MED SURG SUCCESS (RESPIRATORY Q's)

36. Which referral is most appropriate for a client diagnosed with end-stage COPD? 1. The Asthma Foundation of America. 2. The American Cancer Society. 3. The American Lung Association. 4. The American Heart Association.

3 The American Lung Association has information helpful for a client with COPD. TEST-TAKING HINT: The test taker should be familiar with organizations, but if the test taker had no idea what the answer was, the only option containing a word referring to respiration—"lung"—is option "3."

30. Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required? 1. "I should contact my health-care provider if my sputum changes color or amount." 2. "I will take my bronchodilator regularly to prevent having bronchospasms." 3. "This metered-dose inhaler gives a precise amount of medication with each dose." 4. "I need to return to the HCP to have my blood drawn with my annual physical."

4 Clients should have blood levels drawn every six (6) months when taking bron- chodilators, not yearly. This indicates the client needs more teaching. TEST-TAKING HINT: When evaluating whether the client has learned the information presented, the test taker is observing for incorrect information. The test taker should pay close attention to time frames such as "every 12 months."

1. Which diagnostic test should the nurse anticipate the health-care provider ordering to rule out the diagnosis of asthma? 1. A bronchoscopy. 2. An immunoglobulin E. 3. An arterial blood gas. 4. A bronchodilator reversibility test.

4 During a bronchodilator reversibility test, the client's positive response to a bronchodilator confirms the diagnosis of asthma.

38. 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? 1. Remain with the client. 2. Notify the health-care provider. 3. Administer an anxiolytic medication. 4. Encourage the client to drink fluids.

1 Anxiety is an expected sequela of being unable to meet the oxygen needs of the body. Staying with the client lets the client know the nurse will intervene and the client is not alone. TEST-TAKING HINT: Before choosing an answer option that directs the test taker to notify a health-care provider, the test taker should determine if the option is describing an expected event or data for the disease process being discussed. If it is expected, then notifying the health-care provider would not be the correct answer.

96. Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

1 Assessment of the lung sounds could indicate the client's lung has reexpanded because it has been three (3) days since the chest tube has been inserted. TEST-TAKING HINT: When the stem asks the test taker to identify the first inter- vention, all four (4) answer options could be interventions appropriate for the situa- tion, but only one (1) is the first interven- tion. Remember to apply the nursing process: the first step is assessment.

91. Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

1 Checking to see if someone has increased the suction rate is the simplest and a noninvasive action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system. TEST-TAKING HINT: The test taker should always think about assessing the client if there is a problem and the client is not in immediate danger. This would cause the test taker to eliminate options "3" and "4." If the test taker thinks about bubbling, he or she should know it has to do with suctioning.

35. Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD? 1. "I need to get an influenza vaccine each year, even when there is a shortage." 2. "I need to get a vaccine for pneumonia each year with my influenza shot." 3. "If I reduce my cigarettes to six (6) a day, I won't have difficulty breathing." 4. "I need to restrict my drinking liquids to keep from having so much phlegm."

1 Clients diagnosed with COPD should receive the influenza vaccine each year. If there is a shortage, these clients have top priority. TEST-TAKING HINT: Nurses are expected to serve as community resources. The nurse should be knowledgeable about health promotion activities such as immunizations. One (1) option describes a desired goal, but the other three (3) do not.

23. The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse's best response? 1. Close the door and discuss the UAP's action after coming out of the room. 2. Make the UAP come back outside the room and then reenter, closing the door. 3. Say nothing to the UAP but report the incident to the nursing supervisor. 4. Enter the client's room and discuss the matter with the UAP immediately.

1 Closing the door reestablishes the negative air pressure, which prevents the air from entering the hall and contaminating the hospital environment. When correcting an individual, it is always best to do so in a private manner. TEST-TAKING HINT: An action must be taken; the test taker must determine which action would have the desired results with the least amount of disruption to client care. Correcting the UAP in this manner has the greatest chance of creating a win-win situation.

82. The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) L/day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.

1 Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE.`

24. The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client? 1. Pleuritic chest discomfort and anxiety. 2. Asymmetrical chest expansion and pallor. 3. Leukopenia and CRT <three (3) seconds. 4. Substernal chest pain and diaphoresis.

1 Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever, chills, dyspnea, and cough. TEST-TAKING HINT: Options "1" and "4" have chest pain as part of the answer. The adjectives describing the chest pain determine the correct answer.

44. The charge nurse is making rounds. Which client should the nurse assess first? 1. The 29-year-old client diagnosed with reactive airway disease who is complaining the nurse caring for him was rude. 2. The 76-year-old client diagnosed with heart failure who has 2+ edema of the lower extremities. 3. 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. 4. The 62-year-old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at two (2) liters per minute.

1 The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have expected and non-life-threatening situations. TEST-TAKING HINT: All the options with physiological data are expected and not life-threatening, so the nurse should address the client with a psychosocial problem.

48. The nurse is discharging a client newly diagnosed with restrictive airway disease (asthma). Which statement indicates the client understands the discharge instructions? 1. "I will call 911 if my medications don't control an attack." 2. "I should wash my bedding in warm water." 3. "I can still eat at the Chinese restaurant when I want." 4. "If I get a headache, I should take a nonsteroidal anti-inflammatory drug."

1 The client must be able to recognize a life-threatening situation and initiate the correct procedure. TEST-TAKING HINT: Dietary questions or answer options should be analyzed for the content. The test taker should decide, "What about Chinese foods could be a problem for a client diagnosed with asthma?" or "What might be good for the client about this diet?"

87. Which intervention should the nurse implement for a male client who has had a left- sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die.

1 The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis. TEST-TAKING HINT: If the test taker reads options "2" and "3" and notices that both reflect the same idea—namely, that deep breaths are not necessary—then both can either be eliminated as incorrect answers or kept as possible correct answers. Option "4" should be eliminated based on being a very rude and threatening comment.

26. The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client into a sitting position at 90 degrees. 2. Administer oxygen at six (6) LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health-care provider about the client's status

1 The client should be assisted into a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain the client's safety. TEST-TAKING HINT: When a question asks for the test taker to choose the intervention to implement first, the test taker should select an intervention directly caring for the client. Remember: in distress do not assess.

13. 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? 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention.

1 The elderly client diagnosed with pneumonia may present with weakness, fatigue, lethargy, confusion, and poor appetite but not have any of the classic signs and symptoms of pneumonia. TEST-TAKING HINT: The question provides an age range—"elderly"—so age can be expected to affect the disease process—in this case, causing atypical symptoms. The prefix brady- means "slow" when attached to a word. Knowing the definition of medical prefixes can assist the test taker in determining the correct answer.

74. The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging.

1 The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis. TEST-TAKING HINT: The key to answering this question is "confirms the diagnosis." The test taker should eliminate options "2" and "3" based on the fact these are diagnostic tests used for many disease processes and conditions.

32. Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD? 1. The client demonstrates the correct way to pursed-lip breathe. 2. The client lists three (3) signs/symptoms to report to the HCP. 3. The client will drink at least 2,500 mL of water daily. 4. The client will be able to ambulate 100 feet with dyspnea.

1 Pursed-lip breathing helps keep the alveoli open to allow for better oxygen and carbon dioxide exchange. TEST-TAKING HINT: The test taker needs to identify the outcome for the client problem cited—namely, "ineffective gas exchange." The only answer option addressing the airway is option "1," pursed-lip breathing.

39. 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. 1. Nursing. 2. Pharmacy. 3. Social work. 4. Occupational therapy. 5. Speech therapy.

1, 2, 3 1. Nursing is the one discipline remaining with the client around the clock. Therefore, nurses have knowledge of the client that other disciplines might not know. 2. The pharmacist will be able to discuss the medication regimen the client is receiving and make suggestions regarding other medications or medication interactions. 3. The social worker may be able to assist with financial information or home care arrangements. TEST-TAKING HINT: Cost containment issues are always a concern the nurse must address. The use of limited resources (health-care personnel) should be on an as-needed basis only. Cost containment must be considered when using other disciplines or supplies.

20. The nurse and an unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? Select all that apply. 1. Keep the head of the bed elevated. 2. Encourage deep breathing exercises. 3. Record pulse oximeter reading. 4. Assess level of conscious. 5. Auscultate breath sounds.

1, 2, 3 Keeping the head of the bed elevated maximizes lung excursion and improves gas exchange and can be delegated. Encouraging breathing exercises can be delegated. Recording pulse oximeter readings can be delegated. Evaluating is the responsibility of the nurse.

31. 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. 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.

1, 2, 3, 4, 5 1. The client diagnosed with COPD has difficulty exchanging oxygen with carbon dioxide, which is manifested by physical signs such as fingernail clubbing and respiratory acidosis as seen on arterial blood gases. 2. The client should avoid extremes in temperatures. Warm temperatures cause an increase in the metabolism and increase the need for oxygen. Cold temperatures cause bronchospasms. 3. The client has increased respiratory effort during activities and can be fatigued. Activities should be timed so rest periods are scheduled to prevent fatigue. 4. The client may have difficulty adapting to the role changes brought about because of the disease process. Many cannot maintain the activities involved in meeting responsibilities at home and at work. Clients should be assessed for these issues. 5. Clients often lose weight because of the effort expended to breathe. TEST-TAKING HINT: This is an example of an alternate-type question. There may be more than one (1) correct answer. The test taker should consider all options independently and understand that the question is not a trick.

50. Which nursing interventions should the nurse implement for the client who has a respiratory disorder? Select all that apply . 1. Administer oxygen via a nasal cannula. 2. Assess the client's lung sounds. 3. Encourage the client to cough and deep breathe. 4. Monitor the client's pulse oximeter reading. 5. Increase the client's fluid intake.

1, 2, 3, 4, 5 A client with a respiratory disorder may have decreased oxygen saturation; therefore, administering oxygen via a nasal cannula is appropriate. The client's lung sounds should be assessed to determine how much air is being exchanged in the lungs. Coughing and deep breathing will help the client expectorate sputum, thus clearing the bronchial tree. The pulse oximeter evaluates how much oxygen is reaching the periphery. Increasing fluids will help thin secretions, making them easier to expectorate.

43. The nurse and a licensed practical nurse (LPN) are caring for five (5) clients on a medical unit. Which clients would the nurse assign to the LPN? Select all that apply. 1. The 32-year-old female diagnosed with exercise-induced asthma who has a forced vital capacity of 1,000 mL. 2. The 45-year-old male with adult-onset asthma who is complaining of difficulty completing all of the ADLs at one time. 3. The 92-year-old client diagnosed with respiratory difficulty who is beginning to be confused and keeps climbing out of bed. 4. The 6-year-old client diagnosed with intrinsic asthma who is scheduled for discharge and the mother needs teaching about the medications. 5. The 20-year-old client diagnosed with asthma who has a pulse oximetry reading of 95% and wants to sleep all the time.

1, 2, 5 1. A forced vital capacity of 1,000 mL is considered normal for most females; therefore, the LPN could care for this client. 2. The client should be encouraged to pace the activities of daily living; this is expected for a client diagnosed with asthma, so the LPN could care for this client. 5. A pulse oximetry level of 95% is normal, so this client could be assigned to an LPN. TEST-TAKING HINT: The nurse cannot assign a licensed practical nurse assessment, teaching, evaluation, or an unstable client.

19. The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. 1. Place the client on oxygen delivered by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1,000 mL/day. 4. Restrict the client's smoking to two (2) to three (3) cigarettes per day. 5. Monitor the client's pulse oximetry readings every four (4) hours.

1, 2, 5 The client diagnosed with pneumonia will have some degree of gas-exchange deficit. Administering oxygen would help the client. Activities of daily living require energy and therefore oxygen consumption. Spacing the activities allows the client to rebuild oxygen reserves between activities. Pulse oximetry readings provide the nurse with an estimate of oxygenation in the periphery. TEST-TAKING HINT: Maslow's hierarchy of needs lists oxygenation as the top priority. Therefore, the test taker should select interventions addressing oxygenation.

80. Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.

1, 3, 4, 5 1. Heparin is administered during throm- bolytic therapy, and the antidote is prot- amine sulfate and should be available to reverse the effects of the anticoagulant. 3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. 4. Invasive procedures increase the risk of tissue trauma and bleeding. 5. Stool softeners help prevent constipa- tion and straining, which may precipitate bleeding from hemorrhoids. TEST-TAKING HINT: Thrombolytic therapy is ordered to help dissolve the clot resulting in the PE. Therefore, all nursing interven- tions should address bleeding tendencies. The test taker must select all interventions applicable in these alternative questions.

34. The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective? 1. A decrease in the white blood cells in the sputum. 2. The client's symptoms are improving. 3. No change in the chest x-ray. 4. The skin test is now negative.

2 As the bacilli are being destroyed, the client should begin to feel better and have fewer symptoms.

92. Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4. The client is able to deep breathe without any pain.

2 At three (3) days postinsertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective. TEST-TAKING HINT: The test taker must be knowledgeable about chest tubes to be able to answer this question. The test taker must know the normal time frame and what is expected for each compartment of the chest tube drainage system.

40. The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client? 1. Daily inhaled corticosteroids. 2. Use of a "rescue inhaler." 3. Use of systemic steroids. 4. Leukotriene agonists.

2 Clients with intermittent asthma will have exacerbations treated with rescue inhalers. Therefore, the nurse should teach the client about rescue inhalers. TEST-TAKING HINT: In the stem, there are two (2) words giving the test taker a clue about the correct answer. "Mild" and "intermittent" are words that indicate the client is not experiencing frequent or escalating symptoms. Steroid medications can have multiple side effects.

17 The 56-year-old client diagnosed with tuberculosis (Tb) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? 1. "I will take my medication for the full three (3) weeks prescribed." 2. "I must stay on the medication for months if I am to get well." 3. "I can be around my friends because I have started taking antibiotics." 4. "I should get a Tb skin test every three (3) months to determine if I am well."

2 Compliance with treatment plans for Tb includes multidrug therapy for six (6) months to one (1) year for the client to be free of the Tb bacteria. TEST-TAKING HINT: The test taker should determine if the time of three (3) weeks in option "1," months in option "2," or immediately in option "3" is the correct time interval.

84. The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first? 1. Administer oxygen 10 L via nasal cannula. 2. Place the client in high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.

2 Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system. TEST-TAKING HINT: The test taker must select the option that will directly help the client breathe easier. Therefore, assess- ment is not the first intervention and option "4" can be eliminated as the correct answer. When the client is in distress, do not assess.

42. The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client? 1. Complete blood count. 2. Pulmonary function test. 3. Allergy skin testing. 4. Drug cortisol level.

2 Pulmonary function test are completed to determine the forced vital capacity (FVC), the forced expiratory capacity in the first second (FEV1), and the peak expiratory flow (PEF). A decline in the FVC, FEV1, and PEF indicates respiratory compromise. TEST-TAKING HINT: If the test taker is unsure about the correct response, it is helpful to choose the option that directly relates to the topic. Asthma is a pulmonary problem, and only one (1) option has the word "pulmonary" in it.

37. The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication? 1. The client's partial thromboplastin time (PTT) is 38. 2. The client's international normalized ratio (INR) is 5. 3. The client's prothrombin time (PT) is 22. 4. The client's erythrocyte sedimentation rate (ESR) is 10.

2 The INR therapeutic range is 2 to 3 for a client receiving warfarin. The INR may be allowed to go to 3.5 if the client has a mechanical cardiac valve, but nothing in the stem of the question indicates this.

88. The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The UAP keeps the chest tube below chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of the bed. 4. The UAP uses a bedside commode for the client.

2 The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the UAP. TEST-TAKING HINT: "Warrants immediate intervention" means the test taker must identify the situation in which the nurse should correct the action, demonstrate a skill, or somehow intervene with the UAP's behavior.

33. The nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement? 1. Praise the UAP since this prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the UAP in front of the client oxygen must be left in place at all times. 4. Discuss the UAP's action with the charge nurse so appropriate action can be taken.

2 The client needs the oxygen, and the nurse should not correct the UAP in front of the client; it is embarrassing for the UAP and the client loses confidence in the staff. TEST-TAKING HINT: The test taker must know management concepts, and the nurse should first address the behavior with the person directly, then follow the chain of command.

95. The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the health care provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

2 The insertion of a chest tube is an invasive procedure and requires informed consent. Without a consent form, this procedure should not be done on an alert and oriented client. TEST-TAKING HINT: The test taker must know invasive procedures require informed consent, and legally it must be obtained first before anyone can touch the client.

75. Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

2 The most common signs of a pulmonary embolism are sudden onset of chest pain when taking a deep breath and shortness of breath. TEST-TAKING HINT: The key to selecting option "2" as the correct answer is sud- den onset. The test taker would need to note "left-sided" in option "3" to elimi- nate this as a possible correct answer, and option "4" is nonspecific for a pulmonary embolism.

27. The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amounts of thick white sputum. 2. Oxygen flowmeter set on eight (8) liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.

2 The nurse should decrease the oxygen rate to two (2) to three (3) liters. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the oxygen level increases, the drive to breathe may be eliminated. TEST-TAKING HINT: This question requires interpreting the data to determine which are abnormal or unexpected and require intervention. Options "1," "3," and "4" are expected for the client's disease process.

46. The client diagnosed with restrictive airway disease (asthma) has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication? 1. Do not abruptly stop taking this medication; it must be tapered off. 2. Immediately rinse the mouth following administration of the drug. 3. Hold the medication in the mouth for 15 seconds before swallowing. 4. Take the medication immediately when an attack starts.

2 The steroids must pass through the oral cavity before reaching the lungs. Allowing the medication to stay within the oral cavity will suppress the normal flora found there, and the client could develop a yeast infection of the mouth (oral candidiasis). TEST-TAKING HINT: Option "3" suggests that an inhaled medication is swallowed; the two (2) terms do not match.

79. The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases. 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

2 These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output. TEST-TAKING HINT: The test taker must think about which answer option addresses the problem of the heart's inability to pump blood. Decreased blood to the extremities results in cyanosis and cold extremities.

20. 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? 1. Suction the client's nares. 2. Turn the client to the side. 3. Place the client in Trendelenburg position. 4. Notify the health-care provider.

2 Turning the client to the side allows for the food to be coughed up and come out of the mouth, rather than be aspirated into the lungs. TEST-TAKING HINT: In a question requiring the test taker to determine the first action, all the answer options may be correct for the situation. The test taker must determine which has the greatest potential for improving the client's condition.

85. The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum and consolidation. 4. Barrel chest and polycythemia.

2 Unequal lung expansion and dyspnea indicate a pneumothorax. TEST-TAKING HINT: The test taker can use "chest trauma" or "pneumothorax" to help select the correct answer. Both of these terms should cause the test taker to select option "2" because unequal chest expansion would result from trauma.

83. The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hang the heparin bag on a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

3 A normal PTT is 39 seconds, and for heparin to be therapeutic, it should be 1.5 to 2 times the normal value, or 58 to 78. A PTT of 98 indicates the client is not clotting and the medication should be held. TEST-TAKING HINT: This question is asking the test taker to select a distracter with assessment data that are unsafe for ad- ministering the medication. The test taker must know normal laboratory values to administer medication safely.

33. The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client? 1. A red area is a positive reading that means the client has tuberculosis. 2. The skin test is the only procedure needed to diagnose tuberculosis. 3. A positive reading means exposure to the tuberculosis bacilli. 4. Do not get another skin test for one (1) year if the skin test is positive.

3 A positive reading indicates the client has been exposed to the bacilli.

21. The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? 1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the lab. 2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. 3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.

3 A pulse oximetry reading of 92% means that the arterial blood oxygen saturation is somewhere around 60% to 70%. TEST-TAKING HINT: Be sure to read all the answer options. Pulse oximetry readings do not give the same information as arte- rial blood gas readings.

78. The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.

3 A therapeutic INR is 2 to 3; therefore, the nurse should administer the medication. TEST-TAKING HINT: The test taker must know normal laboratory values; this is the only way the test taker will be able to answer this question. The test taker should make a list of laboratory values that must be memorized for successful test taking.

24. The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first? 1. Take the client's vital signs. 2. Check the client's pulse oximeter reading. 3. Administer oxygen via a nasal cannula. 4. Notify the respiratory therapist STAT.

3 After elevating the head of the bed, the nurse should administer oxygen to the client who is in respiratory difficulty.

37. 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? 1. Fever and crepitus. 2. Rales and hives. 3. Dyspnea and wheezing. 4. Normal chest shape and eupnea

3 During an asthma attack, the muscles surrounding the bronchioles constrict, causing a narrowing of the bronchioles. The lungs then respond with the production of secretions that further narrow the lumen. The resulting symptoms include wheezing from air passing through the narrow, clogged spaces, and dyspnea. TEST-TAKING HINT: The test taker must have a basic knowledge of common medical terms to answer this question. Dyspnea, wheezing, and rales are common terms used when describing respiratory function and lung sounds. Crepitus and eupnea are not as commonly used, but they are also terms that describe respiratory processes and problems.

2. Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen? 1. "I will take Singulair, a leukotriene, every day to prevent allergic asthma attacks." 2. "I need to use my Intal, cromolyn, inhaler 15 minutes before I begin my exercise." 3. "I need to take oral glucocorticoids every day to prevent my asthma attacks." 4. "If I have an asthma attack, I need to use my Albuterol, a beta2 agonist, inhaler."

3 Glucocorticoids are administered orally or intravenously during acute exacerbations of asthma, not on a daily basis because of the long-term complications of steroid therapy.

18. The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing? 1. The client's first skin test indicates a purple flat area at the site of injection. 2. The client's second skin test indicates a red area measuring four (4) mm. 3. The client's previous skin test was read as positive. 4. The client has never shown a reaction to the tuberculin medication.

3 If the client has ever reacted positively, then the client should have a chest x-ray to look for causation and inflammation. TEST-TAKING HINT: The test taker should note descriptive terms such as "purple," "flat," or "4 mm" before determining the correct answer. Option "4" has the absolute word "never," and absolutes usually indicate incorrect answers.

36. The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced? 1. Myocardial infarction. 2. Pneumonia. 3. Pulmonary embolus. 4. Pneumothorax.

3 Part of the clot in the deep veins of the legs dislodges and travels up the inferior vena cava, lodges in the pulmonary ar- tery, and causes the chest pain; the client often feels as if he or she is going to die.

34. Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD? 1. Clubbing of the client's fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough.

3 Sputum production, along with cough and dyspnea on exertion, are the early signs/symptoms of COPD. TEST-TAKING HINT: The test taker must be observant of terms such as "recently diagnosed," which help to rule out incorrect answers such as option "1." Option "2" has the word "infrequent." The test taker must notice these words.

28. The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care? 1. The client has no signs of respiratory distress. 2. The client shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.

3 The expected outcome should be that the client has tolerance for activity; because the client is not meeting the expected outcome, the plan of care needs revision. TEST-TAKING HINT: This question is an "except" question. Three of the options indicate desired outcomes and only one (1) option indicates the need for improvement.

86. The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.

3 The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compart- ment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop. TEST-TAKING HINT: The test taker should apply the nursing process to answer the question correctly. The first step in the nursing process is assessment, and "check" (option "3") is a word that can be used synonymously for "assess." Monitoring (option "4") is also assessing, but the test taker should not check a diagnostic test result before caring for the client.

76. The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions. 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

3 The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an arterial oxygen level of around 60. TEST-TAKING HINT: This question is asking the test taker to select abnormal, unex- pected, or life-threatening assessment data in relationship to the client's disease process. A pulse oximeter reading of less than 93% indicates severe hypoxia and requires immediate intervention.

90. The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

3 This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life. TEST-TAKING HINT: The test taker must always be clear about what the question is asking before answering the question. If the test taker can eliminate options "1" and "2" and can't decide between options "3" and "4," the test taker must go back to the stem and clarify what the question is asking.

16. The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? 1. Administer the ordered oral antibiotic STAT. 2. Order the meal tray to be delivered as soon as possible. 3. Obtain a sputum specimen for culture and sensitivity. 4. Have the unlicensed assistive personnel weigh the client.

3 To determine the antibiotic that will effectively treat an infection, specimens for culture are taken prior to beginning the medication. Administering antibi- otics prior to cultures may make it impossible to determine the actual agent causing the pneumonia. TEST-TAKING HINT: Option "1" has a medication classification and a route, and the test taker should question if the route is appropriate for the client being admitted. Clients will not die from a delayed meal, but a client could die from delayed IV antibiotic therapy.

45. The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching? 1. Take two (2) puffs on the rescue inhaler and wait five (5) minutes before exercise. 2. Warm-up exercises will increase the potential for developing the asthma attacks. 3. Use the bronchodilator inhaler immediately prior to beginning to exercise. 4. Increase dietary intake of food high in monosodium glutamate (MSG).

3 Using a bronchodilator immediately prior to exercising will help reduce bronchospasms. TEST-TAKING HINT: Option "1" has two words that are opposed—"rescue" and "wait"—which might lead the test taker to eliminate this option. Remember basic concepts, which are contradicted in option "2." There are a few disease processes that encourage intake of sodium, but asthma is not one of them, which would cause option "4" to be eliminated.

94. The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the licensed practical nurse (LPN)? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hb of 9 g/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.

4 A client two (2) hours post- bronchoscopy procedure could safely be assigned to an LPN. TEST-TAKING HINT: The test taker must understand that the LPN should be assigned the least critical client or the client who is stable and not exhibiting any complications secondary to the admitting disease or condition.

47. Which intervention should the nurse implement first when caring for a client with a respiratory disorder? 1. Administer a respiratory treatment. 2. Check the client's radial pulses daily. 3. Monitor the client's vital signs daily. 4. Assess the client's capillary refill time.

4 Assessing the client's capillary refill time has the highest priority for the nurse because it indicates the oxygenation of the client.

3. Which intervention should the emergency department nurse implement first for the client admitted for an acute asthma attack? 1. Administer glucocorticoids intravenously. 2. Administer oxygen 5 L per nasal cannula. 3. Establish and maintain a 20-gauge saline lock. 4. Assess breath sounds every 15 minutes.

4 Assessment is the first step of the nursing process but in distress do not assess.

77. The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bedrest.

4 Bedrest reduces the risk of another clot becoming an embolus leading to a pulmonary embolus. Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs. TEST-TAKING HINT: The test taker must be aware of adjectives such as "oral" in option "1," which makes this option incorrect. The test taker should apply the body system of the disease process to eliminate option "2" as a correct answer.

14. 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? 1. Performs chest physiotherapy three (3) times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall several times during each shift. 4. Alert and oriented to person, place, time, and events.

4 Impaired gas exchange results in hypoxia, the earliest sign/symptom of which is a change in the level of consciousness. TEST-TAKING HINT: The test taker should match the answer option to the listed nursing problem. Option "1" is a staff goal to accomplish. When writing goals for the client, it is important to remember they are written in terms of what is expected of the client. Options "2" and "3" are appropriately written client goals, but they do not evaluate gas exchange.

41. Which statement indicates to the nurse the client diagnosed with asthma understands the teaching regarding mast cell stabilizer medications? 1. "I should take two (2) puffs when I begin to have an asthma attack." 2. "I must taper off the medications and not stop taking them abruptly." 3. "These drugs will be most effective if taken at bedtime." 4. "These drugs are not good at the time of an attack."

4 Mast cell drugs are routine maintenance medications and do not treat an attack. TEST-TAKING HINT: The test taker must be knowledgeable about medications. There are not many test-taking hints. If the test taker knows that a specific option applies to a medication other than the one (1) mentioned in the stem, the test taker can eliminate that option.

29. The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? 1. The client's pulse oximeter reading is 92%. 2. The client's arterial blood gas level is 74. 3. The client has SOB when walking to the bathroom. 4. The client's sputum is rusty colored.

4 Rusty-colored sputum indicates blood in the sputum and requires further assessment by the nurse. TEST-TAKING HINT: The test taker could rule out options "1" and "2" as correct answers because both describe the same data of decreased oxygen, which is characteristic of COPD.

89. The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

4 Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation. TEST-TAKING HINT: The words "implement first" in the stem of the question indicate to the test taker that possibly more than one (1) intervention could be warranted in the situation but only one (1) is implemented first. Remember, do not select assessment first without reading the question. If the client is in any type of crisis, then the nurse should first do something to help the client's situation.

81. Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a Medic Alert band at all times."

4 The client should wear a Medic Alert band at all times so that, if any accident or situation occurs, the health-care providers will know the client is receiving anticoagulant therapy. The client understands the teaching. TEST-TAKING HINT: This is a higher level question in which the test taker must know clients with a pulmonary embolus are prescribed anticoagulant therapy on discharge from the hospital. If the test taker had no idea of the answer, the op- tion stating "wear a Medic Alert band" is a good choice because many disease processes require the client to take long- term medication and a health-care provider should be aware of this.

25. The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain? 1. Number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medication. 4. Willingness to modify lifestyle.

4 The client's attitude toward lifestyle changes is the most important consideration in health promotion, in this case smoking cessation. The nurse should assess if the client is willing to consider cessation of smoking and carry out the plan. TEST-TAKING HINT: The test taker should read the stem for words such as "health promotion." These words make all the other answer options incorrect because they do not promote health.

46. The public health department nurse is caring for the client diagnosed with active tuberculosis who has been placed on directly observed therapy (DOT). Which statement best describes this therapy? 1. The nurse accounts for all medications administered to the client. 2. The nurse must complete federal, state, and local forms for this client. 3. The nurse must report the client to the Centers for Disease Control. 4. The nurse must watch the client take the medication daily.

4 To ensure the compliance with all medications regimens, the health department has adapted a directly observed therapy (DOT) where the nurse actually observes the client taking the medication every day.

22. The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement? 1. Standard Precautions. 2. Contact Precautions. 3. Droplet Precautions. 4. Airborne Precautions.

4 Tuberculosis bacteria are capable of disseminating over long distances on air currents. Clients with tuberculosis are placed in negative air pressure rooms where the air in the room is not allowed to cross-contaminate the air in the hallway. TEST-TAKING HINT: Standard Precautions and Contact Precautions can be ruled out as the correct answer if the test taker is aware that Tb is usually a respiratory illness. This at least gives the reader a 1:2 chance of selecting the correct answer if the answer is not known.

23. The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement? 1. Assess respiratory rate and depth. 2. Provide for adequate rest period. 3. Administer oxygen as prescribed. 4. Teach slow abdominal breathing.

1 The assessment of respiratory rate and depth is the priority intervention because tachypnea and dyspnea may be early indicators of respiratory compromise.

47. The nurse is discussing the care of a child diagnosed with asthma with the parent. Which referral is important to include in the teaching? 1. Referral to a dietitian. 2. Referral for allergy testing. 3. Referral to the developmental psychologist. 4. Referral to a home health nurse.

2 Because asthma can be a reaction to an allergen, it is important to determine which substances may trigger an attack. TEST-TAKING HINT: The test taker must be aware of the disease process, determine causes, and then make a decision based on interventions required.

93. The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

2, 4, 5 The system must be patent and intact to function properly. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and a potential clogging of the tube. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site. TEST-TAKING HINT: The test taker should be careful with adjectives. In option "1," the word "low" makes it incorrect; in option "3," the word "strict" makes this option incorrect.

73. The client is diagnosed with a pulmonary embolus and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour? ________

880 units. If there are 20,000 units of heparin in 500 mL of D5W, there are 40 units in each mL: 20,000 ÷ 500 = 40 units If 22 mL are infused per hour, then 880 units of heparin are infused each hour: 40 × 22 = 880

38. The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.

2 The nurse should implement the least invasive intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle.