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AH3 CHAPTER 14, 25,26,27,28,29 (12,28,29,30,31,32)

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ANS: A, B, E Acid-base imbalances interfere with normal physiology, including reducing the function of hormones and enzymes, causing fluid and electrolyte imbalances, making heart membranes more excitable, and decreasing the effectiveness of many drugs.

1. A nurse is planning interventions that regulate acid-base balance to ensure the pH of a clients blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? (Select all that apply.) a. Reduction in the function of hormones b. Fluid and electrolyte imbalances c. Increase in the function of selected enzymes d. Excitable cardiac muscle membranes e. Increase in the effectiveness of many drugs

ANS: B The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema

ANS: C Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

11. After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching? a. I dont drink milk because it gives me gas and diarrhea. b. I have been taking digoxin every day for the last 15 years. c. I take sodium bicarbonate after every meal to prevent heartburn. d. In hot weather, I sweat so much that I drink six glasses of water each day.

ANS: B This clients arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate should be replaced to help restore this clients acid-base balance. Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the clients pH, the client has excessive diarrhea and cannot afford to lose more fluid. Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their oxygen saturation at 90%, or who have respirator muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for this client.

12. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive? a. Furosemide (Lasix) 40 mg intravenous push b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W c. Mechanical ventilation d. Indwelling urinary catheter

ANS: A All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.

13. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first? a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.

ANS: B The nurse should assist the client who is experiencing anxiety-induced respiratory alkalosis to identify causes of the anxiety. The other questions will not identify the cause of the acid-base imbalance.

14. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care? a. Do you take any over-the-counter medications? b. You appear anxious. What is causing your distress? c. Do you have a history of anxiety attacks? d. You are breathing fast. Is this causing you to feel light-headed?

Integrated Process: Teaching/Learning 15. The nurse is observing a client performing stoma care for a laryngectomy for the first time. Which action does the nurse reinforce? a. Washing the stoma with soap and water b. Covering the stoma with a gauze pad c. Irrigating the stoma with half-strength peroxide d. Making sure any scab around the stoma is removed

A The client is taught to wash the stoma gently and to prevent anything from getting into the opening. The client should never scrape around the opening because this could cause broken skin, irritation, and infection. Peroxide is not used for irrigation; irrigation of the stoma is not done. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

ANS: B The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvosteks sign are manifestations of the electrolyte imbalances that accompany alkalosis.

5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvosteks sign

Integrated Process: Teaching/Learning 10. What is the highest priority for the nurse to teach the client who is being discharged after a fixed centric occlusion for a mandibular fracture? a. How to use wire cutters b. Eating six soft or liquid meals each day c. How to irrigate the mouth every 2 hours d. Sleeping in semi-Fowler's position postoperatively

A The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. Although the client will need to sleep in a semi-Fowler's position to assist in avoiding aspiration if vomiting does occur, this will not be as high a priority as knowing how to cut the wires. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

ANS: A This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.

Which statement indicates that a client understands teaching about the correct use of a corticosteroid medication? a. "This drug can reverse my symptoms during an asthma attack." b. "This drug is effective in decreasing the frequency of my asthma attacks." c. "This drug can be used most effectively as a rescue agent." d. "This drug can be used safely on a long-term basis for multiple applications daily."

ANS: B Corticosteroids decrease inflammatory and immune responses in many ways, including preventing the synthesis of mediators. Both inhaled corticosteroids and those taken orally are preventive; they are not effective in reversing symptoms during an asthma attack and should not be used as rescue drugs. Systemic corticosteroids, because of severe side effects, are avoided for mild to moderate intermittent asthma and are used on a short-term basis for moderate asthma.

A client's chest tube is accidentally dislodged. What action by the nurse is best? a. No action is necessary because the area will reseal itself. b. Cover the insertion site with a sterile gauze and tape three sides. c. Obtain a suture kit and prepare for the physician to suture the site. d. Cover the area with an occlusive dressing.

The nurse is teaching a client about different medications for asthma. Which medication does the nurse teach the client to administer to control the prolonged inflammatory response? a. Diphenhydramine (Benadryl) b. Montelukast (Singulair) c. Aspirin d. Bitolterol (Tornalate)

ANS: B Leukotriene and eotaxin cause later, prolonged inflammatory responses in asthma, which can be blocked by drugs like montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). No evidence suggests that aspirin helps this inflammatory response. Histamine starts an immediate inflammatory response, which can be blocked by drugs like diphenhydramine (Benadryl). Bitolterol (Tornalate) is a short-acting beta agonist that will enhance bronchodilation during an asthma attack, but it will not assist in controlling late inflammation.

What is the best instruction for a client who has step II (mild persistent) asthma? a. "Avoid participating in aerobic exercise." b. "You will need daily inhaled low-dose steroids." c. "You need to evaluate your diet for asthma triggers." d. "Make sure you use a rescue inhaler three times per day."

ANS: B The most important information for clients with step II (mild persistent) asthma is that they need daily preventive anti-inflammatory medication. Low-dose inhaled steroids are necessary. The client should exercise as tolerated; however, using a rescue inhaler frequently is not recommended and, if this is needed, it should be reported to the health care provider because a change in therapy is likely needed.

A client with lung cancer is lying flat in bed and reports shortness of breath. What action does the nurse take first? a. Notify the health care provider. b. Elevate the head of the bed. c. Assess oxygen saturation. d. Have the client take deep breaths.

ANS: B The nurse's first action should be to elevate the head of the bed. Next, assessing oxygen saturation will help the nurse determine the client's status. If the oxygen is low, the nurse would increase oxygen flow and have the client take deep breaths. The provider could be notified after the nurse performs the interventions.

A client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse? a. Decreased level of consciousness b. Tachycardia c. Increased temperature d. Slowed respiratory rate

ANS: B An increased heart rate may indicate that the client is developing a pneumothorax or hypoxia. Although it is important to note immediately whether the client is experiencing adecreased level of consciousness, increased temperature, or a slowed respiratory rate, none of these is as indicative of a life-threatening complication as tachycardia.

The nurse is caring for an older adult client with a pulmonary infection. Which nursing action is a priority with this client? a. Encouraging the client to increase fluid intake b. Assessing the client's level of consciousness c. Raising the head of the bed to at least 45 degrees d. Providing the client with humidified oxygen

ANS: B Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and breathe deeply frequently; to raise the head of the bed; and to humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.

A client with long-standing pulmonary problems is classified as having class III dyspnea. Based on this classification, what type of assistance does the nurse anticipate providing for ADLs? a. Dyspnea is minimal and the client requires no additional assistance. b. The client may require rest periods during performance of ADLs. c. The client requires assistance for some but not all tasks. d. Owing to severe dyspnea, this client cannot participate in any self-care.

ANS: B Class III dyspnea occurs during usual activities, such as showering, but the client does not require assistance from others. The client may need to rest during activities. A client with class I dyspnea would likely need no assistance. A client with class IV dyspnea may require assistance for some but not all tasks. A client with class V dyspnea cannot participate in any self-care.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the clients bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study

ANS: B Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage of 75 mL/hr

ANS: B, C Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube.

A client diagnosed with asthma has not responded well to medication. The client is concerned and asks the nurse, "What is wrong with me, and why am I not getting better?" What is the nurse's best response? a. "You just weren't used to the medication yet." b. "The medication dose has to be increased." c. "It is possible that genetic testing may help." d. "You should try homeopathic medicine."

ANS: C Some genetic variations may cause the activity of beta-adrenergic receptors to change, meaning that the client would not respond as expected to beta agonists. Genetic testing may help to determine why the drug therapy is not working and may help the clinician to identify new therapy that will work.

Which statement indicates that a client needs additional teaching about using an inhaler? a. "I will not exhale into the inhaler." b. "I will store the inhaler in a drawer in my bedroom." c. "I will soak my inhaler in water to clean it." d. "I will inhale and hold my breath."

ANS: C Submerging an inhaler in water to wash it is not necessary and may cause the medication in the inhaler to clump together if it is a dry powder inhaler. The other statements are all correct—the client should not exhale into the inhaler, can store the inhaler in his or her bedroom, and will need to inhale and hold breath slightly when using the inhaler.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a. "Do you have a strong support system?" b. "What do you understand about your disease?" c. "Do you experience shortness of breath with basic activities?" d. "What medications are you prescribed to take each day?"

ANS: C Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse should ask the client if shortness of breath is interfering with basic activities. Although the nurse should know about the client's support systems, current knowledge, and medications, these questions do not address the client's appearance.

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? a. "I plan to wear my oxygen when I exercise and feel short of breath." b. "I will use my portable oxygen when grilling burgers in the backyard." c. "I plan to use cotton balls to cushion the oxygen tubing on my ears." d. "I will only smoke while I am wearing my oxygen via nasal cannula."

ANS: C Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling and smoking increases the risk for fire.

A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How should the nurse respond? a. "Since many of your family members are carriers, your children will also be carriers of the gene." b. "Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder." c. "Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." d. "Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder."

ANS: C Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

A client is scheduled for pulmonary function tests (PFTs) in the morning. The nurse calls the client to teach about the procedure. Which statement by the client indicates a need for further teaching? a. "I should not smoke for at least 6 hours before the test." b. "PFTs can determine whether my lung problem has gotten worse." c. "I should use my inhaler anytime during the test if I need it." d. "If I get really short of breath, I'll tell the technician."

ANS: C Bronchodilators may need to be held before PFTs. The client should not plan to use them at any time during the test if he or she experiences dyspnea. The other options show adequate understanding.

The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a. Assess the clients oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min

ANS: C For the Venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The clients flow rate is too low and the nurse should increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings.

The nursing assistant reports to the nurse that an African-American client's pulse oximetry reading is 93%. The client has no complaints. Which action by the nurse is most appropriate? a. Replace the sensor probe of the oximeter. b. Place the probe on another finger. c. Assess other signs of respiratory adequacy. d. Prepare to obtain arterial blood gases.

ANS: C Normal pulse oximetry readings are 95% to 100%. However, people with dark skin can have readings that are 3% to 5% lower owing to the darker coloration of the nail bed. The nurse should assess other signs of respiratory adequacy because this may be a normal finding for this client.

A client with asthma reports "not being able to take deep breaths." The nurse auscultates decreased breath sounds in the bases, and no wheezes. What is the nurse's best action? a. Encourage the client to stay calm and take deep breaths. b. Document the findings and continue to monitor. c. Have the client cough forcefully. d. Assess the client's oxygen saturation.

ANS: D Decreased wheezing accompanied by decreased breath sounds can mean airway occlusion from mucus and from inflammation. The nurse should assess the client's oxygenation and determine whether additional interventions are needed. Coughing forcefully may cause the smaller airways to collapse and may not help the client. Encouraging the client to remain calm and to try to take deep breaths is not helpful. Although providing documentation is important, the nurse needs to do more than that.

The nurse observes hematuria in a client receiving IV cyclophosphamide (Cytoxan). After notifying the health care provider, what intervention is the nurse's priority? a. Obtain a urine specimen. b. Assess laboratory studies. c. Increase hydration. d. Stop the medication.

ANS: D Hemorrhagic cystitis is a frequent side effect of cyclophosphamide therapy. The physician should be notified to prescribe co-administration of a bladder-protecting agent. The nurse then should stop the medication. Other actions would be to further assess the client and provide hydration to flush the medication.

A client is using omalizumab (Xolair) for the first time. What is the priority nursing action? a. Make sure the client takes the medication with water. b. Administer ibuprofen (Motrin) because Xolair often causes headaches. c. Teach the client how to use a syringe. d. Remain with the client and assess for anaphylaxis.

ANS: D Immune modulators are monoclonal antibodies that prevent allergens from binding to receptor sites on mast cells and basophils. The risk of anaphylaxis is high; the nurse should assess and stay with the client.

A client is undergoing lung reduction surgery. What is the nurse's highest priority preoperatively? a. Administer medications. b. Discuss the possibility of ventilator dependency. c. Teach how to cough and deep breathe. d. Teach about preoperative testing.

ANS: D In addition to standard preoperative testing, the client who will undergo lung reduction surgery is tested to determine the location of greatest lung hyperinflation and poorest lung blood flow. These tests include pulmonary plethysmography, gas dilution, and perfusion scans. The other interventions are lower priorities.

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. When the insertion site becomes red and warm to the touch b. When the tube drainage decreases and becomes sanguineous c. When the client experiences pain at the insertion site d. When the tube becomes disconnected from the drainage system

ANS: D Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the client's risk for a pneumothorax. Tube drainage should decrease and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the client's risk for a pneumothorax.

Integrated Process: Nursing Process (Assessment) 17. A client develops posterior nasal bleeding and has packing inserted. What is the nurse's priority action? a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the client's cheek.

D The thread is attached to the client's cheek that holds the packing in place. The nurse needs to make sure that this does not move because it can occlude the client's airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests, Treatments, Procedures)

A client has a long-standing history of chronic obstructive pulmonary disease (COPD). Which laboratory finding does the nurse correlate with this condition? a. White blood cell count, 7500/mm3 b. Hemoglobin, 22 g/dL c. Neutrophils, 6000/ mm3 d. Monocytes, 600/mm3

Normal hemoglobin for a female is 12 to 16 g/dL. Clients with COPD have chronic hypoxia, which stimulates the production of erythropoietin and thus raises the red bloodcell count and hemoglobin and hematocrit levels. All other values are normal.

ANS: A This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.

1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys

ANS: A The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the clients respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10 breaths/min. Changing the cannula to a mask does nothing to improve the clients hypoxic drive, nor would it address the clients most pressing need. Positioning will not help the client breathe at a normal rate or maintain client safety.

15. A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases Vital Signs pH = 7.28 Pulse rate = 96 beats/min PaO2 = 85 mm Hg Blood pressure = 135/45 PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min HCO3 = 26 mEq/L O2 saturation = 88% Which action should the nurse take first? a. Notify the Rapid Response Team and provide ventilation support. b. Change the nasal cannula to a mask and reassess in 10 minutes. c. Place the client in Fowlers position if he or she is able to tolerate it. d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.

ANS: A, B, C Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate and depth. A positive Trousseaus sign is associated with alkalosis. Decreased urine output is not a manifestation of metabolic acidosis.

2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseaus sign

ANS: A Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will change as acidosis worsens.

2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythm b. Skin and mucous membranes c. Musculoskeletal strength d. Level of orientation

ANS: D Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

3. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: B, C, E Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

3. A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis Young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis Client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis Postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis Older client prescribed antacids for gastroesophageal reflux disease

ANS: A, E A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Manifestations of metabolic alkalosis include positive Chvosteks sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, and anxiety and irritability.

4. A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance should the nurse assess? (Select all that apply.) a. Positive Chvosteks sign b. Elevated blood pressure c. Bradycardia d. Increased muscle strength e. Anxiety and irritability

ANS: D The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide (Lasix) intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.

ANS: B, C This clients symptoms of anxiety and irritability are related to a state of metabolic acidosis. The nurse should ask the clients spouse or family members if the clients behavior is typical for him or her, and establish a baseline for comparison with later assessment findings. The nurse should also assess for alcohol intake because alcohol can change a clients personality and cause metabolic acidosis. The other options are not causes of metabolic acidosis.

5. A nurse is planning care for a client who is anxious and irritable. The clients arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L. Which questions should the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) a. Are you taking any antacid medications? b. Is your spouses current behavior typical? c. Do you drink any alcoholic beverages? d. Have you been experiencing any vomiting? e. Are you experiencing any shortness of breath?

ANS: A Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.

6. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? a. Assess clients rate, rhythm, and depth of respiration. b. Measure the clients pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the physician as soon as possible.

ANS: B Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred.

7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

ANS: A The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the fastest way to return acid-base balance is to administer oxygen. Applying a paper bag over the clients nose and mouth would worsen the acidosis. Sodium bicarbonate should not be administered because the clients arterial bicarbonate level is normal. Glucose and insulin are administered together to decrease serum potassium levels. This action is not appropriate based on the information provided.

8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the clients nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

ANS: B Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk.

9. After teaching a client who was malnourished and is being discharged, a nurse assesses the clients understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis? a. I will drink at least three glasses of milk each day. b. I will eat three well-balanced meals and a snack daily. c. I will not take pain medication and antihistamines together. d. I will avoid salting my food when cooking or during meals.

Integrated Process: Nursing Process (Assessment) 5. A client had a partial laryngectomy and has received instructions on the supraglottic method of swallowing. Which action by the nurse is most appropriate? a. Place a chart in the client's room detailing the steps in the process. b. Order a dynamic swallow study. c. Repeat the instruction each day. d. Have the client demonstrate swallowing.

A The client who is status post partial laryngectomy should be taught alternative methods of swallowing, and a chart should be placed in the client's room to reinforce teaching. A dynamic swallow study is performed to guide rehabilitation for swallowing. Repeating the steps each shift is not as effective as showing the client a chart. Having the client demonstrate swallowing may not verify that he or she correctly understands supraglottic swallowing. A chart in the room will be most effective in helping both client and staff with this method. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 2. After facial trauma, a client has a nasal fracture and is reporting constant nasal drainage, a headache, and difficulty with vision. What is the nurse's first action? a. Collect the nasal drainage on a piece of filter paper. b. Send the client for a facial x-ray. c. Perform a vision test. d. Palpate all facial areas for crepitus.

A The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebral spinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the client's risk for infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) MULTIPLE RESPONSE 1. The nurse is assessing a client who is 6 hours post surgery for a nasal fracture. The client has facial pain (5 out of 10) and nasal packing in place. What actions by the nurse are most appropriate at this time? (Select all that apply.) a. Observe for clear drainage. b. Observe for bleeding. c. Observe the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing. g. Administer pain medication. h. Place the client in Trendelenburg position.

A, B, C, D, G The nurse should observe for clear drainage because of the risk for cerebrospinal fluid (CSF) leakage. The nurse should note whether the client is swallowing frequently because this could indicate postnasal bleeding. The nurse should also ask the client to open his or her mouth and should observe the back of the throat for bleeding. Pain medication should also be administered. It is too soon to change the packing, which should be changed by the surgeon the first time. A nasal steroid would increase the risk for infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 2. The client with which conditions requires immediate nursing intervention? (Select all that apply.) a. Shortness of breath b. Sternal retractions c. Pulse oximetry reading of 95% d. Occasional expiratory wheeze e. Respiratory rate of 8 breaths/min f. Arterial blood gas showing a pH of 7.35 g. Stridor

A, B, E, G The client with sternal retraction is experiencing serious respiratory difficulty, as is the client with stridor. The client who reports shortness of breath needs immediate assessment, as does the client with a respiratory rate of 8. A pulse oximetry of 95% is within normal limits, as is a pH of 7.35. The client with expiratory wheezes needs to be assessed, but not immediately. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Assessment) 4. The nurse is assessing a client with facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis or bruising behind the ear is called "battle sign" and indicates basilar skull fracture. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

The nurse assesses a client's chest tube and finds continuous bubbling in the water seal chamber. When the nurse clamps the chest tube close to the client's dressing, the bubbling stops. How does the nurse interpret this finding? a. An air leak is present at the chest tube insertion site or in the thoracic cavity. b. An air leak is present in the drainage system. c. More water needs to be added to the water seal. d. The system is functioning appropriately and no intervention is needed.

ANS: A Bubbling in the water seal chamber indicates air drainage from the client and usually is seen when the client's intrathoracic pressure is greater than atmospheric pressure, such as during exhalation, coughing, or sneezing. When the air in the pleural space has been sufficiently removed, bubbling stops. Continuous bubbling indicates an air leak. If the air leak is in the thoracic cavity, air and air pressure increase in the thoracic cavity, forcing more air into the water seal chamber. This air movement is prevented when the chest tube is clamped close to the insertion site

The nurse is teaching a client with cystic fibrosis. What activity does the nurse teach as the priority? a. Taking daily antibiotics b. Having genetic screening c. Maintaining good nutrition d. Exercising daily

ANS: C Clients with cystic fibrosis (CF) often are malnourished owing to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better

The home care nurse observes white patches on the oral mucosa of a client with severe, chronic airflow limitation. What is the nurse's best action? a. Ask the client whether he or she uses a steroid inhaler. b. Inquire about any recent viral illnesses. c. Have the client rinse the mouth with salt water. d. Have the client brush the patches with a soft-bristled brush.

ANS: A Excessive use of steroid inhalers reduces local immune function and increases the client's risk for oral-pharyngeal infection, including candidiasis, which manifests as white patches on the oral mucosa. The client should not brush the lesions, and salt water will not help the sores. Recent illnesses would have no effect on these lesions.

The nurse is assessing a client who has a chest tube. Which assessment finding requires intervention by the nurse? a. Pain at the insertion site b. Bloody drainage in the collection chamber c. Intermittent bubbling in the water seal chamber d. Tidaling in the water seal chamber

ANS: A Pain is the priority for the client. Bloody drainage may be normal, depending on the client's condition. Intermittent bubbling in the water seal indicates air escaping as the lung fully expands, and does not need to be addressed immediately. Tidaling often occurs with inspiration and expiration.

The nurse assesses a client who is on fluticasone (Flovent) and notes oral lesions. What is the nurse's best action? a. Teach the client to rinse the mouth after Flovent use. b. Have the client use a mouthwash daily. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

ANS: A The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using Flovent.

The nurse is teaching a client with asthma about self-management. Which statement by the nurse is best? a. "Keep a daily symptom and intervention diary." b. "Measure your anterior/posterior diameter weekly." c. "Note your symptoms when you don't take your medications." d. "Exercise before and after taking inhalers and compare tolerance."

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. Comparing exercise tolerance before and after activity will not give the client the most complete information about his or her asthma.

A client recently diagnosed with lung cancer is being taught by the nurse. What information does the nurse teach the client? a. "You will receive 6 weeks of daily radiation therapy." b. "Lung cancer has a very good prognosis." c. "Further testing is not needed because lung cancer rarely metastasizes." d. "It is very likely that surgery will be curative."

ANS: A This is the only statement that is accurate. Small doses of radiation given over long periods are an effective routine treatment. Lung cancer does not have a good prognosis, and it often metastasizes. Surgery often is only palliative.

A nurse auscultates a client's lung fields. Which pathophysiologic process should the nurse associate with this breath sound? (Click the media button to hear the audio clip.) a. Inflammation of the pleura b. Constriction of the bronchioles c. Upper airway obstruction d. Pulmonary vascular edema

ANS: A A pleural friction rub can be heard when the pleura is inflamed and rubbing against the lung wall. The other pathophysiologic processes would not cause a pleural friction rub. Constriction of the bronchioles may be heard as a wheeze, upper airway obstruction may be heard as stridor, and pulmonary vascular edema may be heard as crackles.

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.

ANS: A The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this client's history and clinical manifestations? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucus glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

ANS: A Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history.

A nurse auscultates a client's lung fields. Which action should the nurse take based on the lung sounds? (Click the media button to hear the audio clip.) a. Assess for airway obstruction. b. Initiate oxygen therapy. c. Assess vital signs. d. Elevate the client's head.

ANS: A Stridor is the sound heard, and it indicates severe airway constriction. The nurse must administer a bronchodilator to get air into the lungs. Administering oxygen, assessing vital signs, and elevating the client's head will not help until the client's airways are open.

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." a. 4, 2, 1, 3, 5, 6, 7 b. 3, 4, 1, 2, 5, 7, 6 c. 2, 1, 3, 4, 5, 6, 7 d. 1, 3, 2, 5, 6, 7, 4

ANS: A The proper order for obtaining a peak expiratory flow rate is as follows. Make sure the device reads zero or is at base level. The client should stand up (unless he or she has a physical disability). The client should take as deep a breath as possible, place the meter in the mouth, and close the lips around the mouthpiece. The client should blow out as hard and as fast as possible for 1 to 2 seconds. The value obtained should be written down. The process should be repeated two more times, and the highest of the three numbers should be recorded in the client's chart.

A postoperative client has an oxygen saturation of 96% but is pale and dyspneic and says, "I can't get enough air!" The client's lung sounds are clear. Which action by the nurse is most appropriate? a. Call the physician and request a hemoglobin and hematocrit level. b. Notify respiratory therapy and request a breathing treatment. c. Encourage the client to cough and deep breathe 10 times each hour. d. Take the client's temperature and give antipyretics if needed.

ANS: A A normal pulse oximetry reading is 95% to 100%. Pulse oximetry measures the percent of hemoglobin saturated with oxygen. However, if the client's hemoglobin level is low, the pulse oximetry reading may not correlate with his or her condition. A postoperative client is at risk for bleeding, so the nurse should request a hemoglobin and hematocrit level. Respiratory treatment is not indicated. Coughing and deep breathing are appropriate but are not the priority. Monitoring for and treating fevers is also appropriate but is not the priority.

A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Remove the tubing from the clients nose. d. Turn the client every 2 hours or as needed.

ANS: A Oxygen can be drying, so the UAP can apply water-soluble lubricant to the clients lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen.

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

ANS: A Suction should only be applied while withdrawing the catheter. The other actions are appropriate.

What information about nutrition does the nurse teach a client with chronic obstructive pulmonary disease (COPD)? (Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Practice diaphragmatic breathing against resistance four times daily." e. "Eat high-fiber foods to promote gastric emptying." f. "Eat dry foods rather than wet foods, which are heavier." g. "Increase carbohydrate intake for energy."

ANS: A, B, C Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Dry foods can cause coughing. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. Diaphragmatic breathing will not necessarily help nutrition.

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? (Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Increase carbohydrate intake for energy."

ANS: A, B, C Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. The client should increase calorie and protein intake to prevent malnourishment. The client should not increase carbohydrate intake as this will increase carbon dioxide production and increase the client's risk of for acidosis.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home.

ANS: A, B, C Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

ANS: A, B, C, E Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication.

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

ANS: A, B, D Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client's ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

ANS: A, B, D, E The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and should be assessed. Hydration is not directly related to the ability to perform self-care

A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this client's teaching? a. "Take an antibiotic each day." b. "Contact your provider to obtain genetic screening." c. "Eat a well-balanced, nutritious diet." d. "Plan to exercise for 30 minutes every day."

ANS: C Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better.

The nurse is assessing a client with asthma. Scattered wheezes are noted, and the client's oxygen saturation is 88%. What other assessments are essential for the nurse to perform? (Select all that apply.) a. Assess for accessory muscle use. b. Assess anterior-posterior diameter. c. Assess inspiration/expiration ratios. d. Assess the suprasternal notch. e. Perform a stress test. f. Assess a chest x-ray. g. Assess mucous membranes.

ANS: A, C, D, G Accessory muscle use may help the client breathe during an attack. Muscle retraction may be seen at the sternum and at the suprasternal notch. Mucous membranes can also tell the nurse about oxygenation. Inspiration versus expiration can tell the nurse how the client is breathing. The anterior-posterior diameter gives indication of a chronic condition; assessing this during an attack will not help the client. Likewise, performing a stress test and a chest x-ray during an attack would not be beneficial.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the client's safety while on this medication? (Select all that apply.) a. Keep an intravenous line dedicated strictly to the infusion. b. Teach the client that this medication increases pulmonary pressures. c. Ensure that there is always a backup drug cassette available. d. Start a large-bore peripheral intravenous line. e. Use strict aseptic technique when using the drug delivery system.

ANS: A, C, E Intravenous prostacyclin agents should be administered in a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted; therefore, a backup drug cassette should also be available. The nurse should use strict aseptic technique when using the drug delivery system. The nurse should teach the client that this medication decreases pulmonary pressures and increases lung blood flow.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the clients lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

ANS: A, D The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Dont go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

ANS: A, D, E The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.

The nurse is teaching a client with asthma how to avoid attacks. What information does the nurse give the client? (Select all that apply.) a. "You should not dust your furniture." b. "Stay inside as much as possible." c. "Stay away from people who are sick." d. "Do not go out in the fall." e. "Stay out of the snow." f. "Do not take aspirin."

ANS: A, F Dusting the furniture may increase dust in the air and cause an asthma attack. Aspirin may stimulate asthma. Staying inside probably will not help. Staying away from snow probably will not have an effect on the client's attacks; neither will going outside during the fall.

The nurse is caring for an older adult who reports experiencing frequent asthma attacks and severe arthritic pain. What action by the nurse is most appropriate? a. Review pulmonary function test results. b. Assess use of medication for arthritis. c. Assess frequency of bronchodilator use. d. Review arterial blood gas results.

ANS: B Aspirin and other NSAIDs can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.

A client is demonstrating diaphragmatic breathing for the nurse. Which action by the client shows adequate understanding of this breathing technique? a. Lying on his or her side with knees bent b. Having his or her hands on the abdomen c. Having his or her hands over the head d. Lying in the prone position

ANS: B To perform diaphragmatic breathing correctly, the client should put the hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? a. Review the client's pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the provider and request arterial blood gases.

ANS: B Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. Bronchodilator - Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators b. Cholinergic antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system c. Corticosteroid - Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors d. Cromone - Disrupts the production of pathways of inflammatory mediators

ANS: B Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that actives beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators.

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique.

ANS: B Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30-pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions

ANS: B The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure. The other clients are not in acute distress.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lays on his or her side with his or her knees bent. b. The client places his or her hands on his or her abdomen. c. The client lays in a prone position with his or her legs straight. d. The client places his or her hands above his or her head.

ANS: B To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the clients oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

ANS: B Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has approved switching to a nasal cannula during meals. If not, the nurse should consult with the provider about this issue. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days

ANS: B Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem.

A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%

ANS: B Room air is 21% oxygen.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

ANS: B Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

ANS: B The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.

The nurse observes that a client's anteroposterior (AP) chest diameter is the same as his lateral chest diameter. What is the nurse's most important question for the client in response to this finding? a. No questions are needed regarding this normal finding. b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?"

ANS: B The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter.

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) to determine activity tolerance. Which questions elicit the most important information? (Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?"

ANS: B, C, E Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?"

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site

ANS: B, D, E, F Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

A client has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Oxygen saturation greater than 95% d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Pain at insertion site g. Disconnection at Y site

ANS: B, D, E, G Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax; sudden shortness of breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 mL/hr because this could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

. A client has a chest tube. What assessment findings require immediate intervention from the nurse? (Select all that apply.) a. Intermittent bubbling in the water seal chamber in the client with a pneumothorax b. "Silent chest" in the client with a pneumothorax c. Tidaling in the water seal chamber in a client with a pneumothorax d. Bloody drainage in the tubing of a client with a hemothorax e. Tracheal deviation in a client after chest trauma f. No drainage in the chest tube of a client with a pneumothorax g. Constant bubbling in the water seal chamber in a client post chest surgery

ANS: B, E, G The client with a silent chest could have a mucous plug, the client with tracheal deviation could have a collapsed lung or tension pneumothorax, and the client with constant bubbling in the water seal could have an air leak. All of these assessments require intervention. The others are normal for the condition stated.

A client with lung cancer refuses pain medications because he or she is "afraid of addiction." What is the nurse's best response? a. "I can ask the physician to change your medication to a drug that is less potent." b. "I can use other measures such as music therapy to distract you." c. "It is unlikely you will become addicted from taking medicine for pain." d. "I can just give you aspirin or acetaminophen (Tylenol) if you like."

ANS: C Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medications.

The nurse is teaching a client with bronchiolitis obliterans organizing pneumonia (BOOP) about corticosteroid therapy. What statement is accurate for the nurse to teach the client? a. "You will be on this drug the rest of your life." b. "You will be prone to many long-term side effects of this drug." c. "A short course of therapy will help with acute episodes." d. "This medication cannot be taken with antibiotic therapy."

ANS: C Corticosteroids are used for acute episodes and are very effective in decreasing manifestations. The client may never have another relapse after therapy. The client is not on the drug for "life," and therefore is not prone to long-term side effects. Agents can be given with antibiotics.

A client with pulmonary fibrosis is being discharged home. What is the highest priority teaching need? a. Dietary modifications b. Determining activity tolerance c. Avoiding infection d. Medication therapy

ANS: C It is extremely important to teach the client with pulmonary fibrosis to avoid infection because the disease will quickly become worse as a result of decreased lung function. The client may take longer to recover from an infection, and the ability to recover may be severely limited owing to the progression of the disease. Teaching the client about modifications in diet, how to determine response to activity, and treatment medications would be secondary.

A client with chronic obstructive pulmonary disease (COPD) reports social isolation. What does the nurse encourage the client to do? a. Join a support group for people with COPD. b. Ask the client's physician for an antianxiety agent. c. Verbalize his or her thoughts and feelings. d. Participate in community activities.

ANS: C Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

What statement indicates that a client needs further teaching regarding therapy with salmeterol (Serevent)? a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in my asthma." c. "I will use the drug when I have an asthma attack." d. "I will be careful not to let the drug escape out of my nose and mouth."

ANS: C Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. The client does not have to keep this inhaler with him or her always because it is not used as a rescue medication. Salmeterol (Serevent) has a slow onset of action; therefore it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client's part allows the drug to escape through the nose and mouth.

. A client is undergoing radiation therapy as treatment for lung cancer and has developed esophagitis. Which is the best diet selection for this client? a. Spaghetti with meat sauce, ice cream b. Scrambled eggs, bacon, toast c. Omelet, whole wheat bread d. Pasta salad, custard, orange juice

ANS: C Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. Toast is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

The nurse assesses a client with asthma and finds wheezing throughout the lung fields and decreased pulse oxygen saturation. In addition, the nurse notes suprasternal retraction on inhalation. What is the nurse's best action? a. Perform peak expiratory flow readings. b. Assess for a midline trachea. c. Administer oxygen and a rescue inhaler. d. Call a code.

ANS: C Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.

The nurse is evaluating a client's response to medication therapy for asthma. The client has a peak flowmeter reading in the yellow zone. What does the nurse do next? a. Nothing; this is an acceptable range. b. Teach the client to take deeper breaths. c. Assist the client to use a rescue inhaler. d. Assess the client's lungs.

ANS: C The client with a peak flow reading in the yellow zone needs to use a rescue inhaler, then have a reading taken again within a few minutes. The nurse has no reason to assess the client's lungs at this point in time, nor would the nurse take the time to teach at this moment.

The nurse is assessing a client with lung disease. Which symptom does the nurse intervene for first? a. The client's anterior-posterior chest diameter is 2:2. b. Clubbing of the finger tips is noted. c. The client has bilateral dependent leg edema. d. The client is pale.

ANS: C The client with bilateral dependent edema may be developing right-sided heart failure in response to respiratory disease. This symptom should be investigated right away and reported to the health care provider. Further assessment is needed. The client with chronic lung disease may develop increased anterior-posterior diameter and clubbing as responses to chronic hypoxia. These symptoms do not require immediate intervention. The client is often pale or has a dusky appearance; this also would not warrant immediate intervention.

A client infected with Burkholderia cepacia is admitted to the unit. What is the nurse's priority action when caring for this client? a. Instruct the client to wash his or her hands after contact with other people. b. Place the client on strict isolation. c. Keep the client isolated from other clients with cystic fibrosis. d. Administer IV vancomycin daily.

ANS: C The infection is spread through casual contact between cystic fibrosis clients, thus the need for isolation of these clients from each other. Strict isolation measures will not be necessary. Although the client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other cystic fibrosis clients

Which statement indicates that the client understands teaching about the use of long-acting beta2 agonist medications? a. "I will not have to take this medication every day." b. "I will take this medication when I have an asthma attack." c. "I will take this medication daily to prevent an acute attack." d. "I will eventually be able to stop using this medication."

ANS: C This medication will help prevent an acute asthma attack because it is long acting. The client will take this medication every day for best effect. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit? a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client isolated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.

ANS: C Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for these clients to be separated from one another. Strict isolation measures will not be necessary. Although the client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with Burkholderia cepacia infection.

The nurse is caring for a client with lung cancer who states, "I don't want any pain medication because I am afraid I'll become addicted." How should the nurse respond? a. "I will ask the provider to change your medication to a drug that is less potent." b. "Would you like me to use music therapy to distract you from your pain?" c. "It is unlikely you will become addicted when taking medicine for pain." d. "Would you like me to give you acetaminophen (Tylenol) instead?"

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching? a. "I will carry this medication with me at all times in case I need it." b. "I will take this medication when I start to experience an asthma attack." c. "I will take this medication every morning to help prevent an acute attack." d. "I will be weaned off this medication when I no longer need it."

ANS: C Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. "There are a variety of support groups for people who have COPD." b. "I will ask your provider to prescribe you with an antianxiety agent." c. "Share any thoughts and feelings that cause you to limit social activities." d. "Friends can be a good support system for clients with chronic disorders."

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in my asthma." c. "I will use the drug when I have an asthma attack." d. "I will be careful not to let the drug escape out of my nose and mouth."

ANS: C Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client's part allows the drug to escape through the nose and mouth.

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole wheat bread d. Pasta salad, custard, orange juice

ANS: C Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, "What does this mean?" How should the nurse respond? a. "Your children will be at high risk for the development of chronic obstructive pulmonary disease." b. "I will contact a genetic counselor to discuss your condition." c. "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." d. "This is a recessive gene and should have no impact on your health."

ANS: C The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent chronic obstructive pulmonary disease (COPD) unless the client smokes. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partner's AAT levels. Contacting a genetic counselor may be helpful but does not address the client's current question.

The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. "Press down firmly on the canister to release one dose of medication." 2. "Breathe in slowly and deeply." 3. "Shake the whole unit vigorously three or four times." 4. "Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer." 5. "Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece." 6. "Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds." a. 2, 3, 4, 5, 6, 1 b. 3, 4, 5, 1, 6, 2 c. 4, 3, 5, 1, 2, 6 d. 5, 3, 6, 1, 2, 4

ANS: C The proper order for correctly using an inhaler with a spacer is as follows. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. Shake the whole unit vigorously three or four times. Place the mouthpiece into the mouth, over the tongue, and seal the lips tightly around it. Press down firmly on the canister of the inhaler to release one dose of medication into the spacer. Breathe in slowly and deeply. Remove the mouthpiece from the mouth, and, keeping the lips closed, hold the breath for at least 10 seconds. Then breathe out slowly. Wait at least 1 minute between puffs.

The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client feels "dizzy;" nurse applies oxygen and pulse oximeter. b. Client's heart rate is 55 beats/min; nurse withholds pain medication. c. Client has reduced breath sounds; nurse calls physician immediately. d. Client's respiratory rate is 18 breaths/min; nurse decreases oxygen flow rate.

ANS: C A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.

The nurse is calculating a client's smoking history in pack-years. The client has recently been diagnosed with lung cancer. Which is the nurse's priority intervention during the interview? a. Encourage the client to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.

ANS: C Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs a day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure

A client tells the nurse that he usually expectorates about 2 ounces of thin, clear, colorless sputum each day, mostly in the morning after getting out of bed. What is the nurse's initial action after gaining this information? a. Ask the client to provide a morning sputum sample for laboratory analysis. b. Obtain a specimen of the sputum in a sterile container for culture. c. Monitor for an increase in sputum production or a change in color. d. Notify the health care provider and prepare the client for possible bronchoscopy.

ANS: C Sputum production is a normal function of the respiratory tract. Most healthy people produce about 90 mL of sputum/day. This sputum should be thin, clear, and odorless, and should have minimal or no color. The nurse's only action should be to monitor the client for an increase in sputum production or a change in color. It will not be necessary at this time to obtain a specimen for analysis or to prepare for a bronchoscopy.

A client had a bronchoscopy 2 hours ago and is requesting water to drink. Which action by the nurse is most appropriate? a. Call the physician and request an order for food and water. b. Give the client ice chips instead of a drink of water. c. Assess the client's gag reflex before giving anything. d. Let the client have a small sip to see whether he or she can swallow.

ANS: C The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

The nurse is caring for several clients on a respiratory unit. Which client does the nurse see first? a. Older adult with an SaO2 of 96% on room air b. Adult client with an SaO2 of 94% on 2 L/min c. Young adult with an arterial oxygen level of 85% d. Young adult with an arterial oxygen level of 94%

ANS: C The young adult with an impaired arterial oxygen level should be seen first. A level of 90% to 100% is a normal level for this age-group. The older adult with a pulse oxygen of 96% is within normal limits, as is an adult with a pulse oxygen of 94%. An arterial oxygen level of 94% would also be seen as normal.

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

ANS: C To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the clients neck, not in back. The other actions are appropriate.

The nurse is assessing a client's breath sounds. Which assessment finding has been correctly linked to the nurse's primary intervention? a. Hollow sounds heard over trachea; increase oxygen flow rate. b. Crackles heard in bases; have the client cough forcefully. c. Wheezes heard in central areas; administer inhaled bronchodilator. d. Vesicular sounds heard over the periphery; have the client breathe deeply.

ANS: C Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no interventions.

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

ANS: C, E Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.

Which symptoms in chronic lung disease require nursing intervention? (Select all that apply.) a. Clubbed fingers b. Increased residual volume c. Decreased peak flow d. Increased anterior-posterior diameter e. Elevated platelets f. Expiratory wheezing g. Stridor h. Change in sputum color and amount

ANS: C, F, G, H Decreased peak flow could indicate worsening of symptoms of airflow occlusion. Likewise, expiratory wheezing and stridor can indicate inflammation and fluid accumulation leading to airway occlusion. A change in the amount and color of sputum can indicate infection. The other symptoms normally occur with chronic disease.

A client with asthma has been having frequent asthma attacks. What is the nurse's best action? a. Teach the client to stay away from pets. b. Assist the client in using an incentive spirometer. c. Administer aspirin for its anti-inflammatory properties. d. Administer montelukast (Singulair).

ANS: D A client who has been having increased attacks can have some chronic inflammation occurring. This inflammation is probably stimulated by mediators such as histamine and leukotriene and can be blocked by drugs like diphenhydramine (Benadryl) and montelukast (Singulair).

A client was diagnosed with lung cancer and appears distressed. The client states, "I am so afraid." What is the best action for the nurse to take? a. Provide comfort by holding the client's hand. b. Offer to give the client a back rub for relaxation. c. Offer the client a PRN antianxiety medication. d. Ask the client what is causing the most fear right now.

ANS: D A diagnosis of lung cancer often causes fear for many reasons, usually poor prognosis, fear of pain, and fear of dyspnea. The nurse should assess what is worrying the client most at the moment so appropriate interventions can be planned. Touch is often a powerful tool, but the nurse should assess whether this is acceptable to the client. The nurse should assess the client further and provide assistance with coping before offering to medicate him.

A client has recently been placed on prednisone (Deltasone). What is the highest priority instruction the nurse will provide? a. "Expect to experience weight gain." b. "Watch your diet while on this medication." c. "Take the drug with food or milk." d. "Report any abdominal pain or dark-colored vomit."

ANS: D All of these directions are appropriate to give the client; however, telling the client to report abdominal pain and dark-colored vomit is most important because these could signal gastric ulceration.

Which is the highest priority problem for a client with late-stage lung cancer? a. Malnutrition b. Constipation c. Weakness and fatigue d. Pain

ANS: D Although all of these problems are important issues, effective pain management is the most important issue for this client and family. The nurse must serve as a client advocate and must ensure that all appropriate measures for management of intractable, severe pain are implemented.

The nurse assesses a client receiving chemotherapy for lung cancer and notes red swollen mucous membranes and open sores in the mouth. The client reports mouth pain and difficulty swallowing. Which action does the nurse perform first? a. Document the size of the sores. b. Perform mouth hygiene. c. Have the client rinse his or her mouth. d. Call the health care provider and hold chemotherapy.

ANS: D Although the nurse should perform all interventions for mucositis, the priority is to call the health care provider and hold the chemotherapy. Mucositis may be a dose-limiting condition in chemotherapy. The nurse should call the provider, then should assist the client with mouth hygiene, rinsing the mouth, and obtaining pain relief. Documenting the size and location of ulcers is also important.

The nurse is caring for a client with bronchiolitis obliterans organizing pneumonia (BOOP) and assesses decreased vital capacity during pulmonary function testing. What is the nurse's best action? a. Administer intermittent positive-pressure breathing treatments. b. Administer a short-acting beta-adrenergic medication. c. Prepare to administer IV antibiotics. d. Document the finding in the client's chart.

ANS: D Decreased vital capacity is a common finding with this disorder because the white blood cells clump and obliterate airways. The nurse should note the finding and should assist the client in activities that help him or her maintain quality of life

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the client's anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

ANS: D A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client's discomfort and need to take deep breaths to prevent complications.

Which nursing intervention is an example of primary prevention for lung cancer? a. Teaching clients with lung cancer how to cough and deep breathe b. Teaching clients with lung cancer to avoid infection c. Teaching clients about prophylactic antibiotics d. Teaching people about smoking and secondhand smoke

ANS: D Primary prevention for lung cancer focuses on reducing tobacco smoking. The other examples are examples of secondary prevention.

The nurse is caring for four clients with asthma. Which client does the nurse assess first? a. Client with a barrel chest and clubbed fingernails b. Client with an SaO2 level of 92% at rest c. Client whose expiratory phase is longer than the inspiratory phase d. Client whose heart rate is 120 beats/min

ANS: D Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, "The medication is too expensive to use every day. I only use my inhaler when I have an attack." How should the nurse respond? a. "You are using the inhaler incorrectly. This medication should be taken daily." b. "If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks." c. "Tell me more about your fears related to feelings of breathlessness." d. "It is important to use this type of inhaler every day. Let's identify potential community services to help you."

ANS: D Long-acting beta2 agonists should be used every day to prevent asthma attacks. This medication should not be taken when an attack starts. Asthma medications can be expensive. Telling the client that he or she is using the inhaler incorrectly does not address the client's financial situation, which is the main issue here. Clients with limited incomes should be provided with community resources. Asking the client about fears related to breathlessness does not address the client's immediate concerns.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3- = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 92%.

ANS: D Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the client's hypoxia, which is the priority.

A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction at the level prescribed by the provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

ANS: D Padded clamps should be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse should never strip the tubing. Tubing junctions should be taped, not clamped. Wall suction should be set at the level indicated by the device's manufacturer, not the provider.

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who has a longer expiratory phase than inspiratory phase d. A 27-year-old client with a heart rate of 120 beats/min

ANS: D Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.

The nurse is caring for a client after a thoracentesis. Which assessment finding by the nurse warrants immediate action? a. Client rates pain as 5/10 at the site of the procedure. b. Small amount of drainage is noted from the site. c. Pulse oximetry is 93% on 2 liters of oxygen. d. Trachea is deviated toward opposite side of the neck.

ANS: D A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near-normal.

A client is scheduled to undergo a thoracentesis. What is the nurse's priority intervention? a. Measure oxygen saturation before and after a 12-minutewalk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Verify that informed consent has been given by the client.

ANS: D A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

The nurse is caring for four clients who had arterial blood gases (ABGs). Which laboratory value warrants immediate intervention by the nurse? a. HCO3 - of 25 mEq/L b. SpO2 of 96% c. pH of 7.38 d. PaCO2 of 48 mm Hg

ANS: D Although the nurse should note the results of all laboratory work, only a PaCO2 of 48 mm Hg is likely to culminate in serious symptoms for the client. HCO3-, SpO2, and pH levels as assessed would not be life threatening, nor would they be indicative of serious complications that would override the importance of the PaCO2 level.

A client had a flexible bronchoscopy 2 hours ago and has become mildly cyanotic despite the application of oxygen. When giving change-of-shift report, which question by the oncoming nurse elicits the most useful information? a. "How long was the client sedated for the procedure?" b. "Were the oximetry readings during the test normal?" c. "Are you sure the client was NPO before the bronchoscopy?" d. "What kind of topical anesthetic was used on the client?"

ANS: D Benzocaine spray can be used as a topical anesthetic before bronchoscopy to numb the throat. However, its use is associated with methemoglobinemia. Methemoglobin does not carry oxygen, and a clue to this problem is increasing cyanosis refractory to oxygen. Chocolate brown blood is another characteristic of this problem. The other options are all appropriate but are not the priority.

When assessing a client's respiratory status, which information is of highest priority for the nurse to obtain? a. Average daily fluid intake b. Neck circumference c. Height and weight d. Occupation and hobbies

ANS: D Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment.

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

ANS: D This client may have a tracheainnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.

Integrated Process: Teaching/Learning 8. A client has a closed fracture of the nose. Which intervention is best when encouraging self-care for this client? a. Advise the client not to eat or drink for 24 hours after sustaining the fracture. b. Teach the client how to apply cold compresses to the area to reduce swelling. c. Urge the client to sleep without a pillow to hasten resolution of the swelling. d. Reassure the client that his or her appearance will normalize after the swelling is gone.

B After a closed fracture of the nose, the nurse will encourage rest and the use of cool compresses on the nose, eyes, or face to help reduce swelling and bruising. Avoiding eating or drinking and sleeping without a pillow will not hasten resolution of the swelling. Reassuring the client regarding his or her appearance is not included in self-care. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Teaching/Learning 9. Which statement indicates that the client needs more teaching regarding rhinoplasty? a. "I will take my temperature twice each day and will report any fever to my doctor." b. "I will wait a few weeks to have my photograph taken, when the swelling is gone." c. "I will take acetaminophen instead of aspirin for pain to avoid excessive bleeding." d. "I will drink at least 3 quarts of liquids a day and will use a stool softener."

B Explain that edema and bruising may last for weeks, and that the final surgical result will be evident in 6 to 12 months. The client should take his or her temperature and report fever in case of infection. The client should take acetaminophen because risk of bleeding is less than with aspirin. Fluids and stool softeners will decrease the risk of straining. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Teaching/Learning 6. A client has open vocal cord paralysis. Which technique does the nurse teach the client to do to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

B The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Teaching/Learning 7. Which client does the nurse safely delegate to the LPN/LVN who has been assigned to the unit for the first time? a. Young adult who is 6 hours post radical neck dissection b. Older adult client with esophageal cancer who is awaiting gastric tube placement c. Client who is status post laryngectomy and is awaiting discharge teaching d. Client who is awaiting preoperative teaching for laryngeal cancer

B The nurse can delegate stable clients to the LPN. The client who is 6 hours post surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching. Teaching cannot be delegated. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation)

Integrated Process: Nursing Process (Implementation) 18. A client who has sleep apnea is reporting constant daytime sleepiness. The client has multiple other chronic diseases. What is the nurse's best action? a. Refer the client for surgery. b. Perform a health history. c. Request an order for a sleeping pill. d. Move the client to a private room.

B The nurse should first assess the client and determine whether he or she has other chronic diseases. If the client's other disorders are not contradictory, the client may be eligible for therapy with modafinil (Attenace) to increase wakefulness during the day. Certain cardiac disorders may prohibit the use of this drug owing to its simulative effects. A sleeping pill would not be an appropriate intervention for a client with sleep apnea. A private room will not help to increase the client's sleep in sleep apnea. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Assessment) 13. Which statement made by the client who is prescribed "voice rest" therapy for vocal cord polyps indicates the need for more teaching? a. "I will stay out of rooms and places where people are smoking." b. "When I speak at all, I will whisper rather than use a normal tone of voice." c. "For the next several weeks, I will not lift more than 10 pounds." d. "I will drink at least 3 quarts of water each day and will use stool softeners."

B Treatment for vocal cord polyps includes not speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, and to stay hydrated and use stool softeners. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 3. A client develops epistaxis. Which conditions in the client's history could have contributed to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets g. High cholesterol

B, C, D Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraine, and elevated platelets and cholesterol levels do not cause epistaxis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 582 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Teaching/Learning 11. Which client is at greatest risk for development of obstructive sleep apnea? a. Woman who is 8 months pregnant b. Middle-aged man with gastroesophageal reflux disease c. Middle-aged woman who is 50 pounds overweight d. Older man with type 2 diabetes and a history of sinus infections

C The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea. DIF: Cognitive Level: Comprehension/Understanding REF: p. 584 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Teaching/Learning 14. A client states that he is going to relax on the beach between radiation treatments for laryngeal cancer to help his "mental status." What is the nurse's best response? a. "You deserve to do something for yourself." b. "Make sure someone is with you because you shouldn't be alone right now." c. "Your skin can become severely burned, and you should not be out in the sun." d. "You should make sure you use sunscreen that is at least SPF 15."

C The client should stay out of the sun during treatment because the skin can become severely burned. Sunscreen may or may not help, but an SPF of 15 is low and does not provide adequate prevention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 12. Which clinical manifestation in a client with paralysis of one vocal cord alerts the nurse to the possibility of aspiration? a. Oxygen saturation is decreased. b. Voice is weak and tremulous. c. The client coughs immediately after swallowing. d. An audible wheeze is present on exhalation.

C The client with open vocal cord paralysis is at risk for aspiration because the airway may not close during swallowing. Coughing may indicate that the client's airway is irritated from aspirated contents. Decreased oxygen saturation can occur for a number of reasons. A weak voice may indicate weak muscles, and wheezing may indicate swelling or inflammation in the airways. DIF: Cognitive Level: Comprehension/Understanding REF: p. 585 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 4. A client reports waking up feeling very tired, even after 8 hours of good sleep. What is the nurse's best action? a. Ask for an order for sleep medication. b. Tell the client not to drink beverages with caffeine. c. Tell the client not to lie flat at night. d. Ask the client whether he or she has ever been evaluated for sleep apnea.

D Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 3. What is the nurse's most important action after a client's gag reflex has returned post rhinoplasty? a. Teach the client to change position every 2 hours. b. Tell the client to put heating pads on the face. c. Instruct the client to lay flat. d. Have the client drink at least 2500 mL/day.

D Once the gag reflex has returned, the client should drink at least 2 1/2 liters per day. The client should not change position frequently; the best position is semi-Fowler's. Ice rather than heat should be applied. Lying flat is not recommended. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

1. A high school athlete has suffered a nasal fracture. What is the priority action of the nurse caring for the client? a. Assess for pain. b. Pack the nares to prevent blood loss. c. Assess for bone displacement. d. Assess for airway patency.

D A patent airway is the priority. The nurse first should make sure that the airway is patent, then should determine whether the client is in pain, and whether bone displacement or blood loss has occurred. DIF: Cognitive Level: Application/Applying or higher TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Teaching/Learning 16. A client has undergone a nasoseptoplasty 2 hours ago. It is a priority for the nurse to assess for which factor? a. Nasal drainage b. Bleeding c. Pain d. Airway patency

D Assessing and maintaining a patent airway is always the top priority. The other assessments are important but do not take priority over airway. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

A client with a history of chronic obstructive pulmonary disease (COPD) presents to the clinic with increased cough and low-grade temperature. Which question by the nurse elicits the most useful information? a. "How long have you been sick?" b. "Has your sputum changed color?" c. "Is anyone else in your house sick?" d. "Do you take any medications?"

Clients with COPD usually have a productive cough. If the color has changed, that is a noteworthy finding. If the client's sputum is yellow or green, this may indicate a pulmonary infection. The other questions are also appropriate to ask but will not help in gathering information specific to a pulmonary problem.

1. The nurse is teaching a client to cough productively. Put the actions in proper sequence. a. Have the client flex the head and hold a pillow to the stomach. b. Assist the client to a sitting position with feet on the floor. c. Instruct the client to bend forward and to cough two or three times. d. Have the client return to an upright position and take a deep breath. e. Encourage the client to take several deep breaths.

b, a, e, c, d When the client can tolerate it, the best position for effective coughing and secretion removal is sitting with the shoulders turned inward and the head bent slightly down while hugging a pillow. The client should take several deep breaths followed by holding the breath slightly before coughing two or three times in a row. Then the client should cough at the end of exhalation; this should be followed by taking several deep breaths.

Place the steps for obtaining a peak expiratory flow rate in the order in which they should occur. a. Take as deep a breath as possible. b. Stand up (unless you have a physical disability). c. Place the meter in your mouth, and close your lips around the mouthpiece. d. Make sure the device reads zero or is at base level. e. Blow out as hard and as fast as possible for 1 to 2 seconds. f. Write down the value obtained. g. Repeat the process two additional times, and record the highest number in your chart.

d, b, a, c, e, f, g The proper order for obtaining a peak expiratory flow rate is as follows: Make sure the device reads zero or is at base level. Stand up (unless you have a physical disability). Take as deep a breath as possible. Place the meter in your mouth, and close your lips around the mouthpiece. Blow out as hard and as fast as possible for 1 to 2 seconds. Write down the value obtained. Repeat the process two more times, and record the highest of the three numbers in your chart.

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11/9/2020

MAHATMA GHANDI