Oxygenation
ANS: 2 Feedback 1. This is not the first intervention. A pulse oximetry should be assessed to identify the need for oxygen. 2. The first intervention should be to check the childs pulse oximetry. 3. Fever can cause tachypnea. This is not the first action needed. 4. Notifying the physician is not the first action needed. KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Safe and Effective Care Environment | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice
A 15 month old admitted with croup is sleeping in a cool mist tent. The nurse checks on him and notices that he is retracting and tachypneic. What is the first thing she should do? 1. Increase the oxygen flow to the tent 2. Check the childs pulse oximetry 3. Check the childs temperature 4. Notify the physician
ANS: 2 Feedback 1. The equipment is protecting the health-care worker from transmitting the virus to other patients. 2. Prevention of the spread of the disease is the primary reason for the equipment. 3. Not all respiratory illnesses require isolation. 4. The equipment is protecting the health-care worker from transmitting the virus to other patients. KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice
A 2 year old has been placed in contact isolation because of a diagnosis of Respiratory Syncytial Virus (RSV). The father questions why the staff is wearing masks and gowns every time someone comes into the room. The best response would be: 1. The equipment is needed to protect myself and others from your childs illness. 2. Since bronchiolitis is highly contagious for other children, it is important for the staff to wear the equipment to prevent spreading it to others. 3. Every child that comes in with a respiratory illness is required to be in isolation. 4. The equipment is needed to protect your child from acquiring an illness from the staff.
ANS: 1 Feedback 1. Asthma constricts the airway and alveoli in children, causing wheezing to be heard when in auscultation. 2. Rhonchi usually will clear with a cough. A child with an asthma exacerbation will not stop the sound after coughing. 3. Asthma causes the narrowing of airways. Crackles occur only when fluid is present. 4. The airway and alveoli constriction causes wheezing. KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice
A 5-year-old child has been admitted for complications related to asthma. When the nurse auscultates the childs lungs, she would anticipate hearing: 1. Wheezes because the bronchioles have been restricted. 2. Rhonchi because of thick secretions from the flare-up. 3. Crackles because there is fluid in the alveoli. 4. All of the above may be heard.
Ans: D Feedback: The most important risk factor for COPD is cigarette smoking. Lack of exercise and exposure to dust and pollen are not risk factors for COPD. Occupational risks are significant but are far exceeded by smoking.
A clinic nurse is caring for a patient who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The patient asks the nurse what he could have done to minimize the risk of contracting this disease. What would be the nurses best answer? A) The most important risk factor for COPD is exposure to occupational toxins. B) The most important risk factor for COPD is inadequate exercise. C) The most important risk factor for COPD is exposure to dust and pollen. D) The most important risk factor for COPD is cigarette smoking.
ANS: 3 Feedback 1. The infants pulse oximetry is 98 percent and does not need supplemental oxygen. 2. Beta adrenergic meds do not increase blood glucose levels. 3. These interventions are appropriate for croup-like symptoms. 4. The infants pulse oximetry is 98 percent and does not need supplemental oxygen. KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice
A father brings his 6-month-old infant into the clinic with a four day history of nighttime, seal-like cough. The infant is afebrile, tachycardic, and tachypneic with a pulse oximetry reading of 98 percent. What interventions would you expect the physician to order for this child? 1. Cool mist tent with supplemental oxygen, racemic epinephrine, and corticosteroids 2. Beta adrenergics aerosolized, cool mist tent, and periodic testing of blood glucose levels 3. Close monitoring of respiratory status, cool mist tent, beta adrenergics, and corticosteroids 4. Close monitoring of respiratory status, supplemental oxygen with simple mask, and racemic epinephrine
ANS: 2 Feedback 1. Children with bronchopulmonary dysplasia require high nutritional demands to the body. The growth of children with this diagnosis tends to be slower than their peers. 2. Children with this diagnosis tend to be smaller than their peers for a longer period of time. 3. This is a true statement, but does not address why the child is not growing at the same rate. 4. The childs body can grow and may be the same as peers later in life. KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice
A former 24-week, premature infant is now adjusted in age to be one year of age. The baby has a known history of bronchopulmonary dysplasia. The parents of the child are asking if their baby will catch up in height and weight to her peers by the time she is 2 years old. The best reply from the nurse would be: 1. Normally, premature infants will be the same height and weight as their peers by their second birthday. 2. The bronchopulmonary dysplasia requires your childs lungs to work harder to breath. This causes the body to have a higher metabolism, so she may remain on the small side for several years. 3. You baby is now healthy and will continue to grow at her own rate. 4. Your baby will remain small for most of her life due to the bronchopulmonary dysplasia.
ANS: 3 Feedback 1. Suctioning can cause more traumas to the area. 2. The thumb sign will not occur in this condition. 3. The nurse would monitor and be prepared for possible rapid decline in respiratory status and try to keep the child from crying. 4. Suctioning the mouth can cause more damage, and the injection should not be given at this time.
A mother brought her 8 year old into the emergency room because although she was fine when she woke up this morning, she now has a fever of 39.8 C, cannot speak, is drooling, and is tachypneic and stridorous. Her pulse oximetry reading is 90 percent on a rebreather mask. What would be the next appropriate nursing action? 1. Suction her mouth, then conduct throat and blood cultures as well as a test for gram positive bacteria. 2. Prepare the child and mother for an MRI scan to evaluate for a thumb sign. 3. Monitor respiratory status closely, prepare for intubation, and keep the child calm to avoid crying. 4. Suction her mouth, monitor respiratory status closely, and give a Palivizumab injection.
Ans: A Feedback: Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung.
A nurse has been asked to give a workshop on COPD for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has what pathophysiologic effect? A) Increases the amount of mucus production B) Destabilizes hemoglobin C) Shrinks the alveoli in the lungs D) Collapses the alveoli in the lungs
Ans: A Feedback: The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Suctioning is not normally necessary in patients with COPD. Supplementary oxygen is not normally delivered by simple face mask and exercise may or may not be appropriate.
A nurse is admitting a new patient who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the patient achieve the goal of maintaining effective oxygenation? A) Teach the patient strategies for promoting diaphragmatic breathing. B) Administer supplementary oxygen by simple face mask. C) Teach the patient to perform airway suctioning. D) Assist the patient in developing an appropriate exercise program.
ANS: 3 Feedback 1. The fever is low grade and not a priority at this time. 2. 89 percent oxygen saturation on room air needs to have a further assessment to see why the child is low in saturations. 3. Suctioning helps remove all the secretions and opens the airway with the possibility of increasing oxygen saturations. 4. A quiet environment will help the child rest, but is not a priority at this time. KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Analysis | REF: Chapter 11 | Type: Multiple Choice
A nurse is assessing a 3-month-old child with RSV. The nurse identifies the following: HR of 140; RR of 32; Oxygen saturation is 89% on room air; inspiratory and expiratory wheezing of the upper lungs; temperature of 38.1 degrees Celsius; large amounts of thin secretions. Identify the priority at this time. 1. Administering acetaminophen to reduce the fever 2. Providing oxygen for the low saturation 3. Suctioning the nares and oropharnyx to remove the secretions 4. Providing a quiet environment
ANS: 2 Feedback 1. The nailbeds should be used to assess capillary refill. 2. A pen light can be used to examine the inside of a childs mouth in the cheek area for color. 3. The eyes can indicate jaundice, but not any other type of color changes. 4. Capillary refill can be assessed on the chest since the oral mucous membranes are more accurate. KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Choice
A nurse is attempting to assess the skin color of a child with dark skin. The nurse knows the best place to assess the childs skin color is: 1. The nailbeds. 2. Inside the mouth in the cheek area. 3. The eyes. 4. On the chest.
ANS: 4 Feedback 1. The description is not accurate, and a 10 year old is able to comprehend the reason for use of a peak flow meter. 2. The description of normal and abnormal can cause concern for the child. It is important to explain that the peak flow meter is a measurement of health. 3. This description can be used for a younger child. A 10 year old is able to comprehend the use of the peak flow meter. 4. The peak flow meter is a monitor used to indicate when the child is breathing easily and when illness may be starting.
A nurse is attempting to educate a 10-year-old girl in the use of a peak flow meter. Identify the best way to explain the test to the child. 1. The purpose of the test is to see how hard you breathe. 2. The purpose of the test is for you to monitor what is normal and abnormal for you. Then your parents can help with your medication on days when you are not measuring in your normal ranges. 3: We are measuring how well you can blow birthday candles out. 4. The meter will help monitor when you are healthy and when you are becoming ill.
A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? A) Rescue inhalers B) Anti-inflammatory drugs C) Antibiotics D) Antitussives Ans: B Feedback: Because the underlying pathology of asthma is inflammation, control of persistent asthma is accomplished primarily with regular use of anti-inflammatory medications. Rescue inhalers, antibiotics, and antitussives do not aid in the first-line control of persistent asthma.
A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? A) Rescue inhalers B) Anti-inflammatory drugs C) Antibiotics D) Antitussives Ans: B Feedback: Because the underlying pathology of asthma is inflammation, control of persistent asthma is accomplished primarily with regular use of anti-inflammatory medications. Rescue inhalers, antibiotics, and antitussives do not aid in the first-line control of persistent asthma.
Ans: D, E Feedback: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the patients respiratory status. Bronchodilators would not have a direct result on the patients infectious process.
A nurse is caring for a patient with COPD. The patients medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in respiratory status? Select all that apply. A) Negative sputum culture B) Increased viscosity of lung secretions C) Increased respiratory rate D) Increased expiratory flow rate E) Relief of dyspnea
Ans: C Feedback: The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the childs A-P diameter does not normally change.
A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? A) Shallow respirations B) Increased anterior-posterior (A-P) diameter C) Bilateral wheezes D) Bradypnea
Ans: C Feedback: Complications of COPD include respiratory failure, pneumothorax, atelectasis, pneumonia, and pulmonary hypertension (corpulmonale). Lung cancer, cystic fibrosis, and hemothorax are not common complications.
A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? A) Lung cancer B) Cystic fibrosis C) Respiratory failure D) Hemothorax
Ans: B Feedback: Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all patients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit patients to perform these without excessive distress.
A nurse is developing the teaching portion of a care plan for a patient with COPD. What would be the most important component for the nurse to emphasize? A) Smoking up to one-half of a pack of cigarettes weekly is allowable. B) Chronic inhalation of indoor toxins can cause lung damage. C) Minor respiratory infections are considered to be self-limited and are not treated. D) Activities of daily living (ADLs) should be clustered in the early morning hours.
Ans: D Feedback: Prednisone is used for a short-term (310 days) burst to gain prompt control of inadequately controlled, persistent asthma. It is not used to treat infection or to prevent exacerbations in the long term.
A nurse is explaining to a patient with asthma what her new prescription for prednisone is used for. What would be the most accurate explanation that the nurse could give? A) To ensure long-term prevention of asthma exacerbations B) To cure any systemic infection underlying asthma attacks C) To prevent recurrent pulmonary infections D) To gain prompt control of inadequately controlled, persistent asthma
Ans: C Feedback: Inspiratory muscle training and breathing retraining may help improve breathing patterns in patients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing.
A nurse is providing discharge teaching for a client with COPD. When teaching the client about breathing exercises, what should the nurse include in the teaching? A) Lie supine to facilitate air entry B) Avoid pursed lip breathing C) Use diaphragmatic breathing D) Use chest breathing
Ans: C Feedback: Azmacort has possible adverse effects of cough, dysphonia, oral thrush (candidiasis), and headache. In high doses, systemic effects may occur (e.g., adrenal suppression, osteoporosis, skin thinning, and easy bruising). The other listed adverse effects are not associated with this drug.
A nurse is teaching a patient with asthma about Azmacort, an inhaled corticosteroid. Which adverse effects should the nurse be sure to address in patient teaching? A) Dyspnea and increased respiratory secretions B) Nausea and vomiting C) Cough and oral thrush D) Fatigue and decreased level of consciousness
Ans: A, D, E Feedback: Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma.
A nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? Select all that apply. A) Chest tightness B) Crackles C) Bradypnea D) Wheezing E) Cough
Ans: B Feedback: Wheezing and diminished breath sounds are consistent with bronchospasm. Crackles are usually attributable to other respiratory or cardiac pathologies. Bronchospasm usually results in rapid, inefficient breathing and agitation.
A nurses assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the patient is experiencing bronchospasm? A) Fine or coarse crackles on auscultation B) Wheezes or diminished breath sounds on auscultation C) Reduced respiratory rate or lethargy D) Slow, deliberate respirations
Ans: D Feedback: Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of forced expiration volume in 1 second to forced vital capacity. Obstructive lung disease is apparent when an FEV1/FVC ratio is less than 70%.
A patient is having pulmonary-function studies performed. The patient performs a spirometry test, revealing an FEV1/FVC ratio of 60%. How should the nurse interpret this assessment finding? A) Strong exercise tolerance B) Exhalation volume is normal C) Respiratory infection D) Obstructive lung disease
Ans: A Feedback: The typical posture of a person with COPD is to lean forward and use the accessory muscles of respiration to breathe. Low Fowlers positioning would be less likely to aid oxygenation. Prone or Trendelenburg positioning would exacerbate shortness of breath.
A patient with emphysema is experiencing shortness of breath. To relieve this patients symptoms, the nurse should assist her into what position? A) Sitting upright, leaning forward slightly B) Low Fowlers, with the neck slightly hyperextended C) Prone D) Trendelenburg
Ans: C Feedback: LABAs are not used for management of acute asthma symptoms. Tachycardia is a potential adverse effect and decreased protection against exercise-induced bronchospasm may occur with regular use.
A patients severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the patients statements suggests a need for further education? A) I know that these drugs can sometimes make my heart beat faster. B) Ive heard that this drug is particularly good at preventing asthma attacks during exercise. C) Ill make sure to use this each time I feel an asthma attack coming on. D) Ive heard that this drug sometimes gets less effective over time.
Ans: A Feedback: Common causative agents that may trigger an asthma attack are as follows: dust, dust mites, pets, soap, certain foods, molds, and pollens. Lack of sleep, stress, and bacteria are not common triggers for asthma attacks.
A pediatric nurse practitioner is caring for a child who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. What potential causative agent should the nurse describe? A) Pets B) Lack of sleep C) Psychosocial stress D) Bacteria
Ans: C Feedback: Asthma exacerbations are best managed by early treatment and education of the patient. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath.
A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this clients airflow obstruction? A) Administer corticosteroids by metered dose inhaler B) Administer inhaled anticholinergics C) Administer an inhaled beta-adrenergic agonist D) Utilize a peak flow monitoring device
Ans: C Feedback: Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks.
A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing? A) Gradually increase levels of physical exertion. B) Change filters on heaters and air conditioners frequently. C) Take prescribed medications as scheduled. D) Avoid goose-down pillows.
Ans: B Feedback: These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. Kyphosis is a musculoskeletal problem. Sepsis and pneumothorax are atypical complications. Tachypnea is much more likely than bradypnea. Pursed lip breathing can relieve dyspnea.
An admitting nurse is assessing a patient with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what? A) Kyphosis and clubbing of the fingers B) Dyspnea and hypoxemia C) Sepsis and pneumothorax D) Bradypnea and pursed lip breathing
Ans: B Feedback: Peak flow meters measure the highest airflow during a forced expiration.
An asthma educator is teaching a patient newly diagnosed with asthma and her family about the use of a peak flow meter. The educator should teach the patient that a peak flow meter measures what value? A) Highest airflow during a forced inspiration B) Highest airflow during a forced expiration C) Airflow during a normal inspiration D) Airflow during a normal expiration
Ans: B Feedback: Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate patients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not necessarily prevent asthma exacerbations.
An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients? A) Encouraging patients to carry a corticosteroid rescue inhaler at all times B) Educating patients about recognizing and avoiding asthma triggers C) Teaching patients to utilize alternative therapies in asthma management D) Ensuring that patients keep their immunizations up to date
ANS: B An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection. DIF: Cognitive Level: Analysis REF: 577 OBJ: 9 TOP: Respiratory Syncytial Virus KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Physiological Integrity
An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is: a. Fatigue related to increased work of breathing b. Ineffective breathing pattern related to airway inflammation and increased secretions c. Risk for fluid volume deficit related to tachypnea and decreased oral intake d. Fear/anxiety related to dyspnea and hospitalization
ANS: 4 Feedback 1. SIDS is a diagnosis of exclusion. Antibiotics are not known to cause SIDS. 2. A lower birth weight child is at more risk, but is not the only reason SIDS can occur. 3. The amount of feeding does not influence the occurrence of SIDS. 4. SIDS is a diagnosis of exclusion. It is difficult to know what exactly causes the death in SIDS cases. KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Evaluation | REF: Chapter 11 | Type: Multiple Choice
If a nurse suspects that a 2-month-old infants death was related to SIDS, what statement made by the mother reflects an accurate understanding of SIDS? 1. I knew that I should not have given our baby the antibiotics for the ear infection. 2. Being a twin with low birth weight, he didnt have a chance. 3. I should not have fed him that eight-ounce bottle before laying him down. 4. I am having a hard time not knowing what happened. I had just checked on him 20 minutes earlier in the crib, and he was sleeping on his back.
ANS: 1, 4, 5 Feedback 1. A firm mattress keeps the baby from sinking into the bedding, thus preventing suffocation. 2. Bendy bumpers can create pockets for the infants face to become stuck, thus creating a suffocation risk. 3. A pillow is too bulky and can cause an infant to become stuck, thus creating a suffocation risk. 4. Tight-fitting sheets decrease the chance for suffocation because there is little room for the infants head to get stuck. A well-ventilated room creates air movement and a good exchange of oxygen and carbon dioxide. KEY: Content Area: Respiratory | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Response
Parents are attending a pre-baby class and receiving information on SIDS. Identify important information the nurse should provide during the course. Select all that apply. 1. A firm mattress 2. A bendy bumper around the entire bed 3. A pillow 4. Tight-fitting sheets 5. A well-ventilated room
ANS: 1, 4, 5 Feedback 1. Nasal flaring indicates that the child is struggling with breathing. 2. Synchronized rise and fall is a normal breathing pattern of a child. 3. A capillary refill of less than 3 seconds is normal for a child. 4. Grunting indicates that the child has to exhale harder than normal, thus indicating respiratory distress. 5. Intercostal retractions indicate that the child needs to use accessory muscles, creating respiratory distress. KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Knowledge | REF: Chapter 11 | Type: Multiple Response
Signs that a child is exhibiting respiratory distress include: (Select all that apply.) 1. Nasal flaring. 2. Synchronized rise and fall of the abdomen and the chest. 3. A capillary refill of less than three seconds. 4. Grunting. 5. Intercostal retractions.
ANS: D The symptoms described are the signs of theophylline toxicity. DIF: Cognitive Level: Analysis REF: 584 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
The asthmatic child who has been taking theophylline complains of stomach ache and tachycardia and is sweating profusely. The nurse recognizes these symptoms as: a. Severe asthma attack b. Allergic response to theophylline c. Onset of bronchitis d. Drug toxicity
ANS: D This position is comfortable and allows maximum use of the accessory muscles for breathing. Sedatives would mask symptoms of increasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea. DIF: Cognitive Level: Comprehension REF: 583 OBJ: 14 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
The nurse caring for a child experiencing an acute asthma attack would include: a. Offering plenty of fluids, particularly carbonated beverages b. Placing the child in a humidified cool mist tent with oxygen c. Administering sedatives as ordered to decrease anxiety d. Positioning the child with arms resting on the overbed table
Ans: C Feedback: In COPD patients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The nurse most likely would not assess chest pain or long, thin fingers; these are not characteristic of emphysema. The patient would not show signs of oxygen toxicity unless he or she received excess supplementary oxygen.
The nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient? A) Signs of oxygen toxicity B) Chronic chest pain C) A barrel chest D) Long, thin fingers
ANS: D The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying position on a firm mattress to prevent SIDS. DIF: Cognitive Level: Application REF: 595 OBJ: 16 TOP: Sudden Infant Death Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). Significant information would be to: a. Wrap the infant snugly for rest periods. b. Position the infant prone for sleep. c. Sit the baby up in an infant seat. d. Place infants on their back or side for sleep.
ANS: A, B, C Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics. Swimming, gymnastics, and baseball fit this criterion. DIF: Cognitive Level: Application REF: 585 OBJ: 13 TOP: Sports Activities Suitable for Asthmatics KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
The nurse would suggest to the parents of an asthmatic child to encourage participation in such activities as: Select all that apply. a. Swimming b. Gymnastics c. Baseball d. Basketball e. Tennis
ANS: C The child experiencing an acute asthma attack will wheeze as air moves in and out of the narrowed airways. The expiratory wheeze is most pronounced. DIF: Cognitive Level: Knowledge REF: 582 OBJ: 13, 14 TOP: Asthma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptatio
The nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, would expect to find: a. Fine crackles b. Coarse rhonchi c. Expiratory wheezing d. Decreased breath sounds at lung bases
ANS: 4 Feedback 1. BPD occurs because of the increased resistance and amount of damaged alveoli, decreasing the amount of oxygen exchange. 2. Scarring occurs on the alveoli that are present. The preemie baby has the same amount of alveoli, but less surface area to ventilate. 3. Neonates do not commonly have respiratory infections to cause an increased risk for BPD. 4. Ventilator assistance with high oxygen flow rate at birth, causing inflammation and scarring in lungs KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Synthesis | REF: Chapter 11 | Type: Multiple Choice
What is the major contributing factor for the development of BPD? 1. Immature lungs have a decreased number of alveoli for gas exchange 2. Premature birth with decreased number of functional alveoli, leading to lung injury 3. Chronic respiratory infections, leading to pulmonary hypertension and lung scarring 4. Ventilator assistance with high oxygen flow rate at birth, causing inflammation and scarring in lungs
ANS: 3 Feedback 1. Given prior to RSV season 2. Not given to the elderly 3. It is given prophylactically before the start of RSV season. The nurse needs to evaluate platelets and coagulants before administering. 4. The nurse needs to evaluate platelets and coagulants before administering.
What is the most accurate statement regarding Palivizumab? 1. It is a humanized monoclonal antibody given as an IM injection before the start of HPV season. 2. It is recommended for premature infants with 29-35 weeks gestation, children with congenital heart defects, and the elderly. 3. It is costly and is given usually between October to May in a series of five injections. 4. Before administering, you need to evaluate results of complete blood count and electrolyte panel from the laboratory.
ANS: 3 Feedback 1. The child may feel comfortable in this position, but it is not the primary reason for the positioning. 2. A child will squat on their haunches when having a bowel movement. 3. The tripod position enables the diaphragm to fully expand and attempt to get as much oxygen into the body as possible. 4. A child who is resting will sit or lie down on the bed. KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Application | REF: Chapter 11 | Type: Multiple Choice
When a nurse enters the room of a child with chronic lung disease, she notes that the child is sitting in a tripod position. Identify the reason for this positioning by the child. 1. The child feels more comfortable playing in this position. 2. The child is attempting to have a bowel movement. 3. The child is having trouble breathing, and the position is comfortable 4. The child is in a resting position after walking in the hallway.
ANS: 4 Feedback 1. Drooling can indicate swelling of the epiglottitis because the secretions are not able to go to the stomach. 2. Dysphonia can occur because of the swelling. 3. Stridor is common because of the swelling of the epiglottitis. 4. Crackles are heard in lower respiratory illnesses, not the upper respiratory illnesses in children. KEY: Content Area: Respiratory | Integrated Processes: Nursing Process | Client Need: Physiological Integrity | Cognitive Level: Comprehension | REF: Chapter 11 | Type: Multiple Choice
When assessing a child with epiglotitus, the nurse should assess for all of the following except: 1. Drooling. 2. Dysphonia. 3. Stridor. 4. Crackles in the upper lungs.