Evolve Med-Surg Ch. 28 & 31

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care?

"I can only take bath, no showers"

A client has a sore throat; fever; enlarged, red tonsils; and tender, swollen lymph nodes. A rapid antigen test (RAT) performed in the clinic is negative for group A beta-hemolytic streptococcus. What does the nurse tell this client?

"The provider will have final results of a culture in 2 days."

A client with active tuberculosis is ordered to take isoniazid (INH), pyrazinamide (PZA), and rifampin (RIF), and asks the nurse why it is necessary to take three antibiotics. What is the nurse's best answer?

"Three antibiotics help prevent bacterial drug resistance." Multidrug therapy provides quicker destruction of organisms and combats drug resistance.

A client who has pneumonia reports having chest pain associated with inspiration. The nurse notifies the provider and anticipates implementing which order?

-Administering analgesic medications to alleviate discomfort Pleuritic chest pain occurs with inspiration and is a common clinical manifestation in clients with pneumonia; analgesic medications are given to alleviate discomfort.

The nurse is caring for a client with a tracheostomy and a T-piece who has thick tracheal secretions. What does the nurse do to liquefy secretions and facilitate suctioning? Select all that apply.

-Attach a warming device to the humidification water source. -Ensure intake of fluids is adequate. -Increase the flow rate of the air flow meter. A warming device enhances humidification. When a client is adequately hydrated, tracheal secretions are thinner. Increasing the flow rate increases the passage of air through the humidifier and enhances humidification. It is not within the nurse's scope of practice to instill water into the tracheostomy. Condensation should be drained away from the airway to protect from aspiration and infection.

Vagal stimulation during suctioning can contribute to which conditions? Select all that apply.

-Bradycardia -Heart block -Astystole Tracheal suctioning can cause a vagal response. This stimulus influences the electrical system of the heart, potentially leading to decreased heart rate (bradycardia), heart block, asystole, or other dysrhythmias.

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care?

-Contacting the provider if the throat feels more swollen Clients with peritonsillar abscess are at risk for airway obstruction due to swelling and should notify the provider if signs of obstruction occur, such as stridor or drooling.

A client with a cuffed fenestrated tracheostomy tube has been speaking well when the decannulation cap is in place. While visiting, the family alerts the nurse that the client is having difficulty breathing. Which action by the nurse has the highest priority?

-Deflating the cuff An inflated cuff with a capped fenestration tube gives the client no airway. Deflating the cuff around the tube will help relieve this. If the client does not improve with cuff deflation, then the cap should be removed.

When planning the care of a client with a tracheostomy, which interventions does the nurse include? Select all that apply.

-Encourage ambulation and out-of-bed activities. -Use a sponge tooth cleaner or soft toothbrush moistened in water for oral hygiene.

A newly admitted client with pneumonia has an oral temperature of 102° F, an oxygen saturation of 93%, diminished breath sounds bilaterally, and the client is unable to cough effectively. The nurse has received orders for oxygen therapy, intravenous antibiotics, antipyretic medication, and sputum specimen collection. What is the nurse's first action?

-Give intravenous antibiotic The client should receive the antibiotic as soon as possible, since sepsis is a serious complication of pneumonia.

Which actions known as the "ventilator bundle" have been shown to reduce the incidence of ventilator-associated pneumonia (VAP)? Select all that apply.

-Hand hygiene -Oral care -Head of bed elevation

Which principles are important for the nurse to remember about oxygen administration? Select all that apply.

-High levels of oxygen dilute the nitrogen in the lungs leading to alveolar collapse. -Nitrogen helps prevent alveolar collapse, as it doesn't cross over capillary membranes. High levels of oxygen administration dilute the nitrogen when it diffuses across the membrane into the circulation, and the alveoli collapse, leading to atelectasis.

A client receiving oxygen via a simple facemask has a pulse oximetry level of 96% and a respiratory rate of 14 breaths per minute. Oxygen is being delivered at a flow rate of 4 L/min. What is the correct action by the nurse?

-Increase the oxygen flow rate to 5 L/min and review the provider's orders. A minimum flow rate of 5 L/min is needed for clients receiving oxygen via facemask to prevent the rebreathing of exhaled air. The nurse should increase the flow rate to this minimum level and then check the order.

An older client receiving mechanical ventilation with a tracheostomy has poor nutritional status and is dehydrated. Which nursing action is most important to prevent complications in this client?

-Keep the pressure on the tracheal tube cuff between 14 and 20 mm Hg Older clients and those who are malnourished and dehydrated are at increased risk for tissue breakdown caused by tracheostomy tube pressure. Anything that causes movement of the tube causes friction and can contribute to tissue breakdown. Maintenance of cuff pressure between 14 mm Hg and 20 mm Hg will allow adequate circulation to the tracheal mucosa.

Which factors should be considered when determining which type of oxygen a client will require for home oxygen therapy? Select all that apply.

-Liquid oxygen is available in lightweight, easy-to-carry containers. -Liquid oxygen tanks last longer than equal-sized gaseous oxygen tanks

A client is to receive oxygen therapy at home by nasal cannula. What information is important for the nurse to include? Select all that apply.

-Lubricate the nostrils with water-soluble jelly. -Cleanse the cannula by rinsing with clear warm water every 4-8 hours. -Do not smoke or use lit candles or matches in the immediate area. Nonpetroleum jelly or cream lubricates the nostrils, face, and lips to relieve the drying effects of oxygen. Regular cleansing of the cannula is important for good hygiene. Open fires, even small ones like candles or cigarettes, should not be in the same room during oxygen therapy.

Which statements about pulmonary tuberculosis (TB) are correct? Select all that apply.

-Mycobacterium tuberculosis is transmitted from person to person via the airborne route. -Infected people are not infectious to others until manifestations of the disease occur. -An asymptomatic period of up to years or decades can follow the time of primary infection. -Foreign immigrants, especially from Mexico, the Philippines, and Vietnam, are at greatest risk

A client has been receiving 60% oxygen per simple facemask since admission 3 days ago. Which initial findings alert the nurse to oxygen toxicity? Select all that apply.

-Non productive cough -Chest pain -GI upset Initial symptoms of oxygen toxicity include dyspnea, nonproductive cough, chest pain beneath the sternum, and GI upset. Hemoptysis would be a later symptom as the condition worsens. Bradycardia and fever are not present with oxygen toxicity.

A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? Select all that apply.

-Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. -The medications may cause nausea. The client should take them at bedtime. Not taking the medication as prescribed could lead to an infection that is difficult to treat or to total drug resistance. The medications may cause nausea and are best taken at bedtime to prevent this.

Which group of individuals should be encouraged to receive the pneumococcal vaccine as an important health promotion and maintenance intervention?

-Older adults with a chronic health problem Individuals older than age 65 and those with chronic health problems should be encouraged to receive PPV 23 to prevent pneumonia. Since pneumonia often follows influenza among older adults, these individuals should also be encouraged to receive the seasonal influenza vaccination yearly.

A client is wearing a non-rebreather mask prescribed to deliver 100% fraction of inspired oxygen (Fio2). What would ensure that this concentration is delivered? Select all that apply.

-One-way valve between the mask and reservoir should open during inhalation. -Oxygen flow rate should be set at 10-15 L/min. The one-way valve on a non-rebreather mask opens during inhalation to allow oxygen to be inhaled from the reservoir bag; it closes during exhalation to prevent exhaled air (carbon dioxide) from entering the reservoir. The recommended flow rate for a non-rebreather mask is 10-15 L/min.

The nurse is caring for a client who had a tracheostomy placed 48 hours ago. What are important considerations when caring for this client? Select all that apply.

-Provide a writing pad or laptop computer for communication. -Ensure tube feeding is administered at the prescribed rate. -Place a tracheostomy tube, obturator, and insertion tray at the bedside.

An older client has a persistent cough with hemoptysis and has a known exposure to tuberculosis. A tuberculin skin test reveals a reaction less than 5 mm. The nurse documents that this test result indicates which condition?

-Reduced immune function

Which symptom indicates that a client's pharyngitis is most likely bacterial and not viral?

-Scarlatiniform rash

Which symptom indicates that a client's pharyngitis is most likely bacterial and not viral?

-Scarlatiniform rash Dysphagia and lymphadenopathy may all be present with viral or bacterial pharyngitis. A scarlatiniform rash is only present with bacterial pharyngitis. Scant or no tonsillar exudate is typical of viral pharyngitis.

The nurse is caring for a client with severe acute respiratory syndrome (SARS). What is the most important precaution the nurse should take when preparing to suction this client?

-Wearing a disposable particulate mask respirator and protective eyewear To protect health care workers during procedures that induce coughing or promote aerosolization of particles, nurses should wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms.

A client who has been receiving high-flow oxygen via a Venturi mask for several days is reporting respiratory difficulty and that the mask doesn't seem right. What cause could be contributing to this sensation?

-When the mask was changed at the end of the previous shift, a simple facemask was initiated for oxygen delivery.

When caring for the client with hypercarbia who is receiving supplemental oxygen, why must the nurse use caution with the rate of administration?

A lower arterial oxygen level provides the stimulus to breathe.

A prescription for oxygen therapy for a client who has been on a Venturi mask indicates a need for 80% Fio2. What do the options to fulfill this order include? Select all that apply.

Aerosol mask Face tent

Which statements about anthrax infection are correct? Select all that apply.

Although rarely occurring naturally, inhalation anthrax is nearly 100% fatal without treatment. As macrophages in the lungs engulf the anthrax spores, the organism leaves its capsule and replicates. Toxins produced by the organisms in the lungs create massive edema, suppressing neutrophil action. Dyspnea, diaphoresis, and sudden onset of breathlessness are common in late stages of the disease.

A client who has not had the influenza vaccine calls the clinic to report being exposed to influenza A and asks the nurse whether something can be prescribed to prevent contracting the disease. The nurse notifies the provider and expects an order for which medication?

Amantadine (Symmetrel)

Clients receiving oxygen therapy are at risk for skin breakdown. Which areas require special focus? Select all that apply.

Area under the nasal prongs Bridge of the nose Oral cavity membranes

The nurse assesses a client who has begun receiving oxygen therapy of 40% via Venturi mask and notes pink lips and nailbeds, and a pulse oximetry value of 98%. The client is sleeping and has a heart rate of 76 beats per minute, a respiratory rate of 6 breaths per minute, and breaths are nonlabored and shallow. What is the nurse's correct initial response?

Auscultate the client's breath sounds bilaterally.

A client with an artificial airway is receiving oxygen at a rate of 4 L/min. The nurse notes that a humidifier bottle between the oxygen source and the client is half-full of sterile water and that the water is bubbling. Which action by the nurse is correct?

Change the humidification device to a heated nebulizer.

Which finding indicates a need for low-flow oxygen delivery for a client?

Chronic hypercarbia

Following a bioterrorism attack with anthrax, the emergency department nurse checks the medication room for ample supply of which medications? Select all that apply.

Ciprofloxacin (Cipro) Doxycycline (Vibramycin) Amoxicillin (Amoxil) Rifampin (RIF) Vancomycin (Vancocin)

A client with a recent history of a mild respiratory infection is admitted to the hospital after a sudden onset of breathlessness. The client has a temperature of 104° F, is diaphoretic and dyspneic, and the nurse observes stridor and cyanosis. A chest x-ray reveals mediastinal widening. The nurse anticipates an order for administering which antibiotics for this client?

Ciprofloxacin (Cipro) and clindamycin (Cleocin)

Which clinical manifestations are usually present when an older adult has pneumonia? Select all that apply.

Confusion Weakness Poor appetite Fatigue

When caring for a client with a Venturi mask, one strategy to reduce the fraction of inspired oxygen (Fio2) yet maintain oxygenation is to convert to which device

Continuous positive airway pressure mask The continuous positive airway pressure (CPAP) mask administers continuous positive airway pressure, which increases ventilation by increasing volume and pressure of inhalation. This prevents alveolar collapse, thereby enhancing gas exchange/oxygenation, which would allow for lower Fio2.

A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the client appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse observes the client resting with closed eyes, pink coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is correct?

Decrease the oxygen to 2 L/min to improve respiratory rate. Clients with chronic hypercarbia are at risk for oxygen-induced hypoventilation. Clients with COPD are more likely to have chronic hypercarbia. This client has a slowed respiratory rate and an altered level of consciousness indicating hypoventilation, which can occur within the first 30 minutes of oxygen therapy. The nurse should reduce the oxygen flow to see if the respiratory rate improves.

The normal balance of the body's oxygen intake and delivery system can be altered by nonrespiratory conditions including fever, sepsis, heart failure, poisoning, and poor hemoglobin quality. Which possible situations may result? Select all that apply.

Decreased cardiac output Increased oxygen demand by the body Decreased oxygen-carrying capability of the blood

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first?

Draw aerobic and anaerobic blood cultures

What actions prevent tracheostomy decannulation during tie replacement? Select all that apply.

Hold the tracheostomy tube in place with one hand during the process. Do not remove the old ties until the new ones are in place.

Which groups are at greatest risk for drug-resistant Streptococcus pneumoniae? Select all that apply.

Individuals older than age 65 years Older adults exposed to children from a daycare environment

Which assessment findings may indicate a tracheostomy tube is obstructed? Select all that apply.

Noisy respirations Dyspnea Difficulty inserting a suction catheter

Which statements differentiating between viral and bacterial pharyngitis are correct? Select all that apply.

Onset of symptoms is more likely to be abrupt with bacterial pharyngitis. High temperature—usually 102° to 104° F—occurs with bacterial pharyngitis.

A fenestrated tube can be capped to allow the client with a tracheostomy to talk. What should the nurse confirm first?

Oral cavity secretions have been suctioned

The nurse is discharging a client with a prescription for continuous oxygen therapy via nasal cannula at home. What does the nurse include in the discharge teaching?

Pad the tubing behind the ears

A client with a tracheostomy is receiving feedings via a nasogastric tube, during which the client experiences increased coughing and choking. The nurse notes that the tracheostomy cuff requires increasing amounts of air to maintain the seal, and when suctioning the tracheostomy, food particles are present in the tracheal secretions. After notifying the provider of these observations, which procedure does the nurse expect to be performed?

Placement of a jejunostomy tube.

When suctioning a tracheostomy or endotracheal tube, what nursing actions ensure safe and effective practice? Select all that apply.

Preoxygenating the client with 100% oxygen for 30 seconds to 3 minutes before suctioning When suctioning, using a gentle twirling motion of the catheter If needed, repeating suctioning up to three passes

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority?

Prison staff and inmates

Which points does the nurse include when educating an older client and family about pneumonia prevention? Select all that apply.

Receiving an annual influenza vaccine Decreasing exposure to air pollutants Avoiding crowded public places Avoiding dehydration

A client with a sore throat has a temperature of 99.9° F. The nurse palpates mild enlargement of cervical lymph nodes without tenderness and notes erythema of the tonsils without exudate. After performing a throat culture, and reporting these findings to the provider, the nurse expects an order for which treatment course?

Symptomatic care

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress?

The client is receiving oxygen at 4 L/min

A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer?

The client will be treated for 5-7 days

When providing care to a client with a recently placed tracheostomy who is on a mechanical ventilator, which principle guides nursing care?

The pilot balloon should be inflated.

A client who has acute viral rhinitis cares for an older family member who is susceptible to respiratory infections. Which action does the nurse suggest to this client to help prevent the spread of infection?

Thoroughly wash hands after touching the face.

The health care provider has suggested placing a client with chronic obstructive pulmonary disease (COPD) on noninvasive positive-pressure ventilation (NPPV) to improve gas exchange. What information is important to discuss with the client before starting NPPV? Select all that apply.

Tight-fitting masks can lead to skin breakdown. Mask leaks can cause pressure around the eyes. There is a risk of aspiration due to gastric inflation. NPPV may require nasal gastric tube placement.

Immediately after having a tracheostomy tube removed as ordered by the provider, the client begins to cough and has difficulty breathing, talking, and clearing secretions. After notifying the provider, the nurse anticipates an order for which procedure?

Tracheal dilation

Which nursing interventions are focused on preventing the spread of severe acute respiratory syndrome (SARS) caused by coronaviruses? Select all that apply.

Using strict airborne isolation techniques Handwashing before and after all client care Using Contact Precautions with people suspected to have SARS Disinfecting contaminated surfaces and equipment

A client with recurrent tonsillitis is admitted to the hospital with a peritonsillar abscess. The client wonders if surgery will be necessary. How does the nurse predict the doctor will respond?

You will most likely have a surgical tonsillectomy.