Test 3 Chpt 23,34,10

The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse know is the most common cause of death from infectious diseases in the United States?

***Pneumonia Pulmonary embolus Atelectasis Tracheobronchitis

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?

***Receiving vaccinations Using incentive spirometry Using prescribed opioids Mobilizing early

The nurse is reading the previous shift's documentation of an open area on the client's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the client's sacrum will reveal a pressure ulcer in which stage?

***Stage II Stage III Stage I Stage IV

A client who has been admitted for weakness and taking fluids poorly is unable to move well in the bed and requires assistance. What are this client's risk factors for developing pressure sores? Select all that apply.

***inactivity ***dehydration vascular disease localized edema ***immobility

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should:

***instruct the client to drink at least 2 L of fluid daily. administer pain medication as ordered. administer anxiolytics, as ordered, to control anxiety. maintain the client on bed rest.

A client with chronic obstructive pulmonary disease (COPD) expresses a desire to quit smoking. The first appropriate response from the nurse is:

"I can refer you to the American Lung Association." ***"Have you tried to quit smoking before?" "Many options are available for you." "Nicotine patches would be appropriate for you."

A nurse recognizes that a client with tuberculosis needs further teaching when the client states:

"I'll have to take these medications for 9 to 12 months." ***"The people I have contact with at work should be checked regularly." "I'll need to have scheduled laboratory tests while I'm on the medication." "It won't be necessary for the people I work with to take medication."

A client has tested positive for tuberculosis (TB). While providing client teaching, which information should the nurse prioritize?

***The importance of adhering closely to the prescribed medication regimen TB being self-limiting but taking up to 2 years to resolve The disease being a lifelong, chronic condition that will affect activities of daily living (ADLs) The need to work closely with the occupational and physical therapists

The nurse is caring for a client who has paraplegia following a hunting accident. The nurse knows to assess regularly for the development of pressure ulcers on this client. What rationale should the nurse cite for this nursing action?

***The risk for pressure ulcers is directly related to the duration of immobility. The client may not be motivated to prevent pressure ulcers. The client likely has a decreased level of consciousness. The risk for pressure ulcers is related to what caused the immobility.

Which of the following is accurate regarding status asthmaticus?

***A severe asthma episode that is refractory to initial therapy Usually occurs with warning Usually does not progress to severe obstruction Patients have a productive cough.

During a teaching session, a parent asks the nurse which inhaler to use for quick relief if the child has an asthma attack. What teaching should the nurse review with the parent?

***Albuterol is a short-acting inhalant and will relax muscles quickly. Salmeterol is a long-acting inhalant and will not provide relief for an asthma attack. Cromolyn sodium is an inhalant used for asthma. Theophylline is a tablet, so it will take a while to work.

Which statement is true about both lung transplant and bullectomy?

***Both procedures improve the overall quality of life of a client with COPD. Both procedures cure COPD. Both procedures treat patients with bullous emphysema. Both procedures treat end-stage emphysema.

Which type of scale is used to systematically assess and quantify a client's risk for pressure ulcer?

***Braden scale FIM PULSES profile Barthel index

In which statements regarding medications taken by a client diagnosed with COPD do the drug name and the drug category correctly match? Select all that apply.

***Ciprofloxacin is an antibiotic. Dexamethasone is an antibiotic. ***Albuterol is a bronchodilator. ***Prednisone is a corticosteroid. Cotrimoxazole is a bronchodilator.

A nurse is working with a 10-year-old client who is undergoing a diagnostic workup for suspected asthma. Which signs and symptoms are consistent with a diagnosis of asthma? Select all that apply.

***Cough ***Wheezing Bradypnea Crackles ***Chest tightness

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?

***Debridement Culture Incision and drainage Irrigation

A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute and a pulse oximetry of 93% despite receiving nasal oxygen at 2 L/minute. What action should the nurse take?

***Encourage the client to exhale slowly against pursed lips. Teach the client to perform upper chest breaths. Increase the flow of oxygen. Encourage the client to take deep breaths.

An elderly female client who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this ulcer?

***IV II III I

Asthma is cause by which type of response?

***IgE-mediated IgA-mediated IgM-mediated IgD-mediated

A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply.

***Inflamed airways that obstruct airflow ***Overinflated alveoli that impair gas exchange ***Mucus secretions that block airways Dry airways that obstruct airflow Decreased numbers of goblet cells

A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication?

Acute respiratory distress syndrome (ARDS) Aspiration Pulmonary embolism ***Atelectasis

The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective?

Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays Legislation that requires homes and apartments be checked for asbestos leakage ***Classes at community centers to teach about smoking cessation strategies Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

An oral corticosteroid An inhaled corticosteroid An I.V. beta2-adrenergic agonist ***An inhaled beta2-adrenergic agonist

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply.

Ascites ***Wheezes Jugular vein distention ***Decreased airflow ***Compromised gas exchange

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer ***Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Administering pain medications, frequent repositioning, and limiting fluid intake Administering oxygen, coughing, breathing deeply, and maintaining bed rest

A nurse is admitting a new client who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the client achieve the goal of maintaining effective oxygenation?

Assist the client in developing an appropriate exercise program. Teach the client to perform airway suctioning. Administer supplementary oxygen by simple face mask. ***Teach the client strategies for promoting diaphragmatic breathing.

A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effect should the nurse be sure to address in client teaching?

Bradycardia Decreased level of consciousness ***Oral candidiasis Increased respiratory secretions

A client comes to the health clinic after a positive skin test for tuberculosis. What additional diagnostic tests should the nurse begin teaching the client? Select all that apply.

Complete blood count ***Drug susceptibility testing A repeat multiple-puncture skin test ***Complete history and physical examination ***A chest radiograph

While planning a client's care, the nurse identifies nursing actions to minimize the client's pleuritic pain. Which intervention should the nurse include in the plan of care?

Encourage the client to speak as little as possible. Arrange for a soft-textured diet and increased fluid intake. Ambulate the client at least three times daily. ***Administer an analgesic before coughing and deep breathing.

A client experiencing an asthmatic attack is prescribed methylprednisolone intravenously. What action should the nurse take?

Encourages the client to decrease caloric intake due to increased appetite Aspirates for blood return before injecting the medication Informs the client to limit fluid intake due to fluid retention ***Assesses fasting blood glucose levels

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?

Heart rate Skin color ***Lung sounds Respiratory rate

A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects?

High risk for ineffective therapeutic regimen management related to lack of knowledge Activity intolerance related to fatigue Disturbed sleep pattern related to cough ***Ineffective coping related to anxiety

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

Imbalanced nutrition: Less than body requirements Impaired oral mucous membranes ***Impaired gas exchange Activity intolerance

What is histamine, a mediator that supports the inflammatory process in asthma, secreted by?

Lymphocytes ***Mast cells Neutrophils Eosinophils

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses. Host defenses are impaired. ***A nurse washes her hands before beginning client care. A highly virulent organism is present.

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Intermittent positive-pressure breathing (IPPB) Bronchoscopy Positive end-expiratory pressure (PEEP) ***Incentive spirometry

A health care provider orders a beta2-adrenergic agonist agent (bronchodilator) that is short-acting and administered by inhaler. Which drug would the nurse expect to administer to the client?

Ipratropium bromide ***Albuterol Isoproterenol Formoterol

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Maintaining a cool room temperature Turning the client every 2 hours ***Encouraging increased fluid intake Elevating the head of the bed 30 degrees

Which of the following is the most common chronic disease of childhood?

Obesity Autism Cerebral palsy ***Asthma

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?

Older adults are not normally candidates for pneumococcal vaccination. Older adults have less compliant lung tissue than younger adults. ***Older adults often lack the classic signs and symptoms of pneumonia. Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage I pressure ulcer Stage III pressure ulcer Stage IV pressure ulcer ***Stage II pressure ulcer

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma?

Shallow respirations Increased anterior-posterior (AP) diameter ***Bilateral wheezes Bradypnea

A nurse is discussing asthma complications with a client and family. What complications should the nurse include in the teaching? Select all that apply.

Thoracentesis Pertussis ***Atelectasis ***Respiratory failure ***Status asthmaticus

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?

Vancomycin 1 gram intravenously over 1 hour ***Oxygen through nasal cannula at 2 L/minute Intravenous methylprednisolone (Solu-Medrol) 120 mg Ipratropium bromide (Alupent) by metered-dose inhaler

The nurse is caring for an elderly adult who is bedridden. What intervention should the nurse include in the care plan to most effectively prevent pressure ulcers?

Vigorously massage lotion into bony prominences. Slide, rather than lift, the client when turning. Turn and reposition the client a minimum of every 8 hours. ***Post a turning schedule at the client's bedside and ensure staff adherence.

The nurse has been referred to the care of an extended care resident who has been diagnosed with a stage III pressure ulcer. What would be the best meal choice for this client?

Whole wheat macaroni with cheese Skim milk, oatmeal, and whole wheat toast Eggs, hash browns, coffee, and an apple ***Steak, baked potato, spinach and strawberry salad

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's:

extremities for signs of cyanosis. hemoglobin, hematocrit, and red blood cell levels. ***oxygen saturation level. level of consciousness (LOC).

A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply.

family history of pressure ulcers ***potential areas of pressure ulcer development ***presence of pressure ulcers on the client ***overall risk of developing pressure ulcers indwelling catheter output

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

maintain fluid intake of 40 oz (1,200 ml) per day. follow up with the physician in 2 weeks. ***continue to take antibiotics for the entire 10 days. turn and reposition himself every 2 hours.

The nurse is caring for a female client who developed a pressure ulcer as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure ulcers and healing promotion. The nurse determines that the client has understood the teaching by observing the client:

perform range-of-motion exercises. elevate her body parts that are susceptible to edema. ***avoid placing her body weight on the healing site. demonstrate the technique for massaging the wound site.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

pleural effusion. pulmonary edema. ***atelectasis. oxygen toxicity.

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because:

the swelling has decreased. ***the airways are so swollen that no air can get through. the attack is over. crackles have replaced wheezes.