Exam 2 Nurs 327

The nurse is assigned to care for a patient in the ICU who is diagnosed with status asthmaticus. Why does the nurse include fluid intake as being an important aspect of the plan of care? (Select all that apply.)

- To combat dehydration - To loosen secretions - To facilitate expectoration

Which is a correct endotracheal tube cuff pressure?

22 mm Hg

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

A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?

An antiviral agent such as acyclovir

A client experiencing an asthmatic attack is prescribed methylprednisolone (Solu-Medrol) intravenously. The nurse:

Assesses fasting blood glucose levels

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for

Atelectasis In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

Although many signs and symptoms lead to a diagnosis of emphysema, one symptom stands as the primary presenting symptom. Which of the following is the primary presenting symptom?

Dyspnea

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

Dyspnea and wheezing

A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one disorder within its classification. Which of the following is that disorder?

Emphysema

Lung compliance (the ability of the lungs to stretch) is a physical factor that affects ventilation. A nurse is aware that a patient who has lost elasticity in the lung tissue has a condition known as:

Emphysema Explanation: Emphysema, most commonly caused by smoking cigarettes, results in a loss of lung elasticity, which destroys the capillaries that supply the alveoli. This causes airway collapse during expiration, dyspnea, and eventually cyanosis.

Which of the following is a common irritant that acts as a trigger of asthma?

Esophageal Reflux Disease

Bradypnea is associated with which condition?

Increased intracranial pressure

The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?

Lying on the unaffected side. Following a thoracentesis, the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side. Lying flat in a supine position or prone does not promote expansion of the lung.

Histamine, a mediator that supports the inflammatory process in asthma, is secreted by

Mast cells

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Swallow reflex

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 oxygen (PaO2) value of 90 mm Hg or higher.

A commonly prescribed methylxanthine used as a bronchodilator is which of the following?

Theophylline

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.

To provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium

Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy?

Use enteral feedings after the procedure

Most cases of acute pharyngitis are caused by which of the following?

Viral infection

The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?

When the patient has less than 30 mL for 2 consecutive days

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

a feeling of swelling at the back of the throat

A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include

the importance of blood tests to monitor serum concentrations.

A nursing student knows that there are three most common symptoms of asthma. Choose the three that apply.

• Cough • Wheezing • Dyspnea

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

0.5 An FO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air F IO 2 0.18 to 0.21.

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

84 mm Hg

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?

A client experiencing hypothermia Explanation: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.

The wife of a patient who was admitted 3 days ago with an exacerbation of chronic obstructive pulmonary disease (COPD) states that she is worried about her husband because he appears to be breathing "really hard." The nurse performs a respiratory assessment. Which of the following findings would indicate a need for further interventions? (Select all that apply.)

BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 degrees F

Nursing instruction during postural drainage should include telling the patient to:

Change positions frequently and cough up secretions.

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply.

Check for any unusual changes in breathing during the first 48 hours. Observe for any clear drainage from either nostril. Elevate the head of the bed for sleeping during the first week. Restrict from sports activities for 6 weeks.

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?

Chest tube drainage of 190 mL/hr The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is 150 mL/hr or greater. The other findings are normal following a thoracotomy; no intervention is required.

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

Ciprofloxacin is an antibiotic. Prednisone is a corticosteroid. Albuterol is a bronchodilator.

A patient with sinus congestion complains of discomfort when the nurse is palpating the supraorbital ridges. The nurse knows that the patient is referring to which sinus?

Frontal

Which of the following is the key underlying feature of asthma?

Inflammation Explanation: Inflammation is the key underlying feature and leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheeze, and dyspnea.

Which of the following are clinical manifestations associated with obstructive sleep apnea (OSA)? Select all that apply.

Insomnia Arrhythmias Loud snoring Excessive daytime sleepiness Impotence

Which community-acquired pneumonia demonstrates the highest occurrence during summer and fall?

Legionnaires disease

The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply.

Red pharyngeal membranes Swollen lymphoid follicles White-purple exudates on the back of the throat A temperature >100.4 F

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:

mucous membranes.

Pink, frothy sputum may be an indication of

pulmonary edema Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

A nursing instructor is discussing asthma and its complications with medical-surgical nursing students. Which of the following would the group identify as complications of asthma? Choose all that apply.

• Atelectasis • Status asthmaticus • Respiratory failure Explanation: Complications of asthma may include status asthmaticus, respiratory failure, pneumonia, and atelectasis. Pertussis and pneumothorax are not complications.

The nursing student recalls that the underlying pathophysiology of chronic obstructive pulmonary disease (COPD) includes the following components: (Select all that apply.

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

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?

10 to 15 seconds In general, the nurse should apply suction no longer than 10 to 15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. Applying suction for 30 to 35 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 20 to 25 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0 to 5 seconds would provide too little time for effective suctioning of secretions.

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with a pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?

5 - 15 ml

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

5 to 20 minutes. Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

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 with a nasogastric tube

Which is a true statement regarding air pressure variances?

Air is drawn through the trachea and bronchi into the alveoli during inspiration.

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

Compromised gas exchange Decreased airflow Wheezes

A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient?

Continuous positive airway pressure

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?

Crackles in the lung bases When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.

A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus?

Ethmoid

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:

Expect coughing when using the spirometer properly

A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 85% for a patient with COPD. What stage should the nurse document the patient is in?

I Explanation: All grades of COPD are associated with an FEV1/FVC ratio of less than 70%. Grade I (mild) is associated with an FEV1 of greater than or equal to 80%. Grade II (moderate) is associated with an FEV1 of 50%-80%. Grade III is associated with an FEV1 of <30%-50%. Grade IV is associated with an FEV1 of <30%.

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. Included in teaching would be which of the following regarding the MRI?

MRI can view soft tissues and can help stage cancers.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual resuscitation bag The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

Which oxygen administration device has the advantage of providing a high oxygen concentration?

Nonrebreathing mask

Which of the following are risk factors for the development of chronic obstructive pulmonary disease (COPD)? Select all that apply.

Occupational dust Tobacco smoke Air pollution Second-hand smoke

The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.

Oxygen is dissolved. Oxyhemoglobin circulates to the body tissue. Adequate red blood cells are needed for oxygen transport. Explanation: Oxygen transport occurs by dissolving oxygen in the water in the plasma and combining oxygen with red blood cells (oxyhemoglobin). Normal red blood cell count is needed for oxygen transport. High blood pressure does not disrupt transport unless there is disruption in perfusion via a bleeding or occlusion. Dissolved oxygen is the only form which can diffuse across cell membranes.

Which diagnostic imaging modality is more accurate than computed tomography in detecting malignancies?

PET

A nursing student understands that emphysema is directly related to which of the following?

Respiratory acidosis from airway obstruction

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

Runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

The nurse is instructing the patient with asthma in the use of a newly prescribed leukotriene receptor antagonist. What should the nurse be sure to include in the education?

The patient should take the medication an hour before meals or 2 hours after a meal.

The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client

The patient will return to the nursing unit with two chest tubes. The nurse should plan for the patient to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes, only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.

Which of the following is a clinical manifestation of a pneumothorax? Select all that apply

a) Sudden chest pain b) Oxygen desaturation c) Unilateral retractions e) Asymmetry of chest movement

The nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). The nurse instructs the client as follows: (Select all that apply.)

c) Take a slow, deep inhalation from the device. d) Activate the MDI once. e) The device may increase delivery of the MDI medication.

A client is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which medication is contraindicated in the treatment of asthma exacerbations?

Cromolyn sodium

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue?

Delay self-care activities for one hour Explanation: Some clients with COPD have shortness of breath and fatigue in the morning on arising as a result of bronchial secretions. Planning self-care activities around this time may be better tolerated by the client, such as delaying activities until the client is less short of breath or fatigued. The client raising the arms over the head may increase dyspnea and fatigue. Sitting in a chair when bathing or dressing will aid in dyspnea and fatigue but does not address the situation upon arising. Drinking fluids will assist in liquifying secretions which, thus, will aid in breathing, but again does not address the situation in the morning.

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

Flail chest During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

After reviewing the pharmacological treatment for pulmonary diseases, the nursing student knows that bronchodilators relieve bronchospasm in three ways. Choose the correct three of the following options.

Increase oxygen distribution Alter smooth muscle tone Reduce airway obstruction

The nursing student recalls that the underlying pathophysiology of chronic obstructive pulmonary disease (COPD) includes the following components: (Select all that apply.)

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

A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by:

Inspecting the roof of the nasopharynx. Explanation: The adenoids are clusters of lymph tissue located between the back of the nose and the back of the throat in the nasopharynx. The adenoids are usually inspected by using a special mirror. They cannot be seen by looking directly into the mouth.

The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?

Warm and humidify inspired air Explanation: The vascular and ciliated mucous lining of the nasal cavities warms and humidifies inspired air. It is the function of the cilia alone to move mucus in the nasal cavities and filter the inspired air.

Nursing students are gathered for a study session about the pulmonary system. One student asks the others to name the primary causes for an acute exacerbation of COPD. Which of the following responses should be in the reply? Choose all that apply.

• Air pollution • Tracheobronchial infection