RD QUESTIONS NU102

The nurse is teaching the principles of tracheostomy care to a family member. Which statements by the family member indicate a need for further instruction? Select all that apply. 1. "As long as the client can cough, suctioning should not be performed." 2. "Two people should be present when changing the ties on the tracheostomy tube." 3. "A suctioning session should last 10 seconds, but never more than 15 seconds." 4. "Suction pressure should be exerted when inserting and removing the catheter." 5. "Suctioning is indicated when there is a large amount of secretions."

Correct response: "Suction pressure should be exerted when inserting and removing the catheter." "As long as the client can cough, suctioning should not be performed." Explanation: Lack of knowledge would be indicated by applying suction pressure when inserting and removing the catheter. Suction is applied only when removing the suction catheter. Coughing may be an indication of secretions that have accumulated and cannot be expelled. An inability to clear the airway may suggest the need for suctioning.

A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. What should the nurse do first? 1. Call for emergency assistance. 2. Insert the obturator into the stoma to reestablish the airway. 3. Attempt reinsertion of tracheostomy tube. 4. Position the client in semi-Fowler's position with the neck hyperextended.

Correct response: Attempt reinsertion of tracheostomy tube. Explanation: The nurse's first action should be to attempt to replace the tracheostomy tube immediately so that the client's airway is reestablished. Although the nurse may also call for assistance, there should be no delay before attempting reinsertion of the tube. The client is placed in a supine position with the neck hyperextended to facilitate reentry of the tube. The obturator is inserted into the replacement tracheostomy tube to guide insertion and is then removed to allow passage of air through the tube.

The nurse is repositioning a client with a chest tube in bed when the chest tube accidentally becomes disconnected from the chest tube container. What is the nurse's priority action at this time?

Correct response: Immediately tell the client to cough or exhale forcibly while the wound is covered with an occlusive dressing. Explanation: Instructing the client to exhale forces air out and allows the space to be covered before a sucking chest wound occurs. The wound needs to be covered with an occlusive dressing to prevent leak of air. Breathing slowly will still allow air re-entry.

Which instructions should the nurse give to a client who is being discharged with a laryngectomy? 1. Avoid showering; take tub baths instead. 2. Obtain exercise by participating in activities such as walking. 3. Keep the stoma opening covered at all times. 4. Stay inside in an air-conditioned environment in the summer.

Correct response: Obtain exercise by participating in activities such as walking. Explanation: The nurse can instruct the client with a laryngectomy that it is safe to participate in activities such as walking and other moderate recreational sports. It is not necessary to keep the stoma covered at all times, although a gauze bib can be used to protect the clothes from mucus and to keep irritants from entering the stoma. Clients with a new laryngectomy may find air-conditioning too cool and dry at first, so they should avoid such environments. It is not necessary to remain in air-conditioning in the summer. Clients may shower as long as they cover the stoma to prevent water from entering the airway.

The nurse is caring for a client that is having an anaphylactic reaction. The client is wheezing, dyspneic, and cyanotic. Place the interventions in chronological order. All options must be used. You Selected: Provide supplemental oxygen. Administer epinephrine 1:1000 subcutaneously. Start a peripheral IV. Administer normal saline. Document interventions and response to treatment. Educate the client about prevention of anaphylaxis.

Correct response: Provide supplemental oxygen. Administer epinephrine 1:1000 subcutaneously. Start a peripheral IV. Administer normal saline. Document interventions and response to treatment. Educate the client about prevention of anaphylaxis. Explanation: Management depends on the severity of the reaction. Since the client is exhibiting respiratory distress, supplemental oxygen must be provided. Epinephrine, in a 1:1,000 dilution, is administered subcutaneously. Intravenous fluids are administered to maintain blood pressure and normal hemodynamic status. The nurse documents the interventions used, and the client's vital signs and response to treatment. The client who has recovered from anaphylaxis needs instruction about antigens that should be avoided and about other strategies to prevent recurrence of anaphylaxis.

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.7 kPa); HCO3-, 24 mEq/L (24 mmol/l). The nurse determines that which of the following is a possible cause for these findings? 1. Chronic obstructive pulmonary disease (COPD). 2. Diabetic ketoacidosis with Kussmaul respirations. 3. Myocardial infarction. 4. Pulmonary embolus.

Correct response: Pulmonary embolus. Explanation: A PaCO2 of 28 mm Hg (3.7 kPa) and PaO2 of 50 mm Hg (6.7 kPa) are both abnormal; the PaO2 of 50 mm Hg (6.7 kPa) signifies acute respiratory failure. In evaluating possible causes for this disorder, the nurse should consider conditions that lead to hypoxia and hyperventilation, such as pulmonary embolus. COPD is typically associated with respiratory acidosis and elevated PaCO2. The client with diabetic ketoacidosis most often has metabolic acidosis. A myocardial infarction does not often cause an acid-base imbalance because the primary problem is cardiac in origin.

Which information should the nurse include in a postoperative teaching plan for a client with a laryngectomy? 1. Instruct the client to control oral secretions by swabbing them with tissues or by expectorating into an emesis basin. 2. Reassure the client that normal eating will be possible after healing has occurred. 3. Instruct the client to avoid coughing until the sutures are removed. 4. Tell the client to speak by covering the stoma with a sterile gauze pad.

Correct response: Reassure the client that normal eating will be possible after healing has occurred. Explanation: Normal eating is possible once the suture line has healed.Coughing is essential to keep the airway patent.Because the larynx has been removed, the ability to speak is lost.Swallowing is usually not affected nor is the ability to control oral secretions.

The RN is working with a student nurse. The student nurse is to teach a client how to use a metered-dose inhaler without a spacer. Place the steps in the correct order. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1. Open mouth and place the mouthpiece 1-2 inches away. 2. Remove cap and shake inhaler. 3. Press down on the canister and breathe deeply through the mouth. 4. Hold breath for 10 seconds. 5. Wait 1 minute between each puff. 6. Tilt head back and breathe out fully.

Correct response: Remove cap and shake inhaler. Tilt head back and breathe out fully. Open mouth and place the mouthpiece 1-2 inches away. Press down on the canister and breathe deeply through the mouth. Hold breath for 10 seconds. Wait 1 minute between each puff. Explanation: Before each use, the cap is removed and the inhaler is shaken. The client should tilt the head back and breathe out completely. As the client breathes in, the canister should be pressed down to release one puff of the medication. The client should breathe in slowly and then hold their breath for 10 seconds to allow the medication to reach the lungs. The client should wait 1 minute between puffs.

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply.

Correct response: a client who is on complete bed rest following extensive spinal surgery a client who has a large venous stasis ulcer on the right ankle area a client who has recently been admitted with a broken femur and is awaiting surgery a client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy Explanation: Bed rest, poor venous circulation, fractures, and hormone replacement therapy can cause formation of a thromboembolism, placing these clients at risk for developing a PE. A deep vein thrombosis could break loose in the leg and travel to the lungs as a pulmonary embolus. The clot would then lodge in the pulmonary arteries or arterioles and impede blood flow. The client who is on complete bed rest is at risk for venous stasis, and the client who has a venous stasis ulcer is already demonstrating this condition. The client with a broken femur is at risk for a fat embolus, another form of PE. The client on estrogen replacement therapy is at increased risk for thromboembolic disorders. Pleural effusion and infection usually have no effect on thrombus formation, and oxygen therapy does not cause venous stasis or increase the risk of a pulmonary embolism.

The nurse is assessing a client with a right pneumothorax. Which assessment findings would be expected? Select all that apply. 1. inspiratory wheezes in the right thorax 2. bilateral pleural friction rub 3. chest pain on inspiration 4. absence of breath sounds in the right thorax 5. tracheal shift to the right

Correct response: absence of breath sounds in the right thorax chest pain on inspiration Explanation: In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. The trachea will shift to the unaffected side. Commonly chest pain occurs on inspiration.

A client with a suspected pulmonary embolus is brought to the emergency department reporting shortness of breath and chest pain. Which additional signs and symptoms are anticipated? Select all that apply. 1. tachycardia 2. anxiety 3. frothy sputum 4. bradycardia 5. irregular heartbeat 6. blood-tinged sputum

Correct response: anxiety irregular heartbeat tachycardia blood-tinged sputum Explanation: A pulmonary embolism (PE) is a blockage to one or more arteries in the lungs. In addition to pleuritic chest pain and dyspnea, a client with a pulmonary embolus may be anxious and present with a low-grade fever, tachycardia, an arrhythmia, and blood-tinged sputum. Frothy sputum would indicate pulmonary edema. A client with a pulmonary embolus is tachycardic (to compensate for decreased oxygen supply), not bradycardic.

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. What will the nurse report? Select all that apply. 1. arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 2. administration of a corticosteroid inhaler for quick relief 3. increased respiratory effort 4. decreased respiratory rate 5. nasal flaring with abdominal retractions 6. lung sounds of stridor

Correct response: arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 nasal flaring with abdominal retractions lung sounds of stridor increased respiratory effort Explanation: The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor ,and an increased respiratory effort. Also, arterial blood gases with an elevated CO2 and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratory compromise. Administration of a corticosteroid decreases inflammation over a period of time.

A nurse is caring for a client with a traumatic injury and developing tension pneumothorax. Which assessment data would be of concern? Select all that apply.

Correct response: decreased cardiac output hypotension tracheal deviation to the opposite side Explanation: Tension pneumothorax results when air in the pleural space is under higher pressure than air in the adjacent lung. The site of the rupture of the pleural space acts as a one-way valve, allowing the air to enter on inspiration but not to escape on expiration. The air presses against the mediastinum, causing a tracheal shift to the unaffected side and decreased venous return (reflected by decreased cardiac output and hypotension). Neck veins bulge with tension pneumothorax. This also leads to compensatory tachycardia and tachypnea.

The nurse administers two 325-mg aspirin every 4 hours to a client with pneumonia. The nurse should evaluate the outcome of administering the drug by assessing which findings? Select all that apply. 1. decreased pain when breathing 2. increased ability to expectorate secretions 3. decreased temperature 4. prolonged clotting time 5. decreased respiratory rate

Correct response: decreased pain when breathing decreased temperature Explanation: Aspirin is administered to clients with pneumonia because it is an analgesic that helps control chest discomfort and an antipyretic that helps reduce fever. Aspirin has an anticoagulant effect, but that is not the reason for prescribing it for a client with pneumonia, and the use of the drug will be short term. Aspirin does not affect the respiratory rate and does not facilitate expectoration of secretions.

A nurse is reviewing the medications used by a client who has chronic bronchitis and a history of high blood pressure and prostate enlargement. The nurse should verify that the client understands that which medications should be avoided because of the risks they pose? Select all that apply. 1. lisinopril tablets 2. albuterol and ipratropium by metered-dose inhaler 3. tamsulosin 4. generic pseudoephedrine tablets 5. guaifenesin with dextromethorphan liquid

Correct response: guaifenesin with dextromethorphan liquid generic pseudoephedrine tablets Explanation: The cough reflex for these clients promotes airway clearance. While the guaifenesin may thin secretions and facilitate expectoration, dextromethorphan suppresses the cough and should not be used with chronic bronchitis. Pseudoephedrine can increase blood pressure and increase urinary retention with an enlarged prostate and should be avoided. The albuterol and ipratropium is expected, since it promotes bronchial dilation. Lisinopril is an ACE inhibitor and useful in reducing blood pressure. The tamsulosin is commonly prescribed to treat benign prostate hypertrophy.

The nurse is caring for a client who is suspected to have overdosed on opioids. Assessment findings include a heart rate of 60 beats/minute, respiratory rate of 6 breaths/minute, a blood pressure of 95/55 mmHg, and an oxygen saturation of 96% on room air. Based on the assessment findings, what is the nurse's priority concern? 1. hypoxic respiratory failure 2. hypercapnic respiratory failure 3. total airway occlusion 4. decreased organ perfusion

Correct response: hypercapnic respiratory failure Explanation: When ventilation is impaired, as is indicated by the low respiratory rate of 6 breaths/minute, the body retains CO2 because the carbonic acid level increases in the blood. The client's oxygen saturation is in an acceptable range, so hypoxia and airway occlusion are not evident at present. The blood pressure is low but has an adequate mean arterial pressure (MAP) of 68 mmHg, which is adequate for organ perfusion. Preferred MAP is > 65 mmHg, and an adequate MAP for perfusion is > 60 mmHg.

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate in a client with these arterial blood gas results? 1. increase in rate and depth of respirations 2. decrease in the rate of respirations and increase in depth 3. decrease in rate and depth of respirations 4. increase in the rate of respirations and decrease in the depth

Correct response: increase in rate and depth of respirations Explanation: The medulla in the brainstem is the respiratory center. The medulla is stimulated by an increased concentration of carbon dioxide and hydrogen ions and, to a lesser degree, by the decreased amount of oxygen in the arterial blood. Stimulation of the medulla increases the rate and depth of ventilation to blow off carbon dioxide and hydrogen and increase oxygen levels. This compensatory mechanism causes the patient to breathe faster and more deeply.

The nurse is caring for several clients on the respiratory unit who are receiving the β-adrenergic agonist bronchodilator albuterol in the prescribed nebulizer treatments. Which side effects would the nurse expect to assess following administration? Select all that apply. 1. insomnia 2. irritability and nervousness 3. anxiety 4. tachycardia 5. increased tachypnea 6. increased somnolence

Correct response: irritability and nervousness tachycardia insomnia anxiety Explanation: Albuterol is prescribed to prevent and treat wheezing, difficulty breathing, and chest tightness caused by lung diseases such as asthma and chronic obstructive lung disease (COPD). Irritability, nervousness, tachycardia, insomnia, and anxiety are common side effects of β-adrenergic agonist bronchodilators that result from sympathetic nervous system stimulation. The expected therapeutic effect of a bronchodilator is decreased dyspnea and slower (not increased) breathing. Increased somnolence does not occur with sympathetic nervous system stimulation.

A client with asthma is being discharged to home with a peak flow meter. Which healthcare team members are most appropriate to reinforce client teaching with peak flow monitoring? Select all that apply. 1. respiratory therapist 2. unlicensed assistive personnel 3. physical therapist 4. vocational nurse 5. occupational therapist

Correct response: respiratory therapist vocational nurse Explanation: The respiratory therapist and vocational nurse are able to reinforce teaching with the peak flow meter. The occupational therapist and physical therapist are therapy and not able to teach about a peak flow meter. The therapists can reinforce peak flow teaching. The unlicensed personnel does not have teaching within the scope of practice.

A client with emphysema has been admitted to the hospital. The nurse should assess the client further for which symptom? 1. bronchospasms 2. underweight appearance 3. copious sputum 4. frequent coughing

Correct response: underweight appearance Explanation: The client with emphysema is commonly underweight in appearance. The weight loss may be caused by the increased energy required to support the work of breathing. Frequent coughing, bronchospasms, and copious sputum are clinical manifestations of chronic bronchitis.

The nurse is preparing the client diagnosed with pleural effusion for a left-sided thoracentesis. The X-ray shows fluid in the pleural cavity. During the preparation for the procedure, the client asks where the health care provider (HCP) will "put the needle." Select the appropriate site from the diagram.

Explanation: The fluid typically localizes at the base of the thorax.