NRS 230 - TEST 6

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? (Select all that apply.) A. Dizziness and fainting B. Shortness of breath (SOB) worsening over the last 2 weeks C. Inspiratory chest pain D. Productive cough E. Pink, frothy sputum

A. Dizziness and fainting C. Inspiratory chest pain Syncope, hypotension, and fainting are symptoms associated with PE. Sharp, pleuritic, inspiratory chest pain is also characteristic of PE. Sudden, not gradual, SOB occurs with PE. Productive cough is associated with infection; PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema; PE may cause hemoptysis.

During nasotracheal suctioning, the client's heart rate changes from 78 beats/min to 48 beats/min. What is the nurse's best first action? A. Immediately stop suctioning. B. Gently pinch the client's cheek. C. Administer oxygen by mask at 2 L/min. D. Document the change as the only action.

A. Immediately stop suctioning. Rationale: The change in heart rate is a serious response to suctioning. The client is experiencing vagal stimulation and bradycardia from the presence of the suction catheter in the tracheopharyngeal area. Such stimulation can lead to severe hypotension, heart block, and asystole. Administering oxygen would be a good second action but the first action is to stop the activity causing the problem. The client's response is not related to a lack of being alert.

A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? A. "But you know you need this to breathe, right?" B. "Do you have a scarf or a large loose collar that you could place over it?" C. "Your family and friends probably won't even care." D. "It won't take you long to learn to manage."

B. "Do you have a scarf or a large loose collar that you could place over it?" Suggesting strategies to cover the tracheostomy recognizes client concerns and explores options for dealing with the effects of the procedure. Reiterating the reason for the tracheostomy, suggesting that the client's loved ones won't care, and telling the client that he or she will learn to live with the tracheostomy are insensitive responses and minimize the client's concerns.

A ventilated client in the intensive care unit (ICU) begins to pick at the bedcovers. Which action should the nurse take next? A. Increase the sedation. B. Assess for adequate oxygenation. C. Explain to the client that he has a tube in his throat to help him breathe. D. Request that the family leave to decrease the client's agitation.

B. Assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia. Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease the chances of "ICU psychosis" and anxiety, but it does not take priority over assessing for hypoxemia.

The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation? A. Oropharyngeal airway B. Bi-level positive airway pressure (BiPAP) C. Non-rebreather mask with 100% oxygen D. Positive end-expiratory pressure (PEEP)

B. Bi-level positive airway pressure (BiPAP) BiPAP ventilation is a noninvasive method that may provide short-term ventilation without intubation. An oropharyngeal airway is used to prevent the tongue from occluding the airway or the client from biting the endotracheal tube. A non-rebreather mask will assist with oxygenation; however, muscle fatigue and hypoventilation may occur as causes of respiratory failure. The need for PEEP indicates a severe gas-exchange problem; this modality is "dialed in" on the mechanical ventilator.

A client was intubated 30 minutes ago for acute respiratory distress syndrome and possible sepsis. The following orders have been given for the client. In what sequence would the nurse perform these orders for this client? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze postintubation arterial blood gases (ABGs). A. 2, 1, 3, 4 B. 4, 3, 1, 2 C. 3, 4, 2, 1 D. 4, 2, 1, 3

D. 4, 2, 1, 3 ABGs should be analyzed first before the other assessments/actions are carried out. A baseline of sputum cultures should then be obtained before medications are administered. Then levofloxacin can be given. Client and family education on communication methods is important, but is the lowest priority here.

Which precaution is most important for the nurse to teach a client who has cystic fibrosis? A. Report a weight change of 2 pounds to your health care provider immediately. B. Use supplemental oxygen whenever your oxygen saturation is less than 95%. C. Eat six small meals each day instead of only three larger ones. D. Avoid crowds and people who are ill.

D. Avoid crowds and people who are ill. Rationale: The most common cause of death for a client with CF is respiratory failure from a respiratory infection. Avoiding infection in this population is critical for survival. Although many clients who have CF are underweight and need to maintain good nutrition, changes in weight and food intake patterns are not as critical as avoiding infection. Supplemental oxygen use is based on client manifestations. Its use is not as critical as avoiding infection.

Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours alerts the nurse to the possibility of oxygen toxicity? A. Oxygen saturation greater than 100% B. Decreased rate and depth of respiration C. Wheezing on inhalation and exhalation D. Discomfort or pain under the sternum

D. Discomfort or pain under the sternum Rationale: Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. Initial manifestations include dyspnea, nonproductive cough, chest pain beneath the sternum, and gastrointestinal upset. Oxygen saturation falls, not increases. Breathing becomes more rapid with the sensation of dyspnea. Wheezing represents airway obstruction, not damage to the alveolar membrane.

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? A. Homeless people B. Hospital staff C. Politicians D. Prison staff and inmates

D. Prison staff and inmates High-risk groups for respiratory infection include those who live in crowded areas such as long-term care facilities, prisons, and mental health facilities. Although homeless people are a high priority, they are not the group at greatest risk of those listed. Education could be provided in shelters or during outreach activities. Hospital staff are at risk owing to their contact with ill clients and family members; however, they are already aware of how to prevent respiratory infection. Politicians are not at higher risk for respiratory infection than any other group with public exposure.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? A. Ensures that the client is wearing a mask B. Tells the visitor that the client cannot receive visitors at this time C. Provides a particulate air respirator to the visitor D. Provides a mask to the visitor

D. Provides a mask to the visitor Because the visitor is entering the client's isolation environment, the visitor must wear a mask. The client typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator.

What does the nurse do first when setting up a safe environment for the new client on oxygen? A. Ensures that staff members wear protective clothing B. Ensures that no combustion hazards are present in the room C. Sets the oxygen delivery to maintain no fewer than 16 breaths/min D. Uses a pulse oximetry unit

B. Ensures that no combustion hazards are present in the room Oxygen is highly flammable. The nurse must ensure that no open flames or combustion hazards are present in a room where oxygen is in use. Protective clothing is not necessary for a client who requires oxygen therapy other than the use of Standard Precautions. The oxygen delivery setting is usually determined in conjunction with the respiratory therapy care partner. Although the setting is important for safe administration, it is not necessary for a safe environment. Pulse oximetry would be useful for monitoring the client's oxygenation status, but is not necessary for a safe environment.

Which symptom of pneumonia may present differently in the older adult than in the younger adult? A. Crackles on auscultation B. Fever C. Headache D. Wheezing

B. Fever Older adults may not have fever and may have a lower-than-normal temperature with pneumonia. Crackles on auscultation may be present in all age groups as the result of fluid in the lungs. All age ranges may have a headache with pneumonia. Wheezing is an indication of narrowed airways and can be found in all age groups.

A client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? A. Teach the client to avoid using dental floss. B. Monitor the platelet count daily. C. Ensure adequate staffing for the unit. D. Notify radiology of an impending scan.

B. Monitor the platelet count daily. Daily platelet counts are a safety priority in assessing for thrombocytopenia; heparin-induced thrombocytopenia is a possible side effect. Avoiding the use of dental floss is important during anticoagulation therapy, but it is not the priority. Adequate staffing and notifying radiology are not the priority.

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? A. Complete the referral form for a home health agency. B. Suction the tracheostomy using sterile technique. C. Teach the client and spouse about tracheostomy care. D. Consult with the health care provider about using a fenestrated tube.

B. Suction the tracheostomy using sterile technique. Complex sterile procedures are within the education and scope of practice of the experienced LPN/LVN. Completion of client referral forms, client and family teaching, and consulting with the health care provider are all actions that must be performed by an RN.

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions? A. "Asthma drugs help everybody breathe better." B. "I must carry my emergency inhaler only when activity is anticipated." C. "I must have my emergency inhaler with me at all times." D. "Preventive drugs can stop an attack."

C. "I must have my emergency inhaler with me at all times." Because asthma attacks cannot always be predicted, clients with asthma must always carry a rescue inhaler such as a short-acting beta agonist (e.g., albuterol [Proventil]). Asthma medications are specific to the disease and should never be shared or used by anyone other than the person for whom they are prescribed. An emergency inhaler should be carried when activity is anticipated, as well as at other times. Preventive drugs are those that are taken every day to help prevent an attack from occurring. They are not able to stop an attack once it begins.

The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate? A. "Sedation is needed so your loved one does not rip the breathing tube out." B. "Suctioning is important to remove organisms from the lower airway." C. "Paralysis and sedatives help decrease the demand for oxygen." D. "We are encouraging oral and IV fluids to keep your loved one hydrated."

C. "Paralysis and sedatives help decrease the demand for oxygen." Paralytics and sedation decrease oxygen demand. Sedation is needed more for its effects on oxygenation than to prevent the client from ripping out the endotracheal tube. Suctioning is performed to maintain airway patency. Minimizing fluids while administering diuretics leads to better outcomes.

For which activity does the nurse teach the client who is receiving oxygen by a transtracheal oxygen (TTO) delivery system to switch to a nasal cannula oxygen delivery system? A. Eating a meal B. Sleeping at night C. Cleaning the catheter D. Performing mouth care

C. Cleaning the catheter Rationale: A TTO delivery system involves passing a catheter into the trachea through a small incision with the patient under local anesthesia, delivering oxygen directly to the lungs. Thus, the mouth is not involved, and this delivery is not disrupted by eating, drinking, or performing oral care. If the catheter is properly attached to the client, it is no more likely to become dislodged during sleep than is a nasal cannula. To maintain adequate gas exchange and oxygenation, the client should receive supplemental oxygen through a nasal cannula delivery system whenever the transtracheal catheter is not in place for any reason, such as when cleaning it.

Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)? A. Client with diabetic ketoacidosis (DKA) B. Client with atrial fibrillation C. Client with aspiration pneumonia D. Client with acute kidney failure

C. Client with aspiration pneumonia Aspiration of acidic gastric contents is a risk for ARDS. Clients with DKA may develop metabolic acidosis, but not ARDS, which develops in lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? A. Inadequate nutrition related to food-drug interactions and anticoagulant therapy B. Potential for infection related to leukocytosis C. Hypoxemia related to ventilation-perfusion mismatch D. Insufficient knowledge related to the cause of PE

C. Hypoxemia related to ventilation-perfusion mismatch Restoring adequate oxygenation and tissue perfusion takes priority when a client presents with a PE. Although nutrition must be addressed, priorities include airway, breathing, and circulation. The client has a leukocytosis related to lung inflammation; leukopenia places clients at risk for infection, but this is not the priority at this time. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability occur.

A client has just arrived in the postanesthesia care unit following a successful tracheostomy procedure. Which nursing action must be taken first? A. Suction as needed. B. Clean the tracheostomy inner cannula and stoma. C. Listen to lung sounds. D. Change the tracheostomy dressing as needed.

C. Listen to lung sounds. The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs. Suction is not needed if the lungs are clear to auscultation. Although cleanliness is a priority, the nurse must assess the client's respiratory status before cleaning or performing a dressing change.

The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action should the nurse take first? A. Check the ventilator alarm settings. B. Assess the set tidal volume. C. Listen to the client's breath sounds. D. Call the respiratory therapist.

C. Listen to the client's breath sounds. A typical reason for the high-pressure alarm to sound is the need for suctioning or tension pneumothorax. The nurse should begin the assessment with the client, not with the ventilator. Although an excessively high tidal volume could contribute to sounding of the high-pressure alarm, assessment always begins with the client. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

A client with chronic obstructive pulmonary disease (COPD) prescribed a long-acting inhaled beta2 agonist reports hating the inhaler and asks why the drug can't be taken as a pill. What is the nurse's best response? A. "Drugs taken by inhaler work more slowly and remain in the system longer." B. "Drugs taken by inhaler have no side effects and are less expensive." C. "Drugs taken by mouth are more expensive because they must be sterile." D. "Drugs taken by mouth have systemic side effects and are harder to control."

D. "Drugs taken by mouth have systemic side effects and are harder to control." Rationale: When used as prescribed, inhaler drugs go more to the site where the intended responses are needed (the airways), and less drug is absorbed systemically. Thus, inhaled drugs have fewer side effects (but still have side effects). Oral drugs always have systemic side effects.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about the disease? A. "I am here to receive the yearly pneumonia shot again." B. "I am here to get my yearly flu shot again." C. "I should avoid large gatherings during cold and flu season." D. "I should cough into my upper sleeve instead of my hand."

A. "I am here to receive the yearly pneumonia shot again." Clients 65 years and older, as well as those who have chronic health problems, should be encouraged to receive the pneumonia vaccine, which is not given annually but only once. Older clients are encouraged to receive a flu shot annually because the vaccine changes, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. New recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? A. "I can only take baths, but no showers." B. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." C. "I should put cotton or foam over the tracheostomy hole." D. "I will have to learn to suction myself."

A. "I can only take baths, but no showers." The client does not understand that he or she can shower with the use of a shower shield over the tracheostomy tube to prevent water from entering the airway. Additional teaching is necessary. Normal saline should be instilled into the artificial airway 10 to 15 times a day, as prescribed. The stoma should be covered with cotton or foam to protect it during the day; this filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. Clients with tracheostomies should be taught clean suction technique.

Which client has the highest risk for developing a pulmonary embolism (PE)? A. A 25-year-old woman who frequently flies to different countries B. A 67-year-old man who works on a farm C. A 45-year-old man admitted for a heart attack D. A 23-year-old woman with a bleeding disorder

A. A 25-year-old woman who frequently flies to different countries People who engage in prolonged and frequent air travel are at higher risk for PE. A 67-year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs; if on prolonged bedrest, the client's risk is increased. PE is a clotting disorder, not a bleeding disorder.

While assessing a client who has been receiving heparin intravenously for the past 3 days, the nurse notes the IV pump is set at twice the required setting. What orders does the nurse anticipate from the prescriber? Select all that apply. A. Activated partial thromboplastin time B. International normalized ratio C. Prothrombin time D. Vitamin K E. Protamine sulfate

A. Activated partial thromboplastin time E. Protamine sulfate Rationale: The client has been receiving an excessive dose of heparin. The activated partial thromboplastin time will help assess this client's degree of bleeding risk. Depending on the results of this test, the client may need a heparin antidote, which is protamine sulfate.

A client has just been admitted to the intensive care unit after having a left lower lobectomy with a video-assisted thoracoscopic surgery. Which of these requests will the nurse implement first? A. Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. B. Administer 2 g of cephalothin (Keflin) IV now. C. Give morphine sulfate 4 to 6 mg IV for pain. D. Infuse 1 unit of packed red blood cells (PRBCs) over the next 2 hours.

A. Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. Airway and oxygenation are main priorities in the immediate postoperative period. The client will likely be intubated, so coordination of care with respiratory therapy will be important. Although antibiotic therapy may be ordered, this is not a priority at this time. Pain management in the postoperative period is important; a minimally invasive technique will be less painful than an open technique, but is still painful. Pain management is not the first priority, however. PRBCs may or may not need to be infused to maintain the oxygen-carrying capacity of the blood. Less blood is lost during minimally invasive techniques than during open surgical procedures.

A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? A. Adjust the position of the oxygen tubing. B. Assess for signs and symptoms of hypoventilation. C. Change the O2 flow rate to keep SpO2 as prescribed. D. Choose which O2 delivery device should be used for the client.

A. Adjust the position of the oxygen tubing. The scope of a nursing assistant's work includes positioning of oxygen tubing for client comfort. Assessing for signs and symptoms of hypoventilation, choosing which O2 delivery device to use, and changing the O2 flow rate are actions that are beyond the scope of practice for unlicensed personnel.

A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first? A. Albuterol (Proventil) 2 inhalations B. Fluticasone (Flovent) 2 inhalations C. Ipratropium (Atrovent) 2 inhalations D. Salmeterol (Serevent) 2 inhalations

A. Albuterol (Proventil) 2 inhalations Albuterol is a beta2 agonist that acts rapidly as a bronchodilator. Fluticasone is a corticosteroid; it is used to prevent asthma attacks and is not used as a rescue medication. Ipratropium is an anticholinergic drug that allows the sympathetic system to dominate and cause bronchodilation; it is not as effective as a beta2 agonist, so it is not a first-line drug. Salmeterol is a long-acting beta2 agonist that must be used regularly over time; this client needs a rescue medication.

Which client has the most urgent need for frequent nursing assessment? A. An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year, 2-pack-per-day smoking history and is receiving 50% oxygen through a Venturi mask B. A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 at percentages in the upper 90s, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties C. An older adult client who is eager to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy D. A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

A. An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year, 2-pack-per-day smoking history and is receiving 50% oxygen through a Venturi mask The older adult with a long history of smoking and chronic lung disease is at elevated risk for respiratory depression owing to the hypoxic drive of respirations countered by high levels of oxygen; this client must be assessed frequently while receiving high-flow oxygen. The young client with no signs or symptoms of respiratory compromise, and the client who meets discharge criteria, do not require frequent assessment. Although the middle-aged client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the older client on higher-flow oxygen is at greater risk for respiratory demise and therefore needs frequent assessment more urgently.

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment? A. Arrange for a health care worker to watch the client take the medication. B. Give the client written instructions about how to take prescribed medications. C. Have the client repeat medication names and side effects. D. Instruct the client about the possible consequences of nonadherence.

A. Arrange for a health care worker to watch the client take the medication. Because this client is unlikely to adhere to long-term treatment unless directly supervised while taking medications, the best option is to arrange for directly observed therapy. Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. Also, the question does not indicate whether the client can read. The fact that the client can state the names and side effects of medications does not mean that the client understands what the medications are and why he or she needs to take them. A client who is homeless may be more concerned with obtaining shelter and food than with properly taking his or her medication.

After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first? A. Assess the airway, breathing, and circulation. B. Call for the Rapid Response Team. C. Check the patency of the chest tubes. D Listen for breath sounds.

A. Assess the airway, breathing, and circulation. Assessing the "ABCs" is the priority to determine possible causes of burning in the client's chest. The client's situation does not require the Rapid Response Team to be called. The client's symptoms are not caused by a blockage of chest tubes. Listening for breath sounds would be an appropriate action for the nurse to take to evaluate the client's reported symptoms; however, this would not be the nurse's first action.

The peak pressure alarm is sounding on the ventilator of a client with a recent tracheostomy. What intervention should be done first? A. Assess the client's respiratory status. B. Decrease the sensitivity of the alarm. C. Ensure that the connecting tubing is not kinked. D. Suction the client.

A. Assess the client's respiratory status. The client must always be assessed before attention is turned to equipment. If the alarm is sounding as an indicator of worsening client condition, reducing the sensitivity is harmful. Suctioning the client may not even be needed; the client's respiratory status must be assessed before such a determination can be reached.

Because clients with cystic fibrosis (CF) are at increased risk for infection, what will the nurse advise the client with CF who is infected with Burkholderia cepacia to do? A. Avoid Cystic Fibrosis Foundation-sponsored events. B. Avoid the hospital. C. Stay at home most of the time. D. Use an antiseptic hand gel.

A. Avoid Cystic Fibrosis Foundation-sponsored events. A serious bacterial infection for clients with CF is Burkholderia cepacia, which is spread by casual contact from one CF client to another. For this reason, the Cystic Fibrosis Foundation bans infected clients (those who have had a positive sputum culture) from participating in any foundation-sponsored events. Avoiding the hospital completely is unrealistic, although special infection control procedures may be implemented, such as scheduling the client's office visits on different days or in different areas of the hospital. Social isolation is not needed for clients with CF and may be detrimental to the psychosocial well-being of the client. Hand hygiene is important, although this is not the best response.

Which assessment finding is associated with obstructive lung disease and not with interstitial lung disease? A. Barrel chest B. Cough C. Dyspnea D. Reduced gas exchange

A. Barrel chest Interstitial lung diseases are restrictive, not obstructive, so they do not cause barrel chest, which is the result of air trapping. Both types of pulmonary disease cause cough, dyspnea, and reduced gas exchange.

While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do? A. Calmly continues talking B. Checks the tube for blocks or kinks C. Immediately calls the health care provider D. Strips the chest tube

A. Calmly continues talking Gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. Any bubbling that is occurring would stop if a kink or a blockage is present in the chest tube. The chest tube is functioning normally; there is no need to notify the health care provider. "Stripping the chest tube" greatly increases pressure inside the chest and could potentially damage lung tissue; any excessive manipulation should be avoided.

An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? A. Check the resident's oxygen saturation. B. Do a complete neurologic assessment. C. Give the prescribed PRN lorazepam (Ativan). D. Notify the resident's primary care provider.

A. Check the resident's oxygen saturation. A common reason for sudden confusion in older clients is hypoxemia caused by undiagnosed pneumonia. The nurse's first action should be to assess oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation; this will take several minutes to complete. Administering lorazepam may make the client more confused and agitated because antianxiety drugs may cause a paradoxical reaction, or opposite effect, in some older clients. Depending on the results of the client's pulse oximetry and neurologic examination, notifying the primary care provider may be an appropriate next step.

The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure? (Select all that apply.) A. Client with a brainstem tumor B. Client with acute pancreatitis C. Client with a T3 spinal cord injury D. Client using patient-controlled analgesia E. Client experiencing cocaine intoxication

A. Client with a brainstem tumor B. Client with acute pancreatitis C. Client with a T3 spinal cord injury D. Client using patient-controlled analgesia Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect intercostal muscles are affected. Opiates, which can depress the brainstem, present risk factors for respiratory failure. All of these clients should be monitored closely for respiratory failure. Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

The medical-surgical unit nurse should call the Rapid Response Team to assess which client? A. Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis B. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain C. Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94% D. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs

A. Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis The client with a diagnosed pulmonary embolism is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin; this indicates a significant decline in status and warrants activation of the Rapid Response Team. The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment; calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but has normal oxygen saturation. The client who was extubated 3 days ago requires ongoing monitoring or nursing intervention, but does not have evidence of acute deterioration or severe complications.

All of these clients are being cared for on the intensive care stepdown unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit? A. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. B. Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour. C. Client with emphysema who requires instruction about correct use of oxygen at home. D. Client with lung cancer who has just been transferred from the intensive care unit after having a left lower lobectomy the previous day.

A. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis. Although chronic pleural effusions can occur in the pediatric population, this diagnosis is more common in the adult population. If this client has not already received teaching for this procedure, he or she may have questions that the pediatric nurse would not be as comfortable answering as a nurse who is regularly assigned to the stepdown unit. Emphysema is a diagnosis associated with an adult population; although an RN could instruct a client about home oxygen therapy, this client might have questions that would be better answered by an RN with adult experience. The adult client who has just had a lobectomy needs careful assessment from an RN with adult stepdown unit experience.

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? (Select all that apply.) A. Combination drug therapy is effective in preventing transmission. B. Combination drug therapy is the most effective method of treating TB. C. Combination drug therapy will decrease the length of required treatment to 2 months. D. Multiple drug regimens destroy organisms as quickly as possible. E. The use of multiple drugs reduces the emergence of drug-resistant organisms.

A. Combination drug therapy is effective in preventing transmission. B. Combination drug therapy is the most effective method of treating TB. D. Multiple drug regimens destroy organisms as quickly as possible. E. The use of multiple drugs reduces the emergence of drug-resistant organisms. Combination drug therapy is the most effective method for treating TB and preventing transmission. Multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Although combination drug therapy will decrease the required length of time for treatment, the length of treatment is decreased to 6 months from 6 to 12 months.

Which intervention for a client in the intensive care unit (ICU) will decrease the incidence of "ICU psychosis?" A. Decreasing nighttime disruptions B. Keeping the lights on to promote orientation C. Administering sedation D. Providing television or radio for stimulation

A. Decreasing nighttime disruptions ICU psychosis can be minimized not only by encouraging sleep, but also by keeping to a regular routine. Keeping the lights on or providing TV or radio will not encourage sleep. Sedation can promote confusion and disorientation.

A "do not resuscitate" (DNR) client has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? A. Ensure that the tubing is patent and that oxygen flow is high. B. Notify the chaplain and the family member of record. C. Call the Rapid Response Team and prepare to intubate. D. Comfort the client and confirm that signed DNR orders are in the chart.

A. Ensure that the tubing is patent and that oxygen flow is high. Labored breathing and ultimately suffocation can occur if the reservoir bag on a non-rebreather mask kinks, or if the oxygen source disconnects or is not set to high flow levels. The chaplain and the family member of record should not be notified, because death is not imminent at this time. Equipment malfunction must be ruled out before intubation of the client is performed. Additionally, the client may not want to be intubated, as indicated in the DNR orders. Troubleshooting and reversal of nonresuscitative equipment is the standard of care; DNR does not mean "do not treat."

A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? A. Ethambutol B. Isoniazid C. Pyrazinamide D. Rifampin

A. Ethambutol Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Both isoniazid and pyrazinamide may cause liver failure; side effects of major concern include jaundice, bleeding, and abdominal pain. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless. Contact lenses will also be stained and oral contraceptives will be less effective.

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially? A. Face tent B. Venturi mask C. Nasal cannula D. Non-rebreather mask

A. Face tent A client with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a non-rebreather mask are high-flow oxygen delivery devices, they require snug fitting on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? A. Hyperoxygenate before and after suctioning. B. Repeat suctioning until the tube is clear. C. Apply suction during insertion of the tube. D. Suction for 30 seconds.

A. Hyperoxygenate before and after suctioning. The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1 to 5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits. Repeat suctioning as needed for up to three total suction passes; additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult/traumatic. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; never suction longer than 10 to 15 seconds.

A client has been admitted to the hospital with suspected TB. What drugs should the nurse plan to teach the client about before discharge? Select all that apply. A. Rifampin (Rifadin); contact lenses can become stained orange B. Isoniazid (INH); report yellowing of the skin or darkened urine C. Pyrazinamide (PZA); maintain a fluid restriction of 1200 mL/day D. Ethambutol (Myambutol); report any changes in vision E. Amoxicillin (Amoxil); take this drug with food or milk

A. Rifampin (Rifadin); contact lenses can become stained orange B. Isoniazid (INH); report yellowing of the skin or darkened urine D. Ethambutol (Myambutol); report any changes in vision Rationale: Amoxicillin is not prescribed for TB. Pyrazinamide, although prescribed for TB, calls for an increase in fluids, not fluid restriction. Rifampin, isoniazid, and ethambutol are first-line drugs for TB therapy and have side effects. The side effects listed with these drugs are appropriate to teach the client.

A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed tuberculosis (TB). Which medications does the nurse expect to be ordered for the client? A. Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) B. Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) C. Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Zinamide) D. Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)

A. Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) The combination of isoniazid, rifampin, pyrazinamide, and ethambutol is used to treat TB. Metronidazole is used to treat anaerobic bacteria and some parasites, but is not effective against TB. Acyclovir is used to treat viral infection. Flunisolide is a corticosteroid that is useful in asthma or other airway disease to prevent wheezing. Prednisone is a steroid. Guaifenesin is a mucolytic. Ketorolac is a nonsteroidal anti-inflammatory drug that is used for short-term pain relief. Salmeterol and cromolyn sodium would most likely be given to clients with respiratory difficulties such as poorly controlled asthma from allergic sources. Dexamethasone is a steroid.

All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)? A. Keep the head of the bed elevated. B. Teach about incentive spirometer use. C. Monitor vital signs every 5 minutes. D. Adjust the nasal oxygen flow rate.

A. Keep the head of the bed elevated. Positioning of clients is included in UAP education and scope of practice and can be delegated. Client teaching is an activity performed by the professional nurse. Although taking vital signs is an activity of the UAP, monitoring a potentially unstable client is done by the professional nurse. Adjusting oxygen flow rates requires complex decision making and should be done by the RN.

A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? (Select all that apply.) A. Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B. The medications may cause nausea. The client should take them at bedtime. C. The client is generally not contagious after 2 to 3 consecutive weeks of treatment. D. These medications must be taken for 2 years. E. These medications may cause kidney failure.

A. Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B. The medications may cause nausea. The client should take them at bedtime. Not taking the medication as prescribed could lead to an infection that is difficult to treat or to total drug resistance. The medications may cause nausea and are best taken at bedtime to prevent this. The client is generally not contagious after 2 to 3 weeks of consecutive treatment and improvement in the condition has been observed. The combination regimen for treatment of TB has decreased treatment time from 6 to 12 months to 6 months. TB medications may cause liver failure, not kidney failure.

The nurse caring for a client who is intubated and receiving mechanical ventilation notes that her oxygen saturation is 89%, her heart rate is 120 beats/min, and she is increasingly agitated and restless. On auscultation, the nurse finds the lung sounds are diminished on one side. Which action does the nurse perform first? A. Notify the provider and prepare for re-intubation or repositioning the tube. B. Document the findings and request sedation from the provider. C. Call respiratory therapy to obtain a set of arterial blood gasses. D. Reposition the tube, and call radiology for a stat chest x-ray.

A. Notify the provider and prepare for re-intubation or repositioning the tube. Rationale: With the decreased oxygen saturation and decreased breath sounds on one side, the endotracheal tube is incorrectly positioned into one bronchus. For effective gas exchange, the tube must be repositioned, which is a health care provider function, not a nursing function.

Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)? A. Remain with the client and provide oxygen in a calm manner. B. Have the client breathe into a brown paper bag using pursed lips. C. Offer the client a mild sedative. D. Allow a family member to remain in the room.

A. Remain with the client and provide oxygen in a calm manner. The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen; remaining with the client in distress is appropriate. Rebreathing from a brown paper bag is an intervention that increases PaCO2 during hyperventilation, as in a panic attack; it will not provide needed oxygen. Sedation and/or allowing a family member to stay may calm the client, but will not improve oxygenation.

A nurse is caring for an 89-year-old client admitted with pneumonia. He has an IV of normal saline running at 100 mL/hr and antibiotics that were initiated in the emergency department 3 hours ago. He has oxygen at 2 liters/nasal cannula. What assessment finding by the nurse indicates that goals for a priority diagnosis have been met for this client? A. The client is alert and oriented to person, place, and time. B. Blood pressure is within normal limits and client's baseline. C. Skin behind the ears demonstrates no redness or irritation. D. Urine output has been >30 mL/hr per Foley catheter.

A. The client is alert and oriented to person, place, and time. Rationale: One of the first manifestations of pneumonia in an older adult is acute confusion as a result of impaired gas exchange. A client with pneumonia who is alert and oriented to person, place, and time is responding well to appropriate therapy for the disorder. The blood pressure is not an indicator of effective management of pneumonia, and neither is urine output. The skin behind his ears being intact is important and desirable but is not an outcome indicator for pneumonia management.

A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer? A. The client will be treated for 5 to 7 days. B. The client will require IV antibiotics for 7 to 10 days. C. The client will complete 6 days of therapy. D. The client must be afebrile for 24 hours.

A. The client will be treated for 5 to 7 days. Anti-infectives usually are used for 5 to 7 days in uncomplicated community-acquired pneumonia, and for up to 21 days in an immunocompromised client or one with hospital-acquired pneumonia. A client may become afebrile early in the course of treatment with anti-infective medications; this may cause many clients to fail to complete their course of treatment.

An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best? A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula B. The client with chronic lung disease who is being evaluated for possible home oxygen use C. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar D. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula Orthopedic nurses are familiar with pulmonary emboli and with administration of oxygen through nasal cannulas. Orthopedic nurses do not specialize in chronic lung conditions; such care is best assigned to an RN with experience in chronic lung conditions and in the use of various home oxygen delivery devices and the use of various types of oxygen delivery equipment. Orthopedic nurses do not specialize in airway surgery; such care is best assigned to an RN with experience in postoperative tracheostomy care and tracheostomy collar care.

Which statement by a client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction? A. "I don't need to use my oxygen all the time." B. "I don't need to get a flu shot." C. "I need to eat more protein." D. "It is normal to feel more tired than I used to."

B. "I don't need to get a flu shot." An annual influenza vaccine (flu shot) is important for all clients with COPD. At the same time, a pneumonia vaccine could be offered, since pneumonia is one of the most common complications of COPD. The client who is hypoxemic and also has chronic hypercarbia requires lower levels of oxygen delivery, and may not need it all the time. Increased work of breathing in a client with COPD raises calorie and protein needs, which can lead to protein-calorie malnutrition. Clients with COPD often have chronic fatigue.

A client has been diagnosed with asthma. Which statement below indicates that the client correctly understands how to use an inhaler with a spacer? A. "I don't have to wait between the two puffs if I use a spacer." B. "If the spacer makes a whistling sound, I am breathing in too rapidly." C. "I should rinse my mouth and then swallow the water to get all of the medicine." D. "I should shake the inhaler only if I want to see whether it is empty."

B. "If the spacer makes a whistling sound, I am breathing in too rapidly." Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client must wait 1 minute between puffs. The client should rinse the mouth but not swallow the water. The mouth needs to be rinsed after using an inhaler with or without a spacer. This is especially important if the inhaled medication is a corticosteroid, to prevent the development of an oral fungal infection. An empty inhaler will float on its side in water; a full inhaler will sink. Shaking an inhaler helps ensure that the same dose is delivered in each puff.

The nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about thrombolytic therapy? A. "You will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." B. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." C. "Once the health care provider orders warfarin (Coumadin), we will discontinue the intravenous heparin." D. "If bleeding develops, we will give you platelets to reverse the anticoagulant."

B. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." The international normalized ratio (INR), a measurement of anticoagulation with warfarin, is in the therapeutic range between 2 and 3. Enoxaparin (Lovenox) is a low-molecular-weight heparin that is usually given by the subcutaneous route. Heparin and warfarin are overlapped until the INR is in the therapeutic range, then the heparin can be discontinued. Fresh-frozen plasma is used as an antidote for anticoagulant therapy, not platelets.

The client says, "I hate this stupid COPD." What is the best response by the nurse? A. "Then you need to stop smoking." B. "What is bothering you?" C. "Why do you feel this way?" D. "You will get used to it."

B. "What is bothering you?" Encourage the client, and the family, to express their feelings about limitations on their lifestyle and about disease progression. This is not the time to lecture the client regarding his smoking habits; the client is expressing a need for support. "Why" questions can seem accusatory and may make a client less likely to talk about what he or she is feeling. The client's feelings should never be minimized.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? A. "You are not contagious unless you stop taking your medication." B. "You will not be contagious to the people you have been living with." C. "You will have to take these medications for at least 1 year." D. "Your sputum may turn a rust color as your condition gets better."

B. "You will not be contagious to the people you have been living with." The people the client has been living with have already been exposed and need to be tested. They cannot be re-exposed simply because the diagnosis has now been confirmed. The client with active tuberculosis is contagious, even while taking medication. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

Which client needs immediate attention by the nurse? A. A 40-year-old who is receiving continuous positive airway pressure and has intermittent wheezing B. A 54-year-old who is mechanically ventilated and has tracheal deviation C. A 57-year-old who was recently extubated and is reporting a sore throat D. A 60-year-old who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min

B. A 54-year-old who is mechanically ventilated and has tracheal deviation The 54-year-old client is showing signs of a tension pneumothorax that could lead to decreased cardiac output and shock if not addressed promptly. The 40-year-old client has intermittent adventitious breath sounds, but is not in immediate danger or distress. The 57-year-old client has mild discomfort, but is not in danger of a life-threatening situation. The 60-year-old client has mild tachypnea, but is not in immediate distress or danger.

The nurse coming on shift prepares to perform an initial assessment of a sedated, ventilated client. Which are priorities for the nurse to carry out? (Select all that apply.) A. Ask visitors to leave. B. Assess the client's color and respirations. C. Confirm alarms and ventilator settings. D. Ensure that the tube cuff is inflated and is in the proper position. E. Listen for bilateral breath sounds. F. Provide routine tracheotomy and endotracheotomy and mouth care.

B. Assess the client's color and respirations. C. Confirm alarms and ventilator settings. D. Ensure that the tube cuff is inflated and is in the proper position. E. Listen for bilateral breath sounds. The first priority when caring for a critically ill client is to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Confirming that the client cannot speak ensures that air is going through the endotracheal tube and not around it. Auscultating for equal bilateral breath sounds assists in confirming that the tube is above the carina. Having visitors remain with the client may promote comfort and prevent confusion. Routine tracheostomy care is performed according to schedule, not necessarily as part of an initial assessment.

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first? A. Client with chronic obstructive pulmonary disease (COPD) who is ready for discharge, but is not able to pay for prescribed home medications. B. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. C. Hospice client with terminal pulmonary fibrosis and an oxygen saturation level of 89%. D. Client with lung cancer who needs an IV antibiotic administered before going to surgery.

B. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. The client with CF with an elevated temperature and respiratory rate is exhibiting signs of an exacerbation and needs to be assessed first. The nurse will need to speak with the client who has COPD to help find a plan that will enable the client to obtain his or her prescribed medications; this may involve contacting case management or social services and discussing the discharge with the discharge health care provider. An oxygen saturation of 89% may be normal for a hospice client with terminal pulmonary fibrosis; not enough information is provided to determine whether this client is in distress. The client who needs an IV antibiotic could have the medication administered by another RN, or it could be administered in the operating room.

Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? A. Client with group A beta-hemolytic streptococcal pharyngitis who has stridor B. Client with pulmonary tuberculosis who is receiving multiple medications C. Client with sinusitis who has just arrived after having endoscopic sinus surgery D. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

B. Client with pulmonary tuberculosis who is receiving multiple medications The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Stridor is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful assessment and monitoring by the RN.

Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) A. Administering antibiotic prophylaxis B. Continuous removal of subglottic secretions C. Elevating the head of the bed at least 30 degrees whenever possible D. Handwashing before and after contact with the client E. Placing a nasogastric tube F. Placing the client in a negative-airflow room

B. Continuous removal of subglottic secretions C. Elevating the head of the bed at least 30 degrees whenever possible D. Handwashing before and after contact with the client Continuous removal of subglottic secretions, elevating the head of the bed at least 30 degrees whenever possible, and handwashing before and after contact with a client are all part of a VAP bundle. Antibiotics are not given prophylactically; they are given on the basis of cultures to prevent an increase in drug-resistant organisms. A nasogastric tube is not part of the VAP bundle. If a client is going to be mechanically ventilated for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing a client in a negative-airflow room is not part of the VAP bundle. The client does not require this room.

A client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the health care provider requests oxygen via nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention? A. Increasing carbon dioxide levels B. Decreasing respiratory rate C. Increasing adventitious breath sounds D. Increased coughing

B. Decreasing respiratory rate Respiratory rate and depth should be monitored closely while the client receives oxygen, because hypoventilation is seen during the first 30 minutes of oxygen therapy in clients with hypoxic drive for respiration. The client's color will improve (from ashen or gray to pink) because of an increase in PaO2 level before apnea or respiratory arrest occurs from loss of the hypoxic drive. The COPD client is not sensitive to PaCO2; oxygen administration can cause high PaO2 levels. Monitoring for adventitious breath sounds is important, but these would not be a result of the oxygen that the client is receiving. The ability to cough and breathe deeply is a positive sign.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? A. Auscultate the client's breath sounds while applying a nasal cannula. B. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. C. Apply a 100% non-rebreather mask while administering high-flow oxygen. D. Replace the obturator while reinserting the tracheostomy tube.

B. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. Because a fresh tracheostomy stoma will collapse, the client will lose airway patency, which will require the nurse to ventilate the client through the mouth and nose while waiting for assistance to recannulate the client. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client. Auscultation of the client's breath sounds at this time will not improve the client's respiratory status and will be ineffective until airway patency is restored. Further, auscultation should not be done while a nasal cannula is simultaneously applied. Effective use of a 100% non-rebreather mask requires a patent airway. During the first 72 hours following a tracheostomy, reinsertion of the tube is difficult and should not be attempted by the nurse. Reinsertion of the tracheostomy tube should be done once a Rapid Response Team is available to accomplish this.

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? A. Administer levofloxacin (Levaquin) 500 mg IV. B. Draw aerobic and anaerobic blood cultures. C. Give lorazepam (Ativan) as needed for agitation. D. Refer to social worker for alcohol counseling.

B. Draw aerobic and anaerobic blood cultures. Obtaining aerobic and anaerobic cultures is the first action the nurse should perform and is standard procedure in a febrile client for whom antibiotics have been requested. Levofloxacin, an antibiotic, is important to administer, but blood cultures should be drawn before antibiotics are started. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action; the question indicates that the client is agitated but does not indicate whether other attempts to control agitation have been tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge; this client is febrile and agitated, and a referral is not the immediate concern.

Which method is the best way to prevent outbreaks of pandemic influenza? A. Avoiding public gatherings at all times B. Early recognition and quarantine C. Vaccinating everyone with pneumonia vaccine D. Widespread distribution of antiviral drugs

B. Early recognition and quarantine The recommended approach to disease prevention consists of early recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus. Public gatherings should be avoided only if a widespread outbreak has occurred in a community. No vaccine is available for pandemic influenza. The pneumonia vaccine is recommended for high-risk populations because pneumonia may be a complication of influenza. The current influenza vaccine is updated, re-evaluated, and changed yearly to meet anticipated changes in the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.

The charge nurse at an assisted living facility receives report from an emergency department (ED) nurse about one of the resident clients. The client was sent to the ED with a fever, chills, muscle aches, and headache. The ED nurse reports the client's rapid influenza report came back from the laboratory positive for influenza A. What action by the nurse at the assisted living facility is most appropriate? A. Prepare to administer antibiotics. B. Have the resident eat meals in his room. C. Provide oseltamivir (Tamiflu) to the staff. D. Arrange a follow up chest x-ray in 2 weeks.

B. Have the resident eat meals in his room. Rationale: This client is most likely going to be managed at the assisted living facility. Influenza is highly contagious. Keeping the client in his room rather than having him go to the dining room and eat with other residents helps prevent infection spread. Antibiotics are not used for influenza. The staff should not, at this time, require oseltamivir unless they have manifestations of influenza. This is not a pandemic influenza, and oseltamivir is not used for prophylaxis in this situation. Unless the client develops manifestations of pneumonia, radiography is not indicated.

The client with which condition is in greatest need of immediate intubation? A. Difficulty swallowing oral secretions B. Hypoventilation and decreased breath sounds C. O2 saturation of 90% D. Thick, purulent secretions and crackles

B. Hypoventilation and decreased breath sounds Intubation may be indicated for the client who is hypoventilating and has decreased breath sounds. Suctioning, rather than intubation, is indicated for difficulty swallowing secretions, as well as for thick, purulent secretions and crackles (consistent with pneumonia). Intubation is indicated for the client with an O2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia.

The nurse is teaching a client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques? A. Hair loss B. Increased risk for sunburn C. Loss of appetite D. Pain at site of treatment

B. Increased risk for sunburn Skin in the path of radiation is more sensitive to sun damage; therefore, clients must avoid direct skin exposure to the sun during treatment and for at least 1 year after radiation is completed. Alopecia, or hair loss, is a side effect of chemotherapy, not of radiation. Loss of appetite is not specific to radiation therapy. Radiation therapy itself is painless and sensation-free; however, the skin may become sore and prone to breakdown over the course of treatment.

An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? A. It would not be beneficial for this client. B. It would help decrease the bronchospasm. C. It would clear up the density in the bases of the client's lungs. D. It would decrease the client's pain on inspiration.

B. It would help decrease the bronchospasm. A bronchodilator would help decrease bronchospasm and would open up the airways, so it would be beneficial for this client. It would decrease dyspnea and feelings of shortness of breath. A bronchodilator would not be able to clear up the density in the bases of the client's lung. The cause of the density is unknown; however, an infection such as pneumonia is likely, which bronchodilators do not treat. Although a bronchodilator would help a client breathe easier, it does not have any analgesic properties.

Which parameter indicates to the nurse that the short-acting beta-adrenergic agonist the client used 5 minutes ago for an acute asthma attack is effective? A. SpO2 decreased from 85% to 78% B. Peak expiratory flow increase from 50% to 70% C. The obvious use of accessory muscles during inhalation D. Active bubbling in the humidifier chamber of the oxygen delivery system

B. Peak expiratory flow increase from 50% to 70% Rationale: Peak flow measures the effectiveness of expiratory efforts. An increased peak flow rate indicates less obstruction and greater movement of air with expiratory effort. Decreased SpO2 would indicate a worsening of the condition, not effectiveness of the therapy. The use of accessory muscles indicates that the work of breathing has increased. The active bubbling in the humidification chamber is not related to the client's respiratory effort or the drug therapy's effectiveness.

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? A. The chest caves in on inspiration and "puffs out" on expiration. B. The trachea is deviated to the right side and cyanosis is present. C. The left lung field is dull to percussion with crackles present on auscultation. D. The client has bloody sputum and wheezes.

B. The trachea is deviated to the right side and cyanosis is present. Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. Flail chest is manifested by paradoxical chest movement, which consists of "sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

When caring for a client with pulmonary embolism (PE), which arterial blood gas results does the nurse anticipate early in the course of the disease? A. pH 7.24, PaCO2 55 mm Hg, HCO3- 26 mEq/L, PaO2 56 mm Hg B. pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg C. pH 7.35, PaCO2 45 mm Hg, HCO3- 24 mEq/L, PaO2 80 mm Hg D. pH 7.47, PaCO2 35 mm Hg, HCO3- 30 mEq/L, PaO2 75 mm Hg

B. pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). No compensation is present as the bicarbonate (HCO3-) (26 mEq/L) is normal, and hypoxemia is present, consistent with PE. A pH of 7.24 is acidotic, a partial pressure of arterial oxygen (PaO2) of 56 mm Hg reflects hypoxemia, and no compensation is present with a normal HCO3- (26 mEq/L); this blood would be found in a person in acute respiratory failure owing to hypoventilation and hypoxemia. A pH between 7.35 and 7.45, PaCO2 of 35 to 45 mm Hg, HCO3- of 22 to 26 mEq/L, and PaO2 greater than 75 mm Hg all reflect normal blood gas results. A pH of 7.47 and an HCO3- of 30 mEq/L are alkalotic, indicating metabolic alkalosis; a PaCO2 of 35 mm Hg is normal (indicating lack of compensation) and a PaO2 of 75 mm Hg is normal.

The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)? A. A client with diabetes and cellulitis of the leg B. A client receiving IV fluids through a peripheral line C. A client returning from an open reduction and internal fixation of the tibia D. A client with hypokalemia receiving potassium supplements

C. A client returning from an open reduction and internal fixation of the tibia Surgery and immobility are risks for deep vein thrombosis and PE. No evidence suggests that the client with diabetes has been immobile, which is a risk factor for PE; the client will be treated with antibiotics. For the client with a peripheral line, no evidence indicates a problem with the IV or with breakage of the catheter, which could lead to an air embolism. For the client with hypokalemia, no evidence reveals risk for PE; no immobility or hyper-coagulability is present.

What is the greatest risk factor for lung cancer? A. Alcohol consumption B. Asbestos exposure C. Cigarette smoking D. Smoking marijuana

C. Cigarette smoking Cigarette smoking is the number-one risk factor for lung cancer and chronic obstructive pulmonary disease. Alcohol can cause some cancers and liver disease and can increase risky behaviors, but it is not a major cause of lung cancer. Although asbestos is carcinogenic and some components of marijuana are carcinogenic, neither is the major risk factor for lung cancer.

A local hunter is admitted to the intensive care unit with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the health care provider will order? A. Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours B. Ceftriaxone (Rocephin) 2 g IV every 8 hours C. Ciprofloxacin (Cipro) 400 mg IV every 12 hours D. Pyrazinamide (Zinamide) 1000 to 2000 mg orally every day

C. Ciprofloxacin (Cipro) 400 mg IV every 12 hours Intravenous ciprofloxacin (Cipro) is a first-line drug for treatment of inhaled anthrax. A dose of 400 mg IV every 12 hours is typically used for treatment of anthrax, while a dose of 500 mg orally twice daily is usually prescribed for anthrax prophylaxis. Oral doses of amoxicillin are used only as prophylaxis, not as treatment, for inhaled anthrax. Cephalosporins such as ceftriaxone are not used for treatment of anthrax. Pyrazinamide (Zinamide) is used for treatment of tuberculosis.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A. Client with bacterial pneumonia and a cough productive of green sputum B. Client with neutropenia and pneumonia caused by Candida albicans C. Client with possible pulmonary tuberculosis who currently has hemoptysis D. Client with right empyema who has a chest tube and a fever of 103.2° F

C. Client with possible pulmonary tuberculosis who currently has hemoptysis A client with possible tuberculosis should be admitted to the negative-airflow room to prevent airborne transmission of tuberculosis. A client with bacterial pneumonia does not require a negative-airflow room but should be placed in Droplet Precautions. A client with neutropenia should be in a room with positive airflow. The client with a right empyema who also has a chest tube and a fever should be placed in Contact Precautions but does not require a negative-airflow room.

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? A. Completing the antibiotic medication regimen B. Taking pain medications every 4 to 6 hours C. Contacting the provider if the throat feels more swollen D. Using warm saline gargles and irrigations

C. Contacting the provider if the throat feels more swollen Clients with peritonsillar abscess are at risk for airway obstruction due to swelling and should notify the provider if signs of obstruction occur, such as stridor or drooling. It is important to complete the antibiotics to treat the infection, and to adhere to comfort measures such as analgesic medications and saline gargles, but none of these is the most important thing to teach the client.

A client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? A. The low PaO2 level may result in oxygen toxicity. B. The 100% oxygen delivery requirement indicates immediate extubation. C. Lung sounds may indicate absorption atelectasis. D. The level of oxygen delivery may indicate absorption atelectasis.

C. Lung sounds may indicate absorption atelectasis. High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated. High PaO2 levels may result in oxygen toxicity. The need for 100% oxygen delivery does not suggest that the client should be extubated; rather, it suggests that the client continues to require intubation and mechanical ventilation. Although high levels of oxygen delivery can result in absorption atelectasis, this is not an indicator; rather, it is a cause.

A client has asthma that gets worse during the summer. She tells the nurse that she takes a medication every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client? A. Albuterol (Proventil) inhaler B. Guaifenesin (Organidin) C. Montelukast (Singulair) D. Omalizumab (Xolair)

C. Montelukast (Singulair) Montelukast is a leukotriene antagonist that works well for asthma that occurs during certain seasons. It is taken on a daily basis as a preventive medication. Albuterol inhalers are beta2 agonists that are rescue medications used on an as-needed basis only. Guaifenesin is a mucolytic that does not provide any bronchodilation; it may or may not be taken daily. Omalizumab is an immunomodulator that is injected subcutaneously every 2 to 3 weeks; it is not commonly used because a high rate of anaphylaxis is associated with it.

Which value indicates clinical hypoxemia and the need to increase oxygen delivery? A. Hemoglobin of 22 g/dL B. PaCO2 of 30 mm Hg C. PaO2 of 65 mm Hg D. Oxygen saturation of 88%

C. PaO2 of 65 mm Hg A PaO2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is considered hypoxemia. Hemoglobin measures oxygen-carrying capacity. PaCO2 of 30 mm Hg indicates low carbon dioxide levels in the blood. Oxygen saturation measures tissue perfusion.

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period? A. Computer keyboard B. Magic Slate C. Picture board D. Pen and paper

C. Picture board A picture board does not require very much dexterity for communication. Dexterity can be limited to the extent the client finds comfortable. A computer keyboard, Magic Slate, and pen and paper require dexterity that may be difficult and/or painful for a client with degenerative arthritis.

A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? A. Contact the health care provider for tuberculosis (TB) medications. B. Perform a TB skin test. C. Place a respiratory mask on the client. D. Test all family members for TB.

C. Place a respiratory mask on the client. The concern is that this client has TB. A respiratory mask should be placed on the client immediately. Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. It is important to remember to let the client know that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.

A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? A. Ensure that ED staff members receive oseltamivir (Tamiflu). B. Obtain specimens for the H5 polymerase chain reaction test. C. Place the client in a negative air pressure room. D. Start an IV line and administer rehydration therapy.

C. Place the client in a negative air pressure room. If a client is exhibiting symptoms of avian flu or any other pandemic influenza, he or she is assumed to be contagious until proven otherwise. Preventing the spread of disease to the community is the top priority, so placing the client in a negative air pressure room is the nurse's first action. If avian influenza is diagnosed, it is important that those exposed receive oseltamivir or zanamivir (Relenza) within 48 hours of contact with the client. Obtaining specimens will be important to determine whether the client has avian influenza; this test takes approximately 40 minutes to complete. A client with avian flu will become dehydrated because of diarrhea, so starting an IV to administer rehydration fluid is important, but is not the first priority.

The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success? A. Peak flowmeter readings that are yellow after the third reading B. Productive cough C. SpO2 level of 92% after ambulating 50 feet D. Stable arterial blood gases (ABGs)

C. SpO2 level of 92% after ambulating 50 feet Maintaining a baseline SpO2 of 92% after ambulating 50 feet is an excellent indicator that the client has achieved better airflow, and that the nurse's teaching has been effective. A yellow reading means "caution," which indicates narrowing airways. Although a productive cough may be an indication of success, it can also be an indication of infection. ABGs are invasive, costly, and painful and are not the most effective indicator of successful teaching in this situation.

The nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? A. "Handwashing is the best way to prevent transmission." B. "I should avoid kissing and shaking hands." C. "It is best to cough and sneeze into my upper sleeve." D. "The intranasal vaccine can be given to everybody in the family."

D. "The intranasal vaccine can be given to everybody in the family." The intranasal flu vaccine is approved for healthy clients ages 2 to 49 who are not pregnant. Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A new recommendation from the Centers for Disease Control and Prevention for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand.

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? A. "You can quit when you are ready." B. "It's never too late to quit." C. "Just turn off your oxygen when you smoke." D. "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."

D. "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous." The nurse should use this opportunity to educate the client about the dangers of smoking in the presence of oxygen, as well as the benefits of quitting. Telling the client it is OK to quit when ready, or that it's never too late to quit, does not address the safety issue of smoking in the presence of oxygen. Recommending that the client turn off the oxygen when smoking encourages the client to remove his or her oxygen source, which could harm the client.

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who is hypoxemic and hypercarbic. How will the nurse administer the oxygen for this client? A. By nasal cannula at a rate of no more than 1 to 3 L/min B. By nasal cannula at a rate of no more than 2 to 4 L/min C. By Venturi mask at a rate of at least 60% D. By maintaining oxygen saturations greater than 88%

D. By maintaining oxygen saturations greater than 88% In the past, a client with COPD was thought to be at risk for extreme hypoventilation with oxygen therapy because of a decreased drive to breathe as blood oxygen levels increased. However, recent evidence does not support this; this idea has been responsible for ineffective management of hypoxia in clients with COPD. All hypoxic clients, even those with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and bring SpO2 levels up between 88% and 92%

A client with a tracheostomy is at increased risk for aspiration. Which nursing interventions will reduce this risk? (Select all that apply.) A. Encourage frequent sipping from a cup. B. Encourage water with meals. C. Inflate the tracheostomy cuff during meals. D. Maintain the client upright for 30 minutes after eating. E. Provide small, frequent meals. F. Teach the client to "tuck" the chin down in the forward position to swallow.

D. Maintain the client upright for 30 minutes after eating. E. Provide small, frequent meals. F. Teach the client to "tuck" the chin down in the forward position to swallow. At least 30 minutes is required for thinner liquids in the stomach to be thickened in combination with stomach contents and/or removed from the stomach; this reduces the chance of aspiration. Eating requires significant time and energy; when the client becomes tired, he is more likely to aspirate. Shorter and more frequent intervals of eating tire the client less and reduce the chance of aspiration. Tucking the chin downward helps to open the upper esophageal sphincter. Liquids should not be given frequently and should be taken using a spoon to ensure that the client is attempting to swallow only small volumes of liquid; thin liquids such as water are easily aspirated. The tracheostomy cuff should be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.

A client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client? A. Mucolytics decrease secretion production. B. Mucolytics increase gas exchange in the lower airways. C. Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease. D. Mucolytics thin secretions, making them easier to expectorate.

D. Mucolytics thin secretions, making them easier to expectorate. The term mucolytic means "breaking down mucus." Mucolytics cause secretions to thin, making them easier to expectorate; this is important for a client with chronic bronchitis. Mucolytics do not decrease secretion production. Mucolytics may increase gas exchange, but this is an indirect property and is not the main function. Mucolytics do not have any bronchodilation properties.

The nurse is preparing to admit an adult client with pertussis. Which symptom does the nurse anticipate finding in this client? A. "Whooping" after a cough B. Hemoptysis C. Mild cold-like symptoms D. Post-cough emesis

D. Post-cough emesis Clients with pertussis will have paroxysms of coughing often followed by changes in color and/or vomiting. Adults do not usually have the characteristic whooping sound associated with coughing that children with pertussis exhibit. Hemoptysis may occur after the acute phase when changes in the respiratory mucosa occur. Mild, cold-like symptoms occur in the initial stages of pertussis and generally do not require hospitalization.

A newly diagnosed client with asthma says that his peak flowmeter is reading 82% of his personal best. What does the nurse do? A. Nothing. This is in the green zone. B. Provide the rescue drug and reassess. C. Provide the rescue drug and seek emergency help. D. Repeat the peak flow test.

D. Repeat the peak flow test. Since the client is newly diagnosed with asthma, this would be an excellent opportunity for the nurse to observe the client using the peak flowmeter to ensure that the client is using it properly, so readings are accurate and in the green zone, at least 80% of the client's personal best. The result of 82% is in the green zone, but this is not the best answer for a newly diagnosed client. Rescue drugs should be used only in the yellow zone, between 50% and 80% of the client's personal best. They should not be used in this situation, and the nurse does not need to seek emergency help until readings are in the red zone, or below 50% of the client's personal best.

A client with a new tracheostomy has a soiled dressing. What is the best nursing intervention? A. Cut a sterile 4 × 4 gauze to fit around the tracheostomy tube. B. Reinforce the dressing with a sterile 4 × 4 gauze. C. Replace the dressing with a clean, folded 4 × 4 gauze. D. Replace the dressing with a sterile, folded 4 × 4 gauze.

D. Replace the dressing with a sterile, folded 4 × 4 gauze. Tracheostomy dressings may be used to keep the tracheostomy clean and dry. These dressings resemble a 4 × 4 gauze pad with an area removed to fit around the tube. If tracheostomy dressings are not available, fold standard sterile 4 × 4s to fit around the tube. The dressing should never be cut because small bits of gauze could then be aspirated through the tube. Dressings should be changed often, not reinforced, because moist dressings provide a medium for bacterial growth, leading to infection.

The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler? A. Corticosteroids B. Long-acting beta agonists C. Nonsteroidal anti-inflammatory drugs (NSAIDs) D. Short-acting beta agonists

D. Short-acting beta agonists Short-acting beta agonist medications have a rapid onset and cause bronchodilation; they would be excellent for marathon running because some types of asthma may be exercise-induced. Corticosteroids disrupt production pathways of inflammatory mediators. Maximum effectiveness requires 48 to 72 hours of continued use; therefore, they are not appropriate as a rescue medication. Long-acting beta agonists do cause bronchodilation, but have a slow onset; they are not used as rescue inhalers. NSAIDs stabilize the membranes of mast cells and prevent release of inflammatory mediators. They have a slow onset of action and are used for prevention of symptoms, not as rescue medication.

Respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? A. Humidifying the oxygen source B. Increasing oxygenation C. Removing the inner cannula of the tracheostomy D. Suctioning the client

D. Suctioning the client Suctioning the client will likely result in clear lung sounds and lower peak pressure, and the appearance of the sputum will indicate whether bleeding is a concern. Humidifying the oxygen source will help mobilize secretions, but an active cough response is also required to clear the airway; a sedated client has a weak cough. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral diazepam (Valium) 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress? A. The client is not being treated for asthma. B. The client has a mental disorder. C. The client received a dose of Valium. D. The client is receiving oxygen at 4 L/min.

D. The client is receiving oxygen at 4 L/min. A simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath, which has low levels of oxygen and can eventually suffocate the client. The client had a panic attack, not an asthma attack. A panic attack is not a definitive diagnostic indicator of a mental disorder. A small dose of Valium does not place a client at increased risk for respiratory distress; a large dose is required to place a client at high risk.

A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders? A. It affects only young people. B. The client has dyspnea. C. The client is coughing. D. The client is symptom-free between exacerbations.

D. The client is symptom-free between exacerbations. The client may be completely symptom-free between exacerbations. Asthma affects people of all ages. Dyspnea is a common symptom of many chronic lung diseases. Coughing occurs in many acute and chronic lung diseases.

A client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? A. Chest x-ray B. Complete blood count (CBC) C. Tuberculosis (TB) skin test D. Throat culture

D. Throat culture A throat culture is important for distinguishing a viral infection from a group A beta-hemolytic streptococcal infection. A chest x-ray or TB skin test is not indicated by the symptoms given. A CBC might be indicated to evaluate infection and dehydration, but would not be the first action.

A student nurse is working with a client in the ICU who is intubated and being mechanically ventilated. What action by the student causes the registered nurse to intervene? A. Repositioning the client every 2 hours B. Providing oral care with chlorhexidine rinse C. Checking tube placement at the client's incisor D. Turning off ventilator alarms while working in the room

D. Turning off ventilator alarms while working in the room Rationale: Ventilator alarms are critical to safety and indicating a need for early intervention when the client's gas exchange needs are not being met. Even when a nurse or other health care professional is present at the bedside, the alarms should never be turned off or set so inappropriately that they do not sound when parameters indicate a problem.

The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal (GI) bleeding and an international normalized ratio (INR) of 6.9. For which factors should the nurse assess this client? A. Consumption of green leafy vegetables B. Prolonged exhalation C. Client has massaged his calves D. Use of aspirin or salicylates

D. Use of aspirin or salicylates Use of aspirin and salicylates will prolong the INR and cause gastric irritation. Green leafy vegetables are high in vitamin K and would antagonize warfarin, resulting in a low(er) INR. A prolonged expiratory phase is typical in chronic obstructive pulmonary disease, not GI bleeding or a prolonged INR. Massaging the calves may present a risk for PE if deep vein thrombosis is present, but does not relate to GI bleeding and prolonged INR.

The nurse is caring for a client with severe acute respiratory syndrome. What is the most important precaution the nurse should take when preparing to suction this client? A. Keeping the head of the bed elevated 30 to 45 degrees B. Performing oral care after suctioning the oropharynx C. Washing hands and donning gloves prior to the procedure D. Wearing a disposable particulate mask respirator and protective eyewear

D. Wearing a disposable particulate mask respirator and protective eyewear To protect health care workers during procedures that induce coughing or promote aerosolization of particles, nurses should wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. Keeping the head of the bed elevated 30 to 45 degrees is not the most important precaution. Performing oral care is a comfort measure. Washing hands and donning gloves is necessary, but not the most important measure.

An environmental assessment of a factory finds inhalation exposure with a high level of particulate matter. What does the factory nurse do to generate the quickest compliance? A. Encourages proper building ventilation B. Refers workers to a tobacco cessation program C. Suggests that workers find another job D. Teaches workers how to use a mask Correct

Teaching everyone to use a mask when working in areas with high levels of particulate matter can reduce individual exposure. Proper building ventilation often requires work orders, reconstruction, time, and money; this will need to be implemented, but it will not occur quickly. Particulate matter can be emitted from a variety of sources; smoking may be unrelated to the question. Suggesting that workers find another job does not solve the problem of particulate matter in a rapid or safe manner.