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After change-of-shift report, which patient should the nurse assess first?

64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration.

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)?

A 76-year-old nursing home resident A 36-year-old female patient who is pregnant e. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis

The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?

"I can use my nasal decongestant spray until the congestion is all gone." The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider?

. Respirations are 36 breaths/minute The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications.

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

400 mL of blood in the collection chamber The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock

While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?

Administer the PRN supplemental O2. The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising.

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?

Allergy to shellfish Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media.

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?

Diffuse crackles in the lungs The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment.

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?

Discontinuous, high-pitched sounds of short duration heard on inspiration Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?

Elevate the head of the bed to a semi-Fowler's position. The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started).

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse?

Explain that orange discolored urine and tears are normal while taking this medication. Orange-colored body secretions are a side effect of rifampin.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care?

Frequent use of an incentive spirometer Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis

A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first?

Have the patient occlude the left nare and blow the nose Because the highest priority action is to remove the foreign object from the nare, the nurse's first action should be to assist the patient to remove the object

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask?

How much alcohol do you drink in an average week?" Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest.

Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx?

I will need to buy a water bottle to carry with me." Xerostomia can be partially alleviated by drinking fluids at frequent intervals

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?

I will use the incentive spirometer every hour or two during the day." Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture

A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate?

Keep the patient NPO until the gag reflex returns Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food.

A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding?

Kussmaul respirations Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

Label specimens obtained during percutaneous lung biopsy. Labeling of specimens is within the scope of practice of UAP.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?

Medicate the patient with prescribed morphine A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing).

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

My husband will be sleeping in the guest bedroom." Teach the patient how to minimize exposure to close contacts and household members

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?

Observe for distended neck veins Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected.

The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include?

Options for smoking cessation Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

Oxygen saturation is 88%. Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

Paradoxic chest movement Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia.

A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)?

Patient is allergic to shellfish. d. Blood urea nitrogen (BUN) and serum creatinine levels are elevated. Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary.

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?

Patient reports decreased exertional dyspnea. Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective.

Which action should the nurse take first when a patient develops a nosebleed?

Pinch the lower portion of the nose for 10 minutes. The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils.

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?

Place patients with altered consciousness in side-lying positions The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

Position the patient sitting upright on the edge of the bed and leaning forward. When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed.

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?

Put on sterile gloves and use a sterile catheter to suction This patient needs suctioning now to secure a patent airway.

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?

b. Arrange for a daily noon meal at a community center where the drug will be administered Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication.

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?

b. Identification and avoidance of environmental triggers are the best way to avoid symptoms The most important intervention is to assist the patient in identifying and avoiding potential allergens.

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)?

b. Saline nasal spray can be made at home and used to wash out secretions. c. Decongestants can be used to relieve swelling. d. You will be more comfortable if you keep your head in an upright position. e. Taking a hot shower will increase sinus drainage and decrease pain.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

c. Insertion of a chest tube with a chest drainage system The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage.

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?

c. Keep the patient in semi-Fowler's position The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation.

A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?

d. Assist the patient to splint the chest when coughing. Coughing is less painful and more likely to be effective when the patient splints the chest during coughing.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?

d. Impaired gas exchange related to respiratory congestion All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated?

d. Use a manometer to ensure cuff pressure is at an appropriate level. Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider?

pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider.

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed?

"I must keep the stoma covered with an occlusive dressing at all times."

The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective?

"I should inhale deeply and blow out as hard as I can during the test." For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful?

"I will keep my head elevated for 48 hours to minimize swelling and pain." Maintaining the head in an elevated position will decrease the amount of nasal swelling.

After the nurse has received change-of-shift report, which patient should the nurse assess first?

A patient with possible lung cancer who has just returned after bronchoscopy Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

Appropriate use of cough suppressants Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?

Ask the patient whether medications have been taken as directed. The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly.

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?

Assess the ability to swallow before using the fenestrated tube. Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube.

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Attempt to reinsert the tracheostomy tube with the obturator in place The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway

When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?

Bilateral crackles at lung bases Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?

Blood cultures from two sites Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration.

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?

Briefly ask specific questions about this episode of respiratory distress When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later.

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?

Clear nasal drainage Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease?

Require the use of protective equipment Prevention of lung disease requires the use of appropriate protective equipment such as masks

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?

Sitting upright with the arms supported on an over bed table The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier.

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?

Start an IV so contrast media may be given. Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV.

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy?

Suction the tracheostomy when needed. Suctioning of a stable patient can be delegated to LPNs/LVNs.

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care?

Teach patient to "swish and swallow" prescribed oral nystatin (Mycostatin). Oral or pharyngeal fungal infections are treated with nystatin solution

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?

Teaching patients about the need for adult pertussis immunizations The increased rate of pertussis in adults is thought to be due to decreasing immunity after childhood immunization.

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate?

Tell me what you know about the various treatments available." More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient

The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse?

The oxygen saturation is 89% Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications.

The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?

The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg. All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving?

The patient asks how to clean the tracheostomy stoma and tube. Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective?

The patient's white blood cell (WBC) count is 9000/µL. The normal WBC count indicates that the antibiotics have been effective

The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills?

The student places the stethoscope over the posterior chest and listens during inspiration Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented?

Three sputum smears for acid-fast bacilli are negative. Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?

Use a swab to obtain a sample for a rapid strep antigen test. The patient's clinical manifestations are consistent with streptococcal pharyngitis and the

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?

Use and side effects of isoniazid (INH) The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Weak, nonproductive cough effort The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively.

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the best response by the nurse?

You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration." Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication