RESPIRATORY
What is an expected outcome for an adult client with well-controlled asthma? 1. Chest x-ray demonstrates minimal hyperinflation. 2. Temperature remains lower than 100°F (37.8°C). 3. Arterial blood gas analysis demonstrates a decrease in PaO2 . 4. Breath sounds are clear.
4. Between attacks, breath sounds should be clear on auscultation with good airflow present throughout lung fields. Chest x-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal.
How will the nurse teach the client to assess response to asthma therapy at home?a. "Keep a daily symptom and intervention diary."b. "Measure your chest circumference every week."c. "Note your symptoms when you don't take your medications."d. "Use proper technique and correct sequence with your metered dose inhaler."
ANS: A The nurse should tell the client to keep a daily symptom diary. This will help identify triggers and responses to therapy in asthma. Chest circumference is not expected to change in clients with asthma. The client should not be instructed to discontinue medications. Teaching proper technique with inhalers is appropriate; however, this will not assist in assessing response to therapy.
The nurse is assessing a client with COPD. Which requires immediate intervention? 1. distant heart sounds 2. diminished lung sounds 3. inability to speak 4. pursed-lip breathing
3. Inability to speak could indicate respiratory distress. Pursed-lip breathing, while it is an abnormal finding, is not indicative of respiratory distress. Distant heart sounds could indicate heart failure but are not 985 indicative of any distress. Diminished lung sounds may be normal for this client, and do not require immediate intervention
Clients who have had active tuberculosis are at risk for recurrence. Which condition increases that risk? 1. cool and damp weather 2. active exercise and exertion 3. physical and emotional stress 4. rest and inactivity
3. Tuberculosis can be controlled but never completely eradicated from the body. Periods of intense physical or emotional stress increase the likelihood of recurrence. Clients should be taught to recognize the signs and symptoms of a potential recurrence. Weather and activity levels are not related to recurrences of tuberculosis.
Which diet would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)? 1. low-fat, low-cholesterol diet 2. bland, soft diet 3. low-sodium diet 4. high-calorie, high-protein diet
4. The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated. There is no need for the client to eat bland, soft foods.
A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?A. Simple maskB. Non-rebreather maskC. Face tentD. Nasal cannula
B. Non-rebreather mask Explanation:A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.
The RN is preparing to give a bed bath to an immobilized pt w/ TB. The RN should wear which item when performing this care? A. Surgical mask and gloves. B. Particulate respirator, gown, and gloves C. Particulate respirator and protective eyewear D. Surgical mask, gown, and protective eyewear
B. Particulate respirator, gown, and gloves.
The nurse is providing follow-up care to a client with tuberculosis who does not regularly take the prescribed medication. Which nursing action would be most appropriate for this client? 1. Ask the client's spouse to supervise the daily administration of the medications. 2. Visit the client weekly to verify compliance with taking the medication. 3. Notify the healthcare provider (HCP) of the client's noncompliance, and request a different prescription. 4. Remind the client that tuberculosis can be fatal if it is not treated promptly.
1. Directly observed therapy (DOT) can be implemented with clients who are not compliant with drug therapy. In DOT, a responsible person, who may be a family member or an HCP , observes the client taking the medication. Visiting the client, changing the prescription, or threatening the client will not ensure compliance if the client will not or cannot follow the prescribed treatment
Which instruction should the nurse include in the discharge teaching plan for a client with asthma? 1. Incorporate physical exercise as tolerated into the daily routine. 2. Monitor peak flow numbers after meals and at bedtime. 3. Eliminate stressors in the work and home environment. 4. Use sedatives to ensure uninterrupted sleep at night.
1. Physical exercise is beneficial and should be incorporated as tolerated into the client's schedule. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Peak flow does not need to be monitored after each meal. Stressors in the client's life should be modified but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep.
The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which instruction should be included? 1. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation. 2. Lie flat on the back, splint the thorax, take two deep breaths, and cough. 3. Take several rapid, shallow breaths, and then cough forcefully. 4. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing
1. The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process three or four times, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation ("huff" cough). Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing.
When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects: 1. while inhaling through an open mouth. 2. while exhaling through pursed lips. 3. after exhaling but before inhaling. 4. while taking a deep breath and holding it.
2. Exhaling requires less energy than does inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to Valsalva's maneuver, which can stimulate cardiac arrhythmias.
The nurse should teach the client with asthma to avoid which of the most common precipitating factors of an acute asthma attack? 1. occupational exposure to toxins 2. Valsalva maneuver 3. exposure to cigarette smoke 4. exercising in cold temperatures
3. A common precipitator of asthma attacks is exposure to cigarette and cigar smoke. The client should avoid being in environments where there is exposure to smoke. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to smoke. Valsalva's maneuver (holding the breath while defecating or bearing down) is associated with causing cardiac arrhythmias. Rarely, asthmatic attacks are triggered by exercising in cold weather.
A nurse is providing information to a group of clients at a local community center about tuberculosis. Which of the following clinical manifestations should be included in the teaching (select all).A. persistent coughB. weight gainC. fatigueD. night sweatsE. purulent sputum
A,C,D,E Rationale: Persistent cough, fatigue, night sweats and purulent sputum are all manifestations of tuberculosis.
A patient is complaining of dyspnea, SOB, chest pain. What is the nurse's priority action?a.) Apply the nasal cannula @ 2l/minb.) Notify the physicianc.) Assess the vital signs and perform a physical assessmentd.) Encourage the patient to cough and deep breatheing
C.) Assess the vital signs and do a physical assessment.__________D.) is correct but it is not the first action the nurse will take because the priority at the moment is to check the vital signs and do an assessment, whereas encouraging the patient to cough and deep breathing is an intervention (remember the nursing process).A.) is correct but is also an intervention which will occur after the nurse has gathered enough data through assessment.B.) Is not the correct option because the nurse does not have enough assessment data to give to the doctor and secondly the situation is within the scope of the nurse to handle.
When assessing a client with asthma, which findings would most likely indicate the presence of a respiratory infection? 1. cough productive of yellow sputum 2. bilateral expiratory wheezing 3. chest tightness 4. respiratory rate of 30 breaths/min
1. A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all findings associated with an asthma attack and do not necessarily mean an infection is present.
A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; Pco2 48 mm Hg (6.4 kPa); Po2 58 mm Hg (7.7 kPa); HCO3 26 mEq/L(26 mmol/L). Which prescriptions should the nurse implement first? 1. albuterol nebulizer 2. chest x-ray 3. ipratropium inhaler 4. sputum culture
1. The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.
The nurse cares for a patient with a diagnosis of tuberculosis. Which assessment finding best indicates that the patient has been following the prescribed treatment plan? 1Negative sputum cultures 2Clear breath sounds bilaterally 3Decrease in the number of coughing episodes 4Conversion of the Mantoux test from positive to negative
1Negative sputum culturesA patient's sputum is expected to convert to negative within three months of the beginning of treatment. If it does not, the patient is either not taking the medication or has drug-resistant organisms. Bilaterally clear breath sounds and a decrease in coughing are good indications that the patient is following the prescribed plan, but they are not as confirmatory as negative sputum cultures. Once a person has been exposed to the tuberculosis-causing organism, the Mantoux test will always elicit a positive result
When can airborne infection isolation for a patient with pulmonary tuberculosis (TB) be discontinued? 1Once isoniazid drug therapy has been initiated 2After three consecutive acid-fast bacillus (AFB) smears are negative 3After effective instruction on the use of a high-efficiency particulate air (HEPA) mask 4When two consecutive negative x-ray results are confirmed
2 After three consecutive acid-fast bacillus (AFB) smears are negativeAirborne infection isolation is indicated for the patient with pulmonary or laryngeal TB until the patient is noninfectious (defined as effective drug therapy, clinical improvement, and three negative AFB smears). Therapy must be deemed effective. Teaching the patient to properly use the HEPA mask isn't a criterion for terminating isolation. Chest x-rays are not criteria to terminate isolation.
The nurse is instructing a client with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. In which order from first to last should the nurse explain the steps to the client? All options must be used. 1. "Breathe in normally through your nose for two counts (while counting to yourself, one, two)." 2. "Relax your neck and shoulder muscles." 3. "Pucker your lips as if you were going to whistle." 4. "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four).
2,1,3,4. The nurse should first instruct the client to relax the neck and the shoulders and then take several normal breaths. After taking a breath in, the client should pucker the lips and finally breathe out through pursed lips.
The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statements indicate that the client has understood the nurse's instructions? Select all that apply. 1. "I will need to dispose of my old clothing when I return home." 2. "I should always cover my mouth and nose when sneezing." 3. "It is important that I isolate myself from family when possible." 4. "I should use paper tissues to cough in and dispose of them promptly." 5. "I will avoid crowds."
2,4. When teaching the client how to avoid the transmission of tubercle bacilli, it is important for the client to understand that the organism is transmitted by droplet infection. Therefore, covering the mouth and nose when sneezing, using paper tissues to cough in with prompt disposal, indicates that the client has understood the nurse's instructions about preventing the spread of airborne droplets. It is not essential to discard clothing, nor does the client need to be isolated from family members. The client does not need to avoid crowds.
Which finding is an expected outcome for an elderly client following treatment for bacterial pneumonia? 1. a respiratory rate of 25 to 30 breaths/min 2. the ability to perform activities of daily living without dyspnea 3. a maximum loss of 5 to 10 lb (2 to 5 kg) of body weight 4. chest pain that is minimized by splinting the rib cage
2. An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/min indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 lb (2.27 to 4.53 kg) is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.
The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). The results are as follows: pH 7.35; Pco2 62 (8.25 kPa); Po2 70 (9.31 kPa); HCO3 34 mEq/L(34 mmol/L). The nurse should first: 1. apply a 100% nonrebreather mask. 2. assess the vital signs. 3. reposition the client. 4. prepare for intubation.
2. Clients with chronic COPD have CO2 retention, and the respiratory drive is stimulated when the Po2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. After assessing the vital signs, the nurse should assist the client as needed to assume the most comfortable position for breathing. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation
A client is experiencing an acute asthmatic attack. Prior to treatment with levalbuterol, respirations were 40 breaths/min, pulse 132 beats/min, oxygen saturation 86% on room air, and with audible wheezing. Which findings indicate achievement of the desired outcome of asthma treatment? 1. decreased peak expiratory flow (PEF) rate 2. wheezing inaudible with diminished breath sounds 3. pulse 96 bpm and SpO2 92% on room air 4. inspiratory cycle twice as long as the expiratory cycle
3. Quick-acting bronchodilators are used in acute asthma to improve airflow and relieve symptoms; following treatment, tachycardia resolves as gas exchange and work of breathing are improved. SpO2 and PEF rates improve, and wheezing from a constricted airway resolves. The normal inspiratory to expiratory ratio is 1:2.
The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis? 1. hand hygiene 2. contact precautions 3. droplet precautions 4. airborne precautions
4. Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., Mycobacterium tuberculosis, measles, varicella virus [chickenpox], and possibly SARS-CoV). The preferred placement is in an isolation singleclient room that is equipped with special air handling and ventilation. A negative pressure room, or an area that exhausts room air directly outside or through HEPA filters, should be used if recirculation is unavoidable.
Which patient should be the nurse's first priority? a.) A patient whose airway is obstructed by mucous b.) A patient expressing difficulty with breathing c.) A patient whose extremities are cyanotic d.) A patient who is hyperventilating
A.) is correct- because a patient with a compromised airway is the priority based on the ABC framework. This patient is not able to take any oxygen in which can quickly progress to hypoxia and lead to chest pain and cardiac arrest if not promptly treated. B.)- could be correct but this patient is not the priority based on the ABC framework C.)- this patient is not the priority because of the ABC framework. D.)- This patient is also not the priority at the moment because they could be hyperventilating due to anxiety
The nurse auscultates crackles bilaterally at the bases of the lungs for a patient who has CHF. SpO2 is normal and respirations are 14/min What intervention should the nurse apply? a.) administer diuretics and monitor fluid intake b.) administer a nebulizer c.) Adminsiter oxygen via nasal cannula d.) encourage coughing
A.)- is correct because it treats the underlying cause of the crackles which is CHF. Diuretics help excrete water which decreases fluid volume and pressure that can help displace the fluid accumulated in the lungs due to altered capillary pressure. B, C, D- do not treat the underlying cause
During morning assessment the nurse hears audible wheezing. He finds that the patient's SPO2 is 94% and respirations are 24/minute. What should the nurse do?a.) give bronchodilator b.) apply oxygen via nasal prongs c.) notify the physician d.) raise the head of the bed
A.)- is correct because the patient is going through bronchospasms. B.)- is incorrect because the problem is with taking oxygen in, not with the amount of oxygen saturation in the body C.)- is incorrect because the nurse can handle the situation D.)- is incorrect because in this situation the patient's wheezing is audible and wheezing always indicates bronchoconstriction. Additionally, their respirations are elevated meaning the body is compensating by taking more breaths, in an effort to get more oxygen. Raising the hed of the bed will not open up the airways enough. So a bronchodilator will be the best choice for this patient.
During morning assessment the nurse hears crackles upon auscultation. He finds that the patient's SPO2 is 96% and respirations are 16/minute. What should the nurse do? (select all that apply) a.) give bronchodilator b.) apply oxygen via nasal prongs c.) encourage the patient to cough and deep breathe. d.) raise the head of the bed
C&D- are correct. Crackles indicate fluid buildup in the alveoli. So letting the patient sit up and encouraging to cough and deep breathe will displace the fluid from the bases on the lungs. A.)- is incorrect because the respirations are normal B.)- is incorrect because oxygen saturation is normal
A nurse is caring for a client diagnosed with TB. Which assessment, if made by the nurse, would not be consistent with the usual clinical presentation of TB and may indicate the development of a concurrent problem? ANonproductive or productive cough BAnorexia and weight loss CChills and night sweats DHigh-grade fever
D)The client with TB usually experiences cough (non-productive or productive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.
Before weaning a patient off of oxygen who suffers from asthma and COPD, what should the nurse do? a.) Check his O2 sats b.) Obtain vital signs c.) perform a physical assessment d.) Ensure the patient has not received any bronchodilators 20mins prior
D.) is correct- because if the patient has received bronchodilators prior to weaning them off oxygen then it can positively skew their SPO2 levels. A.)- is incorrect because you should constantly be monitoring their oxygen saturation throughout the process. The oxygen monitor should be on the patient's finger constantly. it should not be off.B&C.)- are incorrect because they are not relevant to weaning someone off of oxygen
What would the nurse monitor for before applying oxygen to a COPD patient? a.) breath sounds b.) heart rate c.) BP d.) respirations
D.) is correct- the nurse will need to monitor a patient's respirations before and (even during ) therapy to ensure that the patient does not stop breathing, because they might be a CO2 retainer (err on the side of caution) A.)- is incorrect because monitoring for breath sounds is not relevant to applying the oxygen in a COPD patient. It is not a priority assessment. C&D.) are incorrect- because these are not relevant before applying oxygen. Will matter afterwards because the heart rate and blood pressure would come down.
A patient receiving medical treatment for an active tuberculosis infection asks when she can starting going out in public again. You respond that she is no longer contagious when: A. She has 3 negative sputum cultures B. Her signs and symptoms improve C. She has completed the full medication regime D. Her chest x-ray is normal E. She has been on tuberculosis medications for about 3 weeks
The answers are A, B, and E. These are all criteria for when a patient with active TB can return to public life (school, work, running errands). Until then they are still contagious and must stay home in isolation.
Which assessment findings by the nurse would indicate the need for providing oxygen therapy? (select all that apply) a.) hypoxia b.) hypoxemia c.) anemia d.) chest pain e.) pneumothorax f.) low cardiac output g.) shock and trauma h. resuscitation
A, B, D, E, F, G, H - all would require oxygen c.) anemic patients will not benefit from oxygen therapy
A client with bacterial pneumonia is to be started on IV antibiotics. Which diagnostic test must be completed before antibiotic therapy begins? 1. urinalysis 2. sputum culture 3. chest radiograph 4. red blood cell count
2. A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Urinalysis, a chest radiograph, and a red blood cell count do not need to be obtained before initiation of antibiotic therapy for pneumonia.
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which steps should be included? Select all that apply. 1. Splint or support the incision to promote maximal comfort. 2. Inhale slowly through the nostrils; exhale through pursed lips. 3. Hold the breath for about 5 seconds to expand the alveoli. 4. Repeat this breathing method 5 to 10 times hourly. 5. Close one nostril while inhaling.
1,2,3,4. Splinting the incision is important to avoid stress on the surgical site and to promote comfort so that the client will adhere to the plan of care. Inhaling through the nostrils and exhaling through pursed lips are important to bring in adequate oxygen and clear out carbon dioxide; however, closing one nostril when inhaling would be inappropriate and ineffective. The most important step is asking the client to hold the inhaled breath for about 5 seconds, which keeps the alveoli expanded. This step should be stressed the most. Repeating the exercise 5 to 10 times hourly is the second most important point to emphasize in this teaching plan
The client with chronic obstructive pulmonary disease (COPD) is taking theophylline. The nurse should instruct the client to report which signs of theophylline toxicity? Select all that apply. 1. nausea 2. vomiting 3. seizures 4. insomnia 5. vision changes
1,2,3,4. The therapeutic range for serum theophylline is 10 to 20 mcg/mL(55.5 to 111 μmol/L). At higher levels, the client will experience signs of toxicity such as nausea, vomiting, seizures, and insomnia. The nurse should instruct the client to report these signs and to keep appointments to have theophylline blood levels monitored. If the theophylline level is below the therapeutic range, the client may be at risk for more frequent exacerbations of the disease.
Which findings are significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1. quality of breath sounds 2. presence of bowel sounds 3. occurrence of chest pain 4. amount of peripheral edema 5. color of nail beds
1,3,5. A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the client with pneumonia.
When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the client to expect to: 1. develop respiratory infections easily. 2. maintain current status. 3. require less supplemental oxygen. 4. show permanent improvement.
1. A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.
Which is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? 1. maintaining functional ability 2. minimizing chest pain 3. increasing carbon dioxide levels in the blood 4. treating infectious agents
1. A priority goal for the client with COPD is to manage the signs and symptoms of the disease process so as to maintain the client's functional ability. Chest pain is not a typical symptom of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.
A 79-year-old client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which client information would most likely be a predisposing factor for the diagnosis of pneumonia? 1. age 2. osteoarthritis 3. vegetarian diet 4. daily bathing
1. The client's age is a predisposing factor for pneumonia; pneumonia is more common in elderly or debilitated clients. Other predisposing factors include smoking, upper respiratory tract infections, malnutrition, immunosuppression, and the presence of a chronic illness. Osteoarthritis, a nutritionally sound vegetarian diet, and frequent bathing are not predisposing factors for pneumonia.
The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusing. Despite the nurse's attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observation, in which order should the nurse implement interventions to ensure the client's safety? All options must be used. 1. Review the client's medications for interactions that may cause or increase confusion. 2. Assess the client's respiratory status including oxygen saturation. 3. Ensure the client does not need toileting or pain medications. 4. Contact the healthcare provider (HCP), and request a prescription for soft wrist restraints.
2,3,1,4. The nurse should first assess the client's respiratory status to determine if there is a physiological reason for the client's confusion. Other physiological factors to assess include pain and elimination. Safety needs including medication interactions should then be evaluated. Requesting restraints in order to maintain client safety should be used as a last resort.
The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? 1. offering the client emotional support 2. teaching the client about the disease and its treatment 3. coordinating various agency services 4. assessing the client's environment for sanitation
2. Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. Offering the client emotional support, coordinating various agency services, and assessing the environment may be part of the care for the client with tuberculosis; however, these interventions are of less importance than education about the disease process and its treatment.
A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for: 1. a mild but constant aching in the chest. 2. severe midsternal pain. 3. moderate pain that worsens on inspiration. 4. muscle spasm pain that accompanies coughing.
3. Chest pain in pneumonia is generally caused by friction between the pleural layers. It is more severe on inspiration than on expiration, secondary to chest wall movement. Pleuritic chest pain is usually described as sharp, not mild or aching. Pleuritic chest pain is not localized to the sternum, and it is not the result of a muscle spasm.
On the day of surgery, a client has been breathing room air. The vital signs are normal, and the O2 saturation is 89%. The nurse should first: 1. lower the head of the bed. 2. notify the healthcare provider (HCP). 3. assist the client to take several deep breaths and cough. 4. administer oxygen by nasal cannula as prescribed at 2 L/min
3. Deep breathing and coughing help to increase lung expansion and prevent the accumulation of secretions in postoperative clients. An O2 saturation of 89% is not an unexpected or emergent finding immediately following surgery. Frequent coughing and deep breathing will likely quickly remedy an O2 saturation of 89% but will also effectively help to prevent atelectasis and pneumonia in the remainder of the postoperative period
A client with pneumonia has a temperature of 102.6°F (39.2°C), is diaphoretic, and has a productive cough. The client is able to ambulate. What should the nurse do? 1. Change the client's position every 4 hours. 2. Use nasotracheal suctioning to clear secretions. 3. Change the bedsheets frequently. 4. Offer the use of a bedpan every 2 hours.
3. Frequent changes of the bedsheets are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort, and the client should be kept dry to promote comfort and prevent skin irritation. The client should change position every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. The client can ambulate to the bathroom, but the nurse should offer assistance as needed.
The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client's oxygen therapy can be best determined by the: 1. absence of cyanosis. 2. client's respiratory rate. 3. arterial blood gas values. 4. client's level of consciousness.
3. The client's ABG levels are the most sensitive indicator of the effectiveness of the client's oxygen therapy. Cyanosis is a late sign of decreased oxygenation and is not a reliable indicator. The client's respiratory rate and level of consciousness may be altered because of other problems not related to the client's oxygenation.
The nurse is caring for a client who has asthma. The nurse should conduct a focused assessment to detect: 1. increased forced expiratory volume. 2. normal breath sounds. 3. inspiratory and expiratory wheezing. 4. morning headaches.
3. The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume (forced expiratory flow [FEF] is the flow [or speed] of air coming out of the lung during the middle portion of a forced expiration) due to bronchial constriction. Morning headaches are found in more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.
A patient who has tuberculosis (TB) is being treated with combination drug therapy. The nurse explains that combination drug therapy is essential because:Recommendations for the initial treatment of tuberculosis 1It minimizes the required dosage of each of the medications. 2It helps reduce the unpleasant side effects of the medications. 3It shortens amount of time that the treatment regimen will be needed. 4It discourages the development of resistant strains of the TB organism
4 It discourages the development of resistant strains of the TB organismRecommendations for the initial treatment of tuberculosis (TB) include a four-drug regimen until drug susceptibility tests are available. After susceptibility is established, the regimen can be altered, but patients should still receive at least two drugs to prevent emergence of drug-resistance organisms. Dosage, side effects, and duration of the regimen are not reasons for combination drug therapy in a patient with TB.
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which findings are expected? 1. normal breath sounds 2. prolonged inspiration 3. normal chest movement 4. coarse crackles and rhonchi
4. Exacerbations of COPD are commonly caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended.
A client with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first? 1. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes. 2. Draw blood for an arterial blood gas. 3. Encourage the client to relax and breathe slowly through the mouth. 4. Administer bronchodilators as prescribed.
4. In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, IV corticosteroids, and, possibly, IV theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention.
Which nursing action would most likely be successful in reducing pleuritic chest pain in a client with pneumonia? 1. Encourage the client to breathe shallowly. 2. Have the client practice abdominal breathing. 3. Offer the client incentive spirometry. 4. Teach the client to splint the rib cage when coughing
4. The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain
A patient is sent to your unit from the emergency. The pt's history includes COPD, heart failure. They begin complaining of shortness of breath, and chest pain. After assessing the patient at what rate should this patient's SpO2 be maintained a.) 92% and above b.) between 88-90% c.) 95% and above d.) 100%
A.) is correct- because we don't know whether the pt is a true CO2 retainer, so it is best to treat them as we would a non COPD patient. Maintaining oxygenation between 88-90% might cause severe hypoxia and worsen the condition B.) incorrect because the question doesn't say if the patient has hypoxic drive so it would be dangerous to maintain the oxygen level between 88-90% especially if this patient might not be a CO2 retainer C&D- Incorrect
A client newly diagnosed with tuberculosis (TB) is being admitted with the prescription for "isolation precautions for tuberculosis." The nurse should assign the client to which type of room? 1. a room at the end of the hall for privacy 2. a private room to implement airborne precautions 3. a room near the nurses'station to ensure confidentiality 4. a room with windows to allow sunlight
ANS : 2 Implementing airborne precautions for possible TB requires a private room assignment. In addition to isolating the client by using a private room, engineering controls can help prevent the spread of TB; a room at the end of the hall will aid in controlling airflow direction and can prevent contamination of air in adjacent areas. Confidentiality is provided for every client, regardless of the client's room location. Sunlight is not a component of isolation precautions.
The client with chronic obstructive pulmonary disease (COPD) states that he feels "full after eating a little food." What will the nurse teach the client?a. "Avoid drinking fluids just before and during meals."b. "Use a bronchodilator inhaler 30 minutes before meals."c. "Increase the amount of protein and reduce fat in your diet."d. "Practice diaphragmatic breathing against resistance 4 times daily."
ANS: A Early satiety makes it harder for clients with COPD to eat enough food to meet their energy requirements. Drinking fluids just before a meal or during a meal contributes to the sensation of fullness and clients stop eating sooner. Although it is recommended that clients with COPD use an inhaler before meals to increase ventilation and gas exchange (and to reduce coughing during meals), this practice does not affect early satiety and neither does diaphragmatic breathing. There is no evidence that changing the amount of protein and fat in the diet will change the client's feelings of satiety.
The nurse teaches the client about dietary changes necessary with chronic obstructive pulmonary disease (COPD). Which statement best indicates understanding? a. "I will decrease calories from carbohydrates." b. "I will decrease my calories to 1000 per day." c. "I will increase vegetables in my diet." d. "I will decrease milk products in my diet."
ANS: A The client should decrease his ingestion of carbohydrates, since excess carbohydrate metabolism causes carbon dioxide production. There is no reason to decrease dairy products, decrease calories to 1000/day, or increase vegetables in the diet.
What is the best instruction for the client who has step II asthma that is triggered by exercise?a. "Avoid participating in aerobic exercise more than three times per week."b. "Use a short-acting beta agonist before you participate in exercise."c. "Maintain an exercise diary to determine specific exercises that trigger asthma attacks."d. "Use systemic corticosteroids before you participate in exercise."
ANS: B The most important information for the client with step II asthma is that the short-acting beta agonist should be used before participating in exercise. The client should not avoid exercise but should simply use the agonist before participation. Water-related activity is not restricted for this client. Systemic medications may decrease the frequency of attacks but do not have a rapid onset of action and will not prevent an attack if taken before exercise.
The client has a productive cough, fever, and chills and a history of night sweats. The client's PPD test is negative. Which is the nurse's best intervention related to infection prevention? a. Using standard precautions alone because the client does not have tuberculosis b. Using standard and airborne precautions because the client has tuberculosis c. Using standard and airborne precautions until a chest x-ray shows no evidence of tuberculosis d. Using only airborne precautions because the client is taking penicillin for another infection
ANS: C When clients are very old or have severe immunodeficiency, their PPD tests may be negative, even when active tuberculosis is present, because they have too few immune system cells and cell products to mount an immune response to the test. Therefore, airborne precautions should be used with any older client who presents with clinical manifestations of tuberculosis until other tests rule out tuberculosis. There is no conclusive evidence that the client has tuberculosis, nor that he is taking penicillin therapy.
The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How should the nurse correctly analyze these results? 1. The results are positive for active tuberculosis. 2. The results indicate a less virulent strain of tuberculosis. 3. The results are inconclusive until a repeat sputum specimen is sent. 4. The results are unreliable unless the client has also had a positive tuberculin skin test (TST).
Answer: 1 Rationale: Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue confirms the diagnosis of active tuberculosis. Options 2 and 3 are incorrect statements. The TST is performed to assist in diagnosing TB but does not confirm active disease
A client found to have tuberculosis (TB) is scheduled to go to the radiology department for a chest radiograph. The nurse should take which action when preparing to transport the client? 1. Apply a mask to the client. 2. Apply a mask and gown to the client. 3. Apply a mask, gown, and gloves to the client. 4. Notify the radiology department so that the personnel can be sure to wear masks when the client arrives.
Answer: 1 This question addresses content related to airborne precautions. Focus on the subject, transporting a client with TB. Institution policies and procedures for airborne precautions are always followed; however, clients known or suspected of having TB need to wear a mask when out of the hospital room to prevent the spread of the infection to others. Gown and gloves are not necessary. Others are not protected unless the infected client wears the mask.
A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client? 1. Noting whether the client has visitors 2. Instructing all staff members to not touch the client 3. Giving the client a roommate with TB who persistently tries to talk 4. Removing the calendar and clock in the room so that the client will not obsess about time
Answer: 1 Rationale: The nurse should note whether the client has visitors and social contacts because the presence of others can offer positive stimulation. Touch may be important to help the client feel socially acceptable. A roommate who insists on talking could create sensory overload. In addition, the client on respiratory isolation should be in a private room. The calendar and clock are needed to promote orientation to time.
The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply. 1. "All used dishes should be sterilized." 2. "My close contacts should be tested for TB." 3. "Soiled tissues should be disposed of properly." 4. "House isolation is required for at least 8 months." 5. "The mouth should always be covered when coughing."
Answer: 2, 3, 5 Rationale: Tuberculosis is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.
The nurse places a hospitalized client with a diagnosis of active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room? 1. Wash the hands. 2. Wash the hands and wear a gown and gloves. 3. Wash the hands and place a high-efficiency particulate air (HEPA) respirator over the nose and mouth. 4. The nurse needs no special precautions, but the client is instructed to cover his or her mouth and nose when coughing or sneezing.
Answer: 3 Rationale: Tuberculosis is a highly communicable disease caused by Mycobacterium tuberculosis. The nurse wears a HEPA respirator when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Option 1 is an incomplete action. Option 2 is also inaccurate and incomplete. Gowning is only indicated when there is a possibility of contaminating clothing. Option 4 is an incorrect statement because special precautions are needed.
A client is suspected of having a diagnosis of pulmonary tuberculosis. The nurse should assess the client for which signs/symptoms of tuberculosis? 1. High fever and chest pain 2. Increased appetite, dyspnea, and chills 3. Weight gain, insomnia, and night sweats 4. Low-grade fever, fatigue, and productive cough
Answer: 4 Rationale: The client with pulmonary tuberculosis generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles.
A home health nurse is teaching a client who has active TB. The provider has prescribed the following medication regimen: isoniazid (Nydrazid) 50mg PO daily, rifampin (Rifadin) 500mg PO daily, pyrazinamide 750mg PO daily, and ethambutol (Myambutol) 1mg PO daily. Which of the following client statements indicate understanding of the teaching (select all).A. i can substitute one medication for another if I run out because they all fight infectionsB. I will wash my hands each time i coughC. i will wear a mask when i am in a public areaD. i am glad i dont have to have any more sputum testE. i dont need to worry where i go once i start taking my medications
B,C Rationale: The client should wash her hands eachtime she coughs to prevent spreading the infection.The client should wash her hands each time she coughs to prevent spreading the infection.
A client has active TB. Which of the following symptoms will he exhibit?A) Chest and lower back painB) Chills, fever, night sweats, and hemoptysisC) Fever of more than 104*F and nauseaD) Headache and photophobia
B. Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but isn't usual. Clients with TB typically have low-grade fevers, not higher than 102*F. Nausea, headache, and photophobia aren't usual TB symptoms.
A patient has been put on nasal cannula @2l/min 30 minutes ago. Their SPO2 had returned back into the normal range, resting at 98%. When the nurse comes to check in on the patient he notices that the SPO2 has fallen to 91%, and the patient is short of breath. What should the nurse do? (Select all that apply) a.) apply the simple face mask b.) adjust the SPO2 monitor on the finger c.) notify the physician d.) Turn up the oxygen to 4l/min and monitor the patient's stats.
B.) - is correct because it might be that the monitor is not put on properly and is giving a false reading before doing anything else C.)- is also correct because after ensuring that it is not a false reading, adjusting the oxygen and seeing if the stats come up. O2 should only be turned up if levels fall back below normal after normal saturation had been achieved. A.)- is correct but in this situation the nurse needs to apply the least amount of oxygen to meet the saturation needs of the patient. There is still some leeway with the nasal cannula so normal oxygenation could be achieved by titrating upwards slowly and monitoring, before turning to the face mask.
A pt presents to the ER with difficulty breathing, SOB, chest pain, fatigue and dizziness. Upon checking the vital signs the nursing student notices that the patient's SPO2 level is 89%. What is the next thing the student will do? a.) do nothing because the patient's SpO2 is within normal range b.) apply oxygen via nasal cannula @ 2l/min c.) give the patient a bronchodilator via nebulizer d.) Apply the simple face mask
B.)- is correct in this situation because SPO2 has fallen below normal levels. First you would give oxygen and titrate upwards slowly. If this doesn't work THEN, a nebulizer can be given since it becomes clear that the problem is with breathing in.
A pt dX with COPD is drowsy and unable to expectorate secretions. The nurse should take which of the following actions? a) force fluids b) administer high-flow O2 via mask c) perform nasotracheal suction d) perform postural drainage
C*If pt unable to expectorate secretions, suctioning is appropriate; auscultate breath sounds to determine if suctioning is required
For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?A. Restricting fluid intake to 1,000 ml/dayB. Enforcing absolute bed restC. Teaching the client how to perform controlled coughingD. Administering prescribed sedatives regularly and in large amounts
C. Teaching the client how to perform controlled coughing
For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?A. Encouraging the patient to drink three glasses of fluid dailyB. Keeping the patient in semi-fowler's positionC. Using a high-flow venturi mask to deliver oxygen as prescribeD. Administering a sedative, as prescribe
C. Using a high-flow venturi mask to deliver oxygen as prescribed Explanation:The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.
A pt presents to the ER with difficulty breathing, SOB, chest pain, fatigue and dizziness. Upon checking the vital signs the nursing student notices that the patient's SPO2 level is 96%, yet the patient complains of difficulty with breathing. What is the next thing the student will do?a.) do nothing because the patient's SpO2 is within normal rangeb.) apply oxygen via nasal cannula @ 2l/minc.) give the patient a bronchodilator via nebulizerd.) Apply the simple face mask
C.) Give the patient a nebulizer because the signs they present with are characteristic of asthma so giving them a bronchodilator will help open the airway________a.) is incorrect - although the Spo2 is normal, there could be other things that are causing the dyspnea.b.) Applying oxygen when Spo2 is normal will not help the patient because the problem is not that they are oxygen deficient. It is that they cannot breathe properly.c.) Incorrect because the nursing student should be able to administer the medicationd.) a simple face mask will also not help them because the pt is dealing with an obstructed airway
A client is diagnosed with active TB and started on triple antibiotic therapy. What signs and symptoms would the client show if therapy is inadequate?ADecreased shortness of breath BImproved chest x-ray CNonproductive cough DPositive acid-fast bacilli in a sputum sample after 2 months of treatment
D)Continuing to have acid-fast bacilli in the sputum after 2 months indicated continued infection.
Your patient is diagnosed with a latent tuberculosis infection. Select all the correct statements that reflect this condition: A. "The patient will not need treatment unless it progresses to an active tuberculosis infection." B. "The patient is not contagious and will have no signs and symptoms." C. "The patient will have a positive tuberculin skin test or IGRA test. D. "The patient will have an abnormal chest x-ray." E. "The patient's sputum will test positive for mycobacterium tuberculosis."
The answers are B and C. The patient WILL need medical treatment to prevent this case of LBTI from developing into an active TB infection later on. The patient will NOT have an abnormal chest x-ray or a positive sputum test. This is only in active TB.
You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education? A. Cough for a minimum of 6 weeks B. Night sweats C. Weight gain D. Hemoptysis E. Chills F. Fever G. Chest pain
The answers are B, D, E, F, and G. Option A is wrong because a cough should be present for 3 weeks or more (NOT 6 weeks). Option C is wrong because the patient will experience weight LOSS (not gain).