriction of 1000 mL/day. D) Restrict the client's smoking to 2 to 3 cigarettes per day. E) Monitor the client's pulse oximetry readings every four hours.
C
The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find? A) Fever and crepitus. B) Rales and hives. C) Dyspnea and wheezing. D) Normal chest shape and eupnea.
A
The nurse is discharging a client newly diagnosed with restrictive airway disease. Which statement indicates the client understands the discharge instructions? A) "I will call 911 if my medications don't control an attack." B) "I should wash my bedding in warm water." C) "I can still eat at the Chinese restaurant when I want." D) "If I get a headache, I should take a NSAID."
A, C & D
The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD)? Which factors in the patient's history support the current diagnosis? (Select all that apply.) A) Working in an industrial environment B) Working in an office setting with air conditioning C) History of asthma D) Current cigarette smoking E) Playing golf several times a week
B
The nurse is discussing the care of a child diagnosed with asthma with the parent. Which referral is important to include in the teaching? A) Referral to a dietician. B) Referral for allergy testing. C) Referral to the developmental pathologist. D) Referral to a home health nurse.
B
The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first? A) Suction the client's nares. B) Turn the client to the side. C) Place the client in Trendelenburg position. D) Notify the HCP.
D
The nurse is instructing a client newly diagnosed with chronic bronchitis about his disease. He says a friend has this disease and he calls himself a "blue bloater." The client asks the nurse why. How should the nurse reply? A) "That's a term used for someone who smokes a lot." B) "It has to do with the color of the phlegm." C) "That's from the 'puffing' breathing pattern." D) "The lack of oxygen in the blood gives the skins a blue appearance."
A
The nurse is instructing a patient who is prescribed ipratropium bromide (Atrovent) for asthma. Which should be included in this patient's teaching? A) Take no more than the prescribed number of doses each day. B) Rinse the mouth after taking this medication. C) Take on an empty stomach. D) Take with meals or a full glass of water.
A
The nurse is planning care for an older adult patient recently diagnosed with tuberculosis (TB). The patient lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this patient? A) Ineffective Therapeutic Regimen Management B) Deficient Knowledge C) Ineffective Breathing Pattern D) Risk for Injury
D
The nurse is planning care for the patient diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minute, elevated blood pressure, and fatigue. Which nursing diagnosis is the priority for this patient? A) Ineffective Coping B) Ineffective Airway Clearance C) Anxiety D) Ineffective Breathing Pattern
A
The nurse is planning the care of a client diagnosed with asthma and has written a problem of "anxiety." Which nursing intervention should be implemented? A) Remain with the client. B) Notify the HCP. C) Administer an anxiolytic medication. D) Encourage the client to drink fluids.
D
The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which is an expected outcome for this problem? A) Performs chest phsiotherapy three times a day. B) Able to complete activities of daily living. C) Several times during each shift. D) Alert and oriented to person, place, time and events.
A
The nurse is preparing to hang the next bag of aminophylline, a bronchodilator, for the client diagnosed with asthma. The current theophylline level is 18 mcg/mL. Which intervention should the nurse implement? A) Hang the next bag and continue the infusion. B) Do not hang the next bag and decrease the rate. C) Notify the HCP of the level. D) Confirm the current serum theophylline level.
C
The nurse is providing care for a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which intervention is inappropriate to control the patient's breathing pattern? A) Instruct in pursed-lip breathing B) Teach visualization and meditation C) Deep breathing and coughing every hour D) Instruct in abdominal breathing
B
The nurse is providing care to a patient with pneumonia and has a fever. Which intervention should the nurse implement to attain the goal of normal body temperature? A) Increase the temperature of the room environment to prevent shivering B) Administer antipyretic medications C) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance D) Use ice packs and a tepid bath every two hours
A
The nurse is providing care to an infant in the emergency department (ED). Initial assessment indicates that the infant is experiencing an asthma attack. The infant is unresponsive to medication and a chest x-ray reveals a foreign body partially obstructing the airway. While placing an oxygen mask on the infant, the nurse notes a total obstruction of the airway. Which nursing action is appropriate? A) Attempt to clear the obstruction by delivering back blows and chest thrusts. B) Attempt to clear the obstruction by delivering back blows. C) Attempt to clear the obstruction by delivering back blows and abdominal thrusts. D) Attempt to clear the obstruction by delivering abdominal thrusts.
C
The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement indicates that additional teaching is needed? A) "I can't get the influenza vaccine due to my allergy to eggs." B) "I will get the influenza vaccine every year." C) "I will get the pneumococcal vaccine every fall." D) "I will get the pneumococcal vaccine as soon as I recover from this pneumonia."
C
The nurse is teaching a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which patient statement indicates a need for further teaching? A) "I should inhale by sniffing." B) "I should avoid aerosol sprays." C) "I should limit my fluid intake to 1-1.5 quarts daily." D) "I should get a flu vaccine every year."
A
The nurse observes the UAP entering an airborne isolation room and leaving the door open. Which action is the nurse's best response? A) Close the door and discuss the UAP's action after coming out of the room. B) Make the UAP come back outside the room and then reenter, closing the door. C) Say nothing to the UAP but report the incident to the nursing supervisor. D) Enter the client's room and discuss the matter with the UAP immediately.
B
The nurse observes the UAP removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement? A) Praise the UAP because this prevents the client from tripping on the oxygen tubing. B) Place the oxygen back on the client while sitting in the bathroom and say nothing. C) Explain to the UAP in front of the client oxygen must be left in place at all times. D) Discuss the UAPs action with the charge nurse so appropriate action can be taken.
B
The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child's urine was orange. Which response by the nurse is accurate? A) "Encourage your child to drink cranberry juice." B) "An orange discoloration of urine is expected while your child is on this medication." C) "Bring your child to the clinic for a urinalysis." D) "Bring your child to the clinic for a radiograph of the kidneys."
C
The nurse should include which priority preventive measure when teaching a group of adults about preventing the spread of tuberculosis? A) Handwashing B) Annual vaccination C) Isolation D) Covering mouth when coughing
A, B, C, D & E
Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? (Select all that apply.) A) Impaired gas exchange. B) Inability to tolerate temperature extremes. C) Activity intolerance. D) Inability to cope with changes in roles. E) Alteration in nutrition.
C & D
Which discharge teaching should the nurse include in the teaching plan for a client who was treated for tuberculosis? (Select all that apply.) A) "Family members should have chest x-rays done." B) "Stop medication when coughing subsides." C) "Persons living with you should have skin testing." D) "Use your best judgment in terms of your daily medications." E) "Maintain adequate nutrition."
A, B, C & E
Which topics should the nurse include in the discharge teaching plan of a client newly diagnosed with asthma? (Select all that apply.) A) Pursed-lip breathing B) Possible triggers C) Signs and symptoms D) Using the incentive spirometer E) Using a peak flow meter
A
Which type of medication is used to maintain daily control of asthma? A) Anti-inflammatories B) Anticholinergics C) Bronchodilators D) Vasodilators
