exam 2 nur130

The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%. 54 mm Hg; 84% 56 mm Hg; 86% 58 mm Hg; 88% 60 mm Hg; 90%

60 mm Hg; 90%

A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client? Relieve shortness of breath to a level as close as possible to tolerable. Continue with current level of mobility at home. Increase walking distance around a city block without shortness of breath. Maintain activity level of walking to the mailbox.

Increase walking distance around a city block without shortness of breath.

Which terms means an increase in the red blood cell concentration in the blood? Bronchitis Emphysema Asthma Polycythemia

Polycythemia

A nurse is admitting a client with emphysema. What is a symptom diagnostic of emphysema? Occurrence of cor pulmonale Normal elastic recoil Copious sputum production Dyspnea

dyspnea

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction? "Eat a high-sodium diet." "Maintain bed rest." "Limit yourself to smoking only 2 cigarettes per day." "Weigh yourself daily and report a gain of 2 lb in 1 day."

Weigh yourself daily and report a gain of 2 lb in 1 day."

Which would be least likely to contribute to a case of hospital-acquired pneumonia? Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses. A nurse washes her hands before beginning client care. Host defenses are impaired. A highly virulent organism is present.

A nurse washes her hands before beginning client care

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem? Pleural effusion Pneumoconiosis Pneumonia Acute respiratory failure

Acute respiratory failure Explanation: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? Administration of antiretroviral medications to clients over age 65 Administration of pneumococcal vaccine to vulnerable individuals Obtaining culture and sensitivity swabs from all newly admitted clients Administration of prophylactic antibiotics

Administration of pneumococcal vaccine to vulnerable individuals Explanation: Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A onetime vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all clients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.

In which statements regarding medications taken by a client diagnosed with COPD do the drug name and the drug category correctly match? Select all that apply. Cotrimoxazole is a bronchodilator. Dexamethasone is an antibiotic. Albuterol is a bronchodilator. Ciprofloxacin is an antibiotic. Prednisone is a corticosteroid.

Albuterol is a bronchodilator. Ciprofloxacin is an antibiotic. Prednisone is a corticosteroid. Explanation: Theophylline, albuterol, and atropine are bronchodilators. Dexamethasone and prednisone are corticosteroids. Amoxicillin, ciprofloxacin, and cotrimoxazole are antibiotics. All of these drugs could be prescribed to a client with COPD.

The nurse at the beginning of the evening shift receives a report at 1900 on the following patients. Which patient would the nurse assess first? An 85 year old with COPD with wheezing and an O2 saturation of 89% on 2 L of oxygen An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office A 74 year old with chronic bronchitis who has BP 128/58, HR 104, and R 26 A 62 year old with emphysema who has 300 mL of intravenous fluid remaining

An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office

An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care? Bed rest Administration of probiotic supplements Cautious hydration Nasogastric intubation

Cautious hydration Explanation: Supportive treatment of pneumonia in the older adults includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the older adults); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the client.

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? Call the nurse for oral suctioning, as needed. Increase activity. Lie in a low Fowler or supine position. Increase oral fluids unless contraindicated.

Increase oral fluids unless contraindicated. Explanation: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: Impaired tissue integrity. Ineffective breathing pattern. Risk for falls. Ineffective airway clearance.

Ineffective airway clearance. Explanation: Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client

A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply. Overinflated alveoli that impair gas exchange Decreased numbers of goblet cells Inflamed airways that obstruct airflow Mucus secretions that block airways Dry airways that obstruct airflow

Inflamed airways that obstruct airflow Mucus secretions that block airways Overinflated alveoli that impair gas exchange

Which community-acquired pneumonia demonstrates the highest occurrence during summer and fall? Legionnaires disease Viral pneumonia Streptococcal (pneumococcal) pneumonia Mycoplasma pneumonia

Legionnaires disease

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? Older adults often lack the classic signs and symptoms of pneumonia. Older adults often cannot tolerate the most common antibiotics used to treat pneumonia. Older adults have less compliant lung tissue than younger adults. Older adults are not normally candidates for pneumococcal vaccination.

Older adults often lack the classic signs and symptoms of pneumonia. Explanation: The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in older adult clients. Mortality from pneumonia in older adults is not a result of limited antibiotic options or lower lung compliance. The pneumococcal vaccine is appropriate for older adults

A nurse is caring for a client with COPD. While reviewing breathing exercises, the nurse instructs the client to breathe in slowly through the nose, taking in a normal breath. Then the nurse asks the client to pucker his lips as if preparing to whistle. Finally, the client is told to exhale slowly and gently through the puckered lips. The nurse teaches the client this breathing exercise to accomplish which goals? Select all that apply. Condition the inspiratory muscles Prevent airway collapse Control the rate and depth of respirations Release air trapped in the lungs Strengthen the diaphragm

Prevent airway collapse Control the rate and depth of respirations Release air trapped in the lungs

During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections? Take all prescribed medications Drink six glasses of water daily Exercise daily Receive vaccinations

Receive vaccinations

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? Using incentive spirometry Mobilizing early Receiving vaccinations Using prescribed opioids

Receiving vaccinations

The home care nurse is monitoring a client discharged home after resolution of a pulmonary embolus. For what potential complication should the home care nurse be most closely monitoring this client? Residual effects of compromised oxygenation Swallowing ability and signs of aspiration Signs and symptoms of pulmonary infection Activity level and role performance

Residual effects of compromised oxygenation Explanation: The home care nurse should monitor the client for residual effects of the PE, which involved a severe disruption in respiration and oxygenation. PE has a noninfectious etiology; pneumonia is not impossible, but it is a less likely sequela. Swallowing ability is unlikely to be affected; activity level is important, but secondary to the effects of deoxygenation.

The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is: Respiratory acidosis. Hypoxemia secondary to impaired oxygen diffusion. Hypercapnia resulting from decreased carbon dioxide elimination. Diminished alveolar surface area

Respiratory acidosis

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? Dilated and reactive pupils Respiratory rate of 22 breaths/minute Urine output of 40 ml/hour Heart rate of 100 beats/minute

Respiratory rate of 22 breaths/minute Explanation: In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect

A nurse is providing discharge teaching for a client with COPD. What should the nurse teach the client about breathing exercises? Use diaphragmatic breathing Use chest breathing Lie supine to facilitate air entry Avoid pursed-lip breathing unless absolutely necessary.

Use diaphragmatic breathing

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? Turning the client every 4 hours to prevent fatigue Keeping the head of the bed at 15 degrees or less Using strict hand hygiene Providing oral hygiene daily

Using strict hand hygiene Explanation: The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.

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

atelectasis. Explanation: In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: turn and reposition himself every 2 hours. maintain fluid intake of 40 oz (1,200 ml) per day. continue to take antibiotics for the entire 10 days. follow up with the physician in 2 weeks.

continue to take antibiotics for the entire 10 days. Explanation: The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.

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

lung sounds

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. The client exhibits restlessness and confusion. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client exhibits bronchial breath sounds over the affected area.

orrect response: The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: level of consciousness (LOC). hemoglobin, hematocrit, and red blood cell levels. oxygen saturation level. extremities for signs of cyanosis.

oxygen saturation level. Explanation: The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

A client is being admitted to an acute health care facility with an exacerbation of chronic obstructive pulmonary disease (COPD). The nurse is placing this information on the Medication Reconciliation Record. What medication information needs to be clarified with the health care provider? nicotine patch 21 mg transdermal daily at 0800 salmeterol/fluticasone MDI daily at 0800 azithromycin 600 mg oral daily for 10 days at 0800 prednisone 5 mg oral daily at 0800

salmeterol/fluticasone MDI daily at 0800

Question 24 of 89 A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. vaccinations incentive spirometry prescribed opioids hand antisepsis

vaccinations hand antisepsis Explanation: A powerful weapon against the spread of communicable disease is effective and frequent handwashing. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae.

Which is the most important risk factor for development of chronic obstructive pulmonary disease (COPD)? Genetic abnormalities Occupational exposure Air pollution Cigarette smoking

Cigarette smoking

Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process? Bronchiectasis Empyema Consolidation Atelectasis

Consolidation

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Getting the flu can complicate pneumonia." "Influenza vaccine will prevent typical pneumonias." "Influenza is the major cause of death in the United States." "Viruses like influenza are the most common cause of pneumonia."

"Viruses like influenza are the most common cause of pneumonia."

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Give antibiotics as ordered. Place client on bed rest. Encourage increased fluid intake. Offer nutritious snacks 2 times a day.

Encourage increased fluid intake

The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the client indicates the need for further instruction? "Because I am prescribed a corticosteroid-containing MDI, I will rinse my mouth with water after use." "I will shake the MDI container before I use it." "I will take a slow, deep breath in after pushing down on the MDI." "I can't use a spacer or holding chamber with the MDI."

"I can't use a spacer or holding chamber with the MDI." Explanation: The client can use a spacer or a holding chamber to facilitate the ease of medication administration. The remaining client statements are accurate and indicate the client understands how to use the MDI correctl

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis? Chronic obstructive pulmonary disease (COPD) Pulmonary hypertension Empyema Pulmonary tuberculosis

Pulmonary hypertension Explanation: Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia? Staphylococcus aureus Streptococcus pneumoniae Pseudomonas aeruginosa Mycobacterium tuberculosis

Streptococcus pneumoniae

For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway? Enforcing absolute bed rest Teaching the client how to perform controlled coughing Restricting fluid intake to 1,000 ml/day Administering ordered sedatives regularly and in large amounts

Teaching the client how to perform controlled coughing

A client newly diagnosed with COPD tells the nurse, "I can't believe I have COPD; I only had a cough. Are there other symptoms I should know about"? Which is the best response by the nurse? "You can also expect to experience a progressive weight gain." "There are no other symptoms; however, your cough may get worse as the disease progresses." "As your COPD worsens, you will frequently develop respiratory infections." "Other symptoms you may develop are shortness of breath upon exertion and sputum production."

"Other symptoms you may develop are shortness of breath upon exertion and sputum production.

Question 34 of 89 A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that he should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is: 2 L. unspecified. 3 L. 1.4 L.

1.4 L

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? A client who ambulates in the hallway every 4 hours A client who is receiving acetaminophen (Tylenol) for pain A client with a nasogastric tube A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago

A client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: bronchial asthma. renal failure. chronic obstructive pulmonary disease (COPD). acute respiratory distress syndrome (ARDS).

ARDS A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.

A physician orders a beta2 adrenergic-agonist agent (bronchodilator) that is short-acting and administered only by inhaler. What drug would the nurse know to administer to the client? Formoterol Ipratropium bromide Albuterol Isoproterenol

Albuterol

A client newly diagnosed with emphysema asks the nurse to explain all about the disease. The nurse would include the following response when defining emphysema: An abnormal distention of the air spaces with destruction of the alveolar walls Increased oxygen diffusion with inflammation of the bronchioles Decreased sputum production with dilation of bronchioles Inflammation of the bronchioles with a normal distention of the air spaces

An abnormal distention of the air spaces with destruction of the alveolar walls

The nurse knows that a sputum culture is necessary to identify the causative organism for acute tracheobronchitis. What causative fungal organism would the nurse suspect? Hemophilus Aspergillus Streptococcus pneumoniae Mycoplasma pneumoniae

Aspergillus

Which of the following is a potential complication of a low pressure in the endotracheal cuff? Tracheal ischemia Tracheal bleeding Pressure necrosis Aspiration pneumonia

Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply. Ascites Jugular vein distention Compromised gas exchange Decreased airflow Wheezes

Compromised gas exchange Decreased airflow Wheezes

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? Administering pain medications, frequent repositioning, and limiting fluid intake Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Administering oxygen, coughing, breathing deeply, and maintaining bed rest Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Explanation: Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Dyspnea and wheezing Hemoptysis and dysuria Nonproductive cough and normal temperature Sore throat and abdominal pain

Dyspnea and wheezing Explanation: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Elevating the head of the bed 30 degrees Encouraging increased fluid intake Maintaining a cool room temperature Turning the client every 2 hours

Encouraging increased fluid intake Explanation: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client Has a respiratory rate of 28 breaths/minute Reports shortness of breath Cannot perform activities of daily living Has wheezes in the right lung lobes

Has wheezes in the right lung lobes

A client is admitted to a health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? Anxiety related to actual threat to health status Activity intolerance related to fatigue Impaired gas exchange related to airflow obstruction Risk for infection related to retained secretions

Impaired gas exchange related to airflow obstruction

Which measure may increase complications for a client with COPD? Administration of antibiotics Administration of antitussive agents Increased oxygen supply Decreased oxygen supply

Increased oxygen supply

Which type of pneumonia has the highest incidence in clients with AIDS and clients receiving immunosuppressive therapy for cancer? Fungal Streptococcal Pneumocystis Tuberculosis

Pneumocystis Explanation: Pneumocystis pneumonia incidence is greatest in clients with AIDS and clients receiving immunosuppressive therapy for cancer, organ transplantation, and other disorders.

The nurse is reviewing the electronic health record of a client with an empyema. What health problem in the client's history is most likely to have caused the empyema? Lung cancer Smoking Asbestosis Pneumonia

Pneumonia Explanation: Most empyemas occur as complications of bacterial pneumonia or lung abscess. Cancer, smoking, and asbestosis are not noted to be common causes.

A nurse assesses a client with pneumonia. Which assessments are diagnostic for pneumonia? Select all that apply. Percussion dullness Whispered pectoriloquy Wheezes Presence of crackles Friction rubs Egophony

Presence of crackles Egophony Whispered pectoriloquy Percussion dullness Explanation: Physical examination findings may reveal bronchial breath sounds over consolidated lung areas: soft, high-pitched crackles, inspiratory vesicular sounds that are longer than expired normal breath sounds, increased tactile fremitus (vocal vibration detected on palpation), percussion dullness, egophony, and whispered pectoriloquy (whispered sounds are easily auscultated through the chest wall). Wheezes and friction rubs are not common assessment findings for clients with pneumonia.

The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment? Increasing pH Providing sufficient oxygen to improve oxygenation Avoiding the use of oxygen to decrease the hypoxic drive Monitoring the pulse oximetry to assess need for early intervention when PCO2 levels rise

Providing sufficient oxygen to improve oxygenatio

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances? Respiratory acidosis Respiratory alkalosis Metabolic alkalosis Metabolic acidosis

Respiratory acidosis

A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is: Tachycardia Sharp, stabbing chest pain Dyspnea A dry, hacking cough

Sharp, stabbing chest pain Explanation: The initial symptom is usually chest pain of sudden onset that leads to feelings of chest pressure, dyspnea, and tachycardia. A cough may be present.

When developing a preventative plan of care for a patient at risk for developing chronic obstructive pulmonary disease (COPD), which of the following should be incorporated? Smoking cessation Weight reduction Cancer prevention Cholesterol management

Smoking cessation

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-Medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer: albuterol (Proventil). morphine. alprazolam (Xanax). propranolol (Inderal).

albuterol (Proventil

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis? Unilateral neglect Impaired swallowing Imbalanced nutrition: More than body requirements Anxiety

anxiety

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: empyema. infected chest tube wound site. lobar pneumonia. Pneumocystis carinii pneumonia.

empyema. Explanation: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? Activity intolerance Imbalanced nutrition: Less than body requirements Impaired oral mucous membranes Impaired gas exchange

impaired gas exchange

Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an rise in the death rates from pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza? staphylococcal pneumonia cardiovascular disease tracheobronchitis viral pneumonia

staphylococcal pneumonia