GNRS 555: Exam 2 Review Questions

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms consistent with PE will the nurse assess? Select all that apply. 1. Dizziness and syncope 2. Shortness of breath (SOB) worsening over the last 2 weeks 3. Inspiratory chest pain 4. Productive cough 5. Pink, frothy sputum 6. Tachycardia

1. Dizziness and syncope 3. Inspiratory chest pain 6. Tachycardia Rationale: Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE.Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over two weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.

A client has received packing for a posterior nosebleed. In reviewing the client's prescriptions, which of these does the nurse question? 1. "Ibuprofen 800 mg every 8 hours as needed for pain." 2. "Elevate the head of the bed 45 to 60 degrees." 3. "Provide humidified air." 4. "Have suction available at the bedside."

1. "Ibuprofen 800 mg every 8 hours as needed for pain." Rationale: The nurse must question the prescription for ibuprofen. Ibuprofen is contraindicated in a client with a nosebleed because nonsteroidal anti-inflammatory drugs inhibit clotting.Elevation of the head of the bed is recommended for client comfort and to facilitate drainage of secretions. Humidified air and humidified oxygen, if oxygen is ordered, are recommended because dryness of the nasal mucosa can be a cause of epistaxis (nosebleed). Any client who is admitted for epistaxis needs suction at the bedside in the event of further bleeding.

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device will the nurse select? 1. Face tent 2. Venturi mask 3. Nasal cannula 4. Non-rebreather mask

1. Face tent Rationale: The nurse will initially select a fact tent for this client. A client with smoke inhalation and facial burns who requires high-flow oxygen must initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue.Although a Venturi mask and a non-rebreather mask are high-flow oxygen delivery devices, they are snugly fitted on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to the scan, which of these assessment questions is essential for the nurse to ask? 1. "Do you take supplements containing vitamin K?" 2. "Did you take metformin today?" 3. "Are you allergic to peanuts?" 4. "Have you had shortness of breath recently?"

2. "Did you take metformin today?" Rationale: The assessment question that is essential for the nurse to ask is, "Did you take metformin today?" IV contrast material can be nephrotoxic. Metformin is stopped at least 24 hours before contrast dye is used and is not restarted until adequate kidney function is confirmed.If pulmonary embolism is confirmed, warfarin may be prescribed. If so, vitamin K-containing foods and vitamins will need to be limited. Peanut allergy does not pose a risk with contrast. Shortness of breath is a typical finding when a PE is present, and is not the priority assessment prior to CT.

An older client presents to the emergency department with a 2-day history of cough, pain, wheezing, and dyspnea. The medical record states the client has not received the pneumococcal vaccine. While collaborating with the interprofessional team, which one of these medications does the nurse anticipate the health care provider will recommend as the priority? 1. Corticosteroid 2. Beta agonist 3. Pneumococcal vaccine 4. Antibiotic

2. Beta agonist Rationale: The priority medication the nurse would expect the HCP to order is a beta-2 agonist or bronchodilator to help decrease bronchospasm and wheezing. This medication allows for adequate oxygenation by relaxing bronchial smooth muscle in the airways, and acts quickly to maintain airway patency. A corticosteroid will decrease airway swelling but takes many hours to days to become effective. A diagnosis of pneumonia has not been validated. However, if documented, the client should receive pneumococcal vaccine as an inpatient The anti-infective medication may be ordered after the cause of the symptoms is determined, but restoring adequate airway patency and reducing dyspnea take priority.

The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32 years. How does the nurse document pack-year history of smoking in the medical record? 1. Client has a 32 pack-year history 2. Client has a 96 pack-year history 3. Client smoked 3 packs for years 4. Client was a passive smoker for 32 years

2. Client has a 96 pack-year history Rationale: This client has a 96-year pack history. Pack-year history refers to the number of packs per day multiplied by the number of years the client smoked.

When caring for the client receiving mechanical ventilation, the nurse includes which of these interventions to prevent ventilator-associated pneumonia (VAP)? Select all that apply. 1. Administering antibiotic prophylaxis 2. Continuous removal of subglottic secretions 3. Elevating the head of the bed at least 30 degrees whenever possible 4. Handwashing before and after contact with the client 5. Placing a nasogastric tube 6. Placing the client in a negative-airflow room

2. Continuous removal of subglottic secretions 3. Elevating the head of the bed at least 30 degrees whenever possible 4. Handwashing before and after contact with the client Rationale: Continuous removal of subglottic secretions, elevating the head of the bed at least 30 degrees whenever possible, and handwashing before and after contact with a client are all part of a VAP prevention bundle.Antibiotics are not given prophylactically, but are given on the basis of cultures to prevent an increase in drug-resistant organisms. A nasogastric tube is not part of the VAP bundle; if the stomach is distended, decompression with a NG tube after intubation may be used. If a client is going to receive mechanical ventilation for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing the client in a negative-airflow room may be used in a surgical suite or for care of clients with TB, but is not part of the VAP bundle. The client does not require this room.

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? 1. Complete the referral form for a home health agency. 2. Suction the tracheostomy using sterile technique. 3. Teach the client and spouse about tracheostomy care. 4. Consult with the health care provider (HCP) about using a fenestrated tube.

2. Suction the tracheostomy using sterile technique. Rationale: An experienced LPN/LVN can perform complex sterile procedures such as suctioning a tracheostomy tube using sterile technique.Completion of client referral forms, client and family teaching, and consulting with the (HCP) are all actions that must be performed by an RN.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What primary assessment will the nurse make while preparing the client for a computed tomography (CT) scan? 1. "Do you have any metal anywhere in your body?" 2. "Do you have diabetes?" 3. "Are you allergic to iodine or shellfish?" 4. "Do you drink alcohol regularly?"

3. "Are you allergic to iodine or shellfish?" Rationale: While preparing the client for a CT scan, the nurse's primary assessment would be to determine whether the client has any sensitivity to the contrast material by asking if the client has a known allergy to contrast, iodine or shellfish. CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli.Assessing for any metal in the body is done when clients undergo MRI. Diabetes is not a contraindication for CT with contrast. However, if the client receives metformin, the drug is stopped at least 24 hours before contrast dye is used and withheld until adequate kidney function is confirmed. Assessing regular alcohol intake is important, but is not the primary assessment.

The nurse is caring for a group of clients on a medical surgical unit. For which of these individuals does the nurse provide immediate interventions to reduce the risk for pulmonary embolism (PE)? 1. A client with diabetes and cellulitis of the leg 2. A client receiving IV fluids through a peripheral line 3. A client returning from an open reduction and internal fixation of the tibia 4. A client with fluid volume deficit and hypokalemia receiving potassium supplements

3. A client returning from an open reduction and internal fixation of the tibia Rationale: To reduce the risk for developing PE, the nurse provides immediate interventions for the client returning from an open reduction and internal fixation of the tibia. Surgery and perioperative immobility are very high risks for deep vein thrombosis and PE. Orthopedic surgery compounds this risk.No evidence suggests that the client with diabetes has been immobile, which is a risk factor for PE. Cellulitis is treated with antibiotics. Diabetic vascular disease is typically arterial in nature, rather than venous. The client receiving IV fluids through a peripheral line who evidences no problem with the IV or with breakage of the catheter appears to require no immediate nursing intervention. While severe fluid volume deficit and resulting hemoconcentration may pose a risk for thrombosis, this is not as common as thromboembolic complications after orthopedic surgery, and for the client with hypokalemia, no evidence reveals risk for PE.

A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? 1. Suction as needed. 2. Clean the tracheostomy inner cannula and stoma. 3. Auscultate lung sounds. 4. Change the tracheostomy dressing as needed.

3. Auscultate lung sounds. Rationale: The first step of the nursing process and nursing action for a client following an airway procedure is to assess for a patent airway by auscultating the client's lungs and assessing the client's respiratory status.Suction is not needed if the lungs are clear to auscultation. Although cleanliness is important, the PACU nurse will not typically perform this procedure immediately after the tracheotomy is created, unless copious secretions are blocking the tube.Performing a dressing change is done every 8 hours or per hospital policy. The PACU nurse will perform this if the dressing is soiled or bloody, but assessment of airway must be performed first.

The school nurse is teaching a group of adolescents about risk factors for lung cancer and lung disease. Which of these would be included in the discussion? 1. Alcohol consumption 2. Cocaine use 3. Cigarette smoking 4. Heroin use

3. Cigarette smoking Rationale: Cigarette smoking is highly addictive and is the number-one risk factor for lung cancer and chronic obstructive pulmonary disease.Alcohol can cause some cancers and liver disease and can increase risky behaviors, but it is not a major cause of lung cancer. Cocaine use, while highly addictive, poses a risk for cardiovascular disorders such as ACS, MI, or stroke. Heroin use does not increase one's risk of developing lung disease or lung cancer.

The nurse is providing education on preventing pulmonary disorders at a community health fair. Which of these groups does the nurse target? Select all that apply. Bakers Coal miners Electricians Furniture refinishers Plumbers Potters

Bakers, Coal miners, Furniture refinishers, Potters Rationale: The groups the nurse targets as people at risk for pulmonary disorders include bakers, coal miners, furniture refinishers, and potters. Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. Coal miners are at risk for developing pneumoconiosis as the result of inhalation of coal dust. Owing to the chemicals used to refinish furniture (paint strippers, solvents, etc.), masks and adequate ventilation are essential for furniture refinishers. One of the main solvents involved will metabolize in the body to carbon monoxide and will impair the ability of the tissue to extract oxygen. Silicosis or inhalation of silica dust is a hazard for professional and recreational potters.Except in unique situations, electricians and plumbers do not need to wear masks or utilize special ventilation for their jobs.

The community health nurse is planning treatment for multi-drug resistant tuberculosis for a client who is addicted to heroin. Which action will be most effective in ensuring that the client completes treatment? 1. Arrange for a health care worker to observe the client take the medication. 2. Give the client written instructions about how to take prescribed medications. 3. Have the client repeat medication names and side effects. 4. Instruct the client about the possible consequences of nonadherence.

1. Arrange for a health care worker to observe the client take the medication. Rationale: The most effective action for the nurse to take to ensure that the client completes the treatment is to arrange for the client to be directly observed during therapy. The client is unlikely to adhere to long-term treatment unless closely supervised while taking medications.Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. The fact that the client can state the names and side effects of medications does not mean that the client understands what the medications are and why he or she needs to take them. A client who is homeless and addicted to opiates would most likely be more concerned with obtaining drugs and shelter than with properly taking his or her medication.

The RN has received report about four clients. Which client needs the most immediate assessment? 1. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry 2. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes 3. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago 4. Client with pleural effusion who has decreased breath sounds at the right base

1. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry Rationale: The client in need of the most immediate assessment is the one with acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen saturation level less than 91% indicates hypoxemia and instability requiring immediate assessment and intervention to improve blood and tissue oxygenation.The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed. There is no evidence the client who had a bronchoscopy 3 hours ago is unstable and therefore does not require attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion.

A client who has a "do not resuscitate" (DNR) prescription has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? 1. Ensure that the tubing is patent and that oxygen flow is high. 2. Notify the chaplain and the family member of record. 3. Call the Rapid Response Team (RRT) and prepare to intubate. 4. Comfort the client.

1. Ensure that the tubing is patent and that oxygen flow is high. Rationale: The nurse needs to first ensure that the tubing is patent and that the O2 flow is high. Labored breathing and ultimately suffocation can occur if the reservoir bag on a non-rebreather mask kinks, or if the oxygen source disconnects or is not set to high flow levels.The chaplain and the family member of record would not be notified until assessment confirms that death is imminent at this time. The RRT team can be called but the client may not want to be intubated, as indicated in the DNR orders. The RRT needs to know the client's wishes when they arrive. Comforting the client must be done but is not the first action by the action.

A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest? 1. Expiratory wheezing not cleared by coughing 2. Bronchial breath sounds over the trachea 3. Crackles throughout the lung fields 4. Bronchovesicular breath sounds in the lung bases

1. Expiratory wheezing not cleared by coughing Rationale: In a client with asthma and shortness of breath, the nurse expects to hear expiratory wheezing not cleared by coughing. Wheezes are squeaky, musical, continuous sounds associated with bronchospasm, typical with asthma. They may be heard without a stethoscope and usually do not clear with coughing.Bronchial breath sounds are normal breath sounds, heard over the trachea and larynx. Crackles, an adventitious breath sound, will sound like popping, discontinuous sounds caused by air moving into previously deflated airways or coarse rattling sounds caused by fluid. Bronchovesicular breath sounds are normal breath sounds heard over major bronchi where fewer alveoli are located. They are best heard between the scapula and anterior chest.

The nurse is providing education for a client who is taking isoniazid, rifampin, and ethambutol for tuberculosis. Which of these points does the nurse include in the plan of care? Select all that apply. 1. Take a supplement containing B vitamins. 2. Avoid alcohol containing beverages. 3. Have kidney function tests monthly. 4. Report changes in vision to the health care provider. 5. Notify the health care provider for red-orange urine.

1. Take a supplement containing B vitamins. 2. Avoid alcohol containing beverages. 4. Report changes in vision to the health care provider. Rationale: Teach the client to take a daily multiple vitamin that contains the B-complex vitamins while on this drug as deficiency may occur. These medications can cause liver damage, which is potentiated by alcohol. Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Contact lenses will also be stained and oral contraceptives will be less effective.Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless and expected. Both isoniazid and pyrazinamide may cause liver failure. Side effects of major concern include jaundice, bleeding, and abdominal pain.

When receiving report on a group of clients on the step down unit, which client needs immediate attention by the nurse? 1. A client who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing 2. A client receiving mechanical ventilation who has tracheal deviation 3. A client who was recently extubated and is reporting a sore throat 4. A client who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min

2. A client receiving mechanical ventilation who has tracheal deviation Rationale: The nurse needs to immediately attend to the mechanically ventilated client with a tracheal deviation. This client is showing signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock.The client receiving CPAP has intermittent wheezing, but is not in immediate danger or distress. The client recently extubated has sore throat which is anticipated after intubation. There is no indication this client is in need of immediate intervention. The client wearing oxygen has mild tachypnea, but is not in immediate distress or danger.

The nurse in the clinic is following up on diagnostic testing for a client recently diagnosed with metastatic lung cancer and back pain. Which of these findings does the nurse expect to uncover? 1. Hyperkalemia 2. Hyperglycemia 3. Hypercalcemia 4. Hypernatremia

3. Hypercalcemia Rationale: Hypercalcemia is the result of increasing parathyroid hormone as a paraneoplastic complication of cancer as well as bone metastasis. Bone metastasis should be suspected in the presence of back pain.Paraneoplastic syndromes are manifested by Cushing's syndrome, weight gain and dilution of electrolytes (SIADH) with resulting hyponatremia. Gynecomastia and hypoglycemia may also occur. Hyperkalemia most typically occurs with tumor lysis syndrome where multiple electrolyte imbalances develop impaired renal function and oliguria.

The nurse is caring for a client who has had a tracheostomy placed yesterday. Which of these assessments is essential for the nurse to make? 1. Measure the cuff pressure. 2. Assess the color and consistency of secretions. 3. Ensure a second tracheostomy tube is available. 4. Assess for tachypnea.

4. Assess for tachypnea. Rationale: It is essential for the nurse to assess the client for tachypnea. Tachypnea can indicate hypoxia.Assessing secretions, ensuring a second tube is available in case of accidental extubation, and measuring cuff pressure are all appropriate interventions, after assessing airway and breathing.

The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced respiratory depression does the nurse recommend? 1. Continuous pulse oximetry 2. Serial arterial blood gas measurements 3. Continuous capnography 4. Apnea monitoring

3. Continuous capnography Rationale: For early detection of opioid-induced respiratory depression, the nurse recommends continuous capnography. Capnography detects exhaled carbon dioxide which increases during opioid-induced respiratory depression.Capnography, to detect opioid-induced respiratory depression, has been proven to be superior for early detection of respiratory changes and is a more sensitive indicator of respiratory depression than pulse oximetry. Arterial blood gas measurement is painful and expensive, and is not practical to use this methodology on a continuous basis. Apnea monitoring will detect a lack of breathing, but capnography will alert the nurse to respiratory depression prior to that time.

The charge nurse in the intensive care unit is overseeing care for a group of clients. The nurse is especially vigilant in collaboration with the primary nurse and interprofessional team in assessing for acute respiratory distress syndrome (ARDS) in which of these clients? 1. Client with diabetic ketoacidosis (DKA) 2. Client with atrial fibrillation 3. Client with aspiration pneumonia 4. Client with acute kidney failure

3. Client with aspiration pneumonia Rationale: The nurse will carefully watch the client with aspiration pneumonia for signs of ARDS. Acute Respiratory Distress Syndrome also called noncardiac-associated bilateral pulmonary edema is characterized by widespread inflammation in the lungs. Aspiration of acidic gastric contents promotes inflammation and is a risk for ARDS.Clients with DKA may develop metabolic acidosis, but do not typically ARDS, which develops as a result of lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.

The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize? 1. Administer bronchodilator medication on call. 2. Encourage clear fluid intake 12 hours before the procedure. 3. Ensure the client does not smoke for 6 hours before the test. 4. Provide supplemental oxygen.

3. Ensure the client does not smoke for 6 hours before the test. Rationale: The essential nursing intervention for a client being prepared for a PFT is to make sure that the client does not smoke for 6 hours before the test. Smoking can alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results.Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Encouraging fluid intake does not have an effect on PFT testing. Supplemental oxygen is not required and will alter the results of PFT. However, oxygen may be given if the client develops distress during testing.

The nurse on a medical surgical unit is caring for an adult client who has type 2 diabetes and is now admitted for pneumonia. The nurse must ensure the Joint Commission's National Client Safety Goals for this client are met and therefore follows up on which of these? 1. Hemoglobin A1C 2. Culture and Sensitivity report 3. Evaluating pneumonia vaccine status 4. Ensuring education to cough into the upper sleeve

3. Evaluating pneumonia vaccine status Rationale: The Joint Commission's National Client Safety Goals (NPSGs) and core measures are client-safety oriented and recommends that all inpatients need to have their pneumonia vaccination status evaluated and, if needed, be vaccinated during that admission. It is important to provide diabetes education and assist the client in understanding the role of A1C in diabetes management, but that is not a core measure related to this situation. A culture and sensitivity may be performed, but is not a requirement or core measure. Coughing into the upper sleeve is a technique the center for disease control (CDC) recommends to prevent transmission and reduce the spread of disease.

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? 1. Ecchymosis 2. Edema 3. Excessive swallowing 4. Sore throat

3. Excessive swallowing Rationale: Immediate intervention is needed when the nurse notices excessive swallowing in a client who has undergone a nasoseptoplasty. This may indicate a posterior nasal bleed requiring immediate attention.Ecchymosis is a normal finding in the client who has undergone a nasoseptoplasty, because of the very vascular nature of the face. Edema is a normal reaction to any kind of trauma, including that caused by surgery, so it is not an unexpected finding for this client. A sore throat is a common sensation after endotracheal intubation used during nasoseptoplasty.

The nurse is planning care for the non-English-speaking client who is on complete voice rest after head and neck surgery. The nurse must verify the client's allergies prior to medication administration. What alternative method of communication is best for the nurse to use? 1. Alphabet board 2. Picture board 3. Translation phone service 4. Word board

3. Translation phone service Rationale: The best alternative method of communication in this situation is the translation phone service. The translation phone will provide accurate translation required when verifying health-related information. There also are internet computer apps that translate English into foreign languages and vice versa (e.g., translate.google.com, itranslateapp.com).A picture board may be helpful to clients who do not speak English well if a translator or a translation phone is not readily available. An alphabet board may or may not be useful if the client does not speak English. This is not the best answer, but may be an option depending on what is available at the facility. A translator at the bedside would be beneficial for the nurse to speak with the client, but not for the client to ask questions or communicate concerns to the nurse. If the client can read and write, and the nurse can read and write the client's language the client speaks, a word board might be beneficial. But the translation phone is still more efficient and quicker.

Which statement by a client with a laryngectomy indicates a need for further discharge teaching? 1. "I must avoid swimming." 2. "I can clean the stoma with soap and water." 3. "I can project mucus when I laugh or cough." 4. "I can't put anything over my stoma to cover it."

4. "I can't put anything over my stoma to cover it." Rationale: Loose clothing or a covering such as a scarf can be used to cover the stoma if the client desires.To avoid aspiration, the client with a laryngectomy should not swim. Mild soap and water are the proper way to clean the stoma; however, a shield should be used in the shower so a large amount of water does not enter the airway. The client may project mucus when he laughs or coughs; reinforce with the client and the family that this is normal and is to be expected.

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? 1. "You can quit when you are ready." 2. "It's never too late to quit." 3. "For safety, turn off your oxygen when you smoke." 4. "Let's discuss why smoking around oxygen is dangerous."

4. "Let's discuss why smoking around oxygen is dangerous." Rationale: The nurse best response is to ask the client to discuss why smoking around oxygen is dangerous. The nurse would use this opportunity to educate the client about the dangers of smoking in the presence of oxygen, as well as the benefits of quitting.Telling the client it is okay to quit when ready, or that it's never too late to quit, does not address the safety issue of smoking in the presence of oxygen. Recommending that the client turn off the oxygen when smoking also puts the client at risk for harm.

The nurse is assessing a client admitted with status asthmaticus. The nurse finds a sudden absence of wheezing in the lung fields and sets which of these as the priority action? 1. Education to prevent future exacerbations 2. Administration of a bronchodilator 3. Measures to reduce anxiety 4. Activation of the rapid response team to secure an airway

4. Activation of the rapid response team to secure an airway Rationale: Sudden absence of wheezing in a client having an asthma attack indicates complete airway obstruction and requires immediate action; a tracheotomy may be required.This is an emergency and educating the client is not appropriate. A bronchodilator is given when breath sounds are present and the client can inhale. Reducing anxiety is not a consideration in an emergency situation.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? 1. Ensures that the client is wearing a mask 2. Informs the visitor that the client cannot receive visitors at this time 3. Provides a particulate air respirator to the visitor 4. Provides the visitor with a surgical mask

4. Provides the visitor with a surgical mask Rationale: Because the visitor is entering the client's isolation environment, the visitor must wear a mask.The client typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator which is typically used for TB, H5N1 influenza, or SARS.

A client has returned to the medical surgical unit after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP)? 1. Assess breath sounds. 2. Offer clear liquids when gag reflex returns. 3. Determine level of consciousness. 4. Monitor blood pressure and pulse.

4. Monitor blood pressure and pulse. Rationale: The best nursing task for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP) is monitoring blood pressure and pulse. An experienced UAP would have experience in taking client vital signs after procedures requiring conscious sedation or anesthesia.Evaluating breath sounds, gag reflex, and determining level of consciousness are considered nursing assessments and require the skill and knowledge of a higher-level provider or professional nurse.

The emergency department nurse is assessing a client who believes he has sustained a pneumothorax after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess? Select all that apply. Slowing heart rate Sensation of air hunger Tracheal deviation Pain on the unaffected side Blue discoloration of the lips

Sensation of air hunger, Tracheal deviation, Blue discoloration of the lips Rationale: The nurse would assess for a pneumothorax if the client has a sensation of air hunger, tracheal deviation, and blue discoloration of the lips. All clients need to be taught to go to the ED for symptoms of a pneumothorax after a thoracentesis. Symptoms include pain on the affected side, rapid heart rate, rapid, shallow respirations, sensation of air hunger, prominence of the affected side that does not move in and out with respiratory effort, tracheal deviation to the unaffected, new onset of "nagging" cough and cyanosis.Tachycardia, rather than bradycardia, is consistent with a pneumothorax. Pain occurs on the affected side, not the unaffected side.

When reviewing discharge care with the client who has had a laryngectomy, the client states the morphine doesn't work well because he still has shooting pain in the incisional area. Which of these does the nurse suggest be prescribed? 1. A nonsteroidal anti-inflammatory drug 2. Lorazepam 3. An increase in the morphine dose 4. Acetaminophen

1. A nonsteroidal anti-inflammatory drug Rationale: While morphine is an excellent choice form pain relief, NSAIDs as an adjunct to opioid analgesics or tricyclic antidepressants may also be used for the neuropathic (nerve) pain.Lorazepam is an antianxiety medication; it has no narcotic properties. Oral acetaminophen does not possess anti-inflammatory properties and will be less helpful than the nonsteroidal anti-inflammatory drug.

The nurse is caring for a client who has just been extubated after receiving mechanical ventilation. Which action will the nurse delegate to unlicensed assistive personnel (UAP)? 1. Keep the head of the bed elevated. 2. Teach about incentive spirometer use. 3. Monitor vital signs every 5 minutes. 4. Adjust the nasal oxygen flow rate.

1. Keep the head of the bed elevated.

The nurse is supervising a client during mealtime who has had a recent laryngectomy. Which of these is essential to include in the plan of care? 1. Swallow twice to clear the airway 2. Thicken all foods to a honey consistency 3. Elevate the head of the bed to 45 degrees 4. Review the results of the radiographic swallowing study

1. Swallow twice to clear the airway Rationale: Swallowing twice to clear the airway is done at two separate intervals. This is referred to as the supraglottic method of swallowing for clients post laryngectomy.Discomfort may occur initially and pain medication may be employed, but airway takes priority. The client should remain in the upright position to eat. The results of the swallowing study should be reviewed prior to assisting the client with the meal and its results will direct the readiness and method of swallowing prescribed.

The nurse is providing teaching for a client who has been newly diagnosed with lung cancer and will be undergoing radiation therapy. Which of these points would be covered in the teaching session? Select all that apply. 1. Hair loss will occur. 2. Do not expose the site to sun. 3. Loss of appetite may develop. 4. Pain in the area is expected. 5. Fatigue may occur. 6. Changes in taste may occur.

2. Do not expose the site to sun. 5. Fatigue may occur. 6. Changes in taste may occur. Rationale: Skin in the path of radiation is more sensitive to sun damage. Clients must avoid direct skin exposure to the sun during treatment and for at least 1 year after radiation is completed. Side effects also include skin irritation and peeling, fatigue, nausea, and taste changes. Some clients have esophagitis during therapy, making nutrition more difficult.Alopecia, or hair loss, is a side effect of chemotherapy, not of radiation to the chest. Loss of appetite is not specific to radiation therapy. Radiation therapy itself is painless and sensation-free.

A client has been admitted with a diagnosis of pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? 1. Teach the client to avoid using dental floss. 2. Monitor the platelet count daily. 3. Ensure adequate staffing for the unit. 4. Notify radiology of an impending scan.

2. Monitor the platelet count daily. Rationale: Daily platelet counts are a safety priority in assessing for heparin induced thrombocytopenia, a potential side effect of heparin.Avoiding the use of dental floss is important during anticoagulation therapy, but it is not the priority. The nurse would work with the manager to ensure adequate staffing but this is not a priority. Notifying radiology of needed scans is not a safety priority.

When caring for the client with chronic bronchitis, which of these interventions will assist the client in mobilizing secretions? 1. Elevate the head of the bed 45 degrees 2. consume at least 2 liters of fluid daily 3. avoid triggers which cause coughing 4. assume the tripod position

2. consume at least 2 liters of fluid daily Rationale: Clients with chronic bronchitis tend to have thick secretions. Hydration with at least 2 liters of fluid daily thins tenacious (sticky) secretions, making them easier to expectorate. The goal is to consume fluid to thin secretions and perform controlled coughing. If health issues require fluid restriction, the client would attempt to consume the total amount permitted.Head of bed elevation may promote oxygenation and lung expansion, but does not promote secretion mobilization. Clients need to sit with both feet on the floor when performing controlled coughing. The tripod position is assumed during episodes of hypoxemia, but will not facilitate mobilization of fluid.

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? 1. Completing the antibiotic medication regimen 2. Taking pain medications every 4 to 6 hours 3. Contacting the health care provider (HCP) if drooling occurs 4. Using warm saline gargles and irrigations

3. Contacting the health care provider (HCP) if drooling occurs Rationale: The most important point to teach the client is to notify the HCP if signs of drooling develop. Clients with peritonsillar abscesses are at risk for airway obstruction due to swelling, manifested by drooling.It is also important to tell the client to complete the antibiotics to treat the infection, and to adhere to comfort measures such as analgesic medications and saline gargles, but these are not priority issues.

The nurse is caring for a client who developed GI bleeding 3 weeks after a diagnosis of pulmonary embolism (PE). The international normalized ratio (INR) is 6.9. Which one of these questions is most appropriate for the nurse to ask at this time? 1. "Have you eaten a lot of green leafy vegetables?" 2. "Have you experienced swelling of your legs?" 3. "Were you massaging your calves?" 4. "Have you taken any aspirin or salicylates?"

4. "Have you taken any aspirin or salicylates?" Rationale: It is most appropriate for the nurse to ask about the use of aspirin and salicylates. Use of aspirin and salicylates will prolong the INR and cause gastric irritation and bleeding.Green leafy vegetables are high in vitamin K and would antagonize warfarin, resulting in a low(er) INR; bleeding would be unlikely. Unilateral swelling rather than bilateral swelling is typically present in DVT, which may lead to PE, but is not present in this situation. Massaging the calves may present a risk for PE if deep vein thrombosis is present, but does not relate to GI bleeding and prolonged INR.

A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? 1. "Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe." 2. "Because your body isn't getting enough oxygen you wake up and breathe." 3. "Your tongue may be blocking your throat, and you wake up because you are choking." 4. "You really aren't waking up that often. It just feels that way."

1. "Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe." Rationale: The nurse's best response is related to the buildup of carbon dioxide stimulating the body to wake up and breathe. During sleep, the muscles relax and the tongue and neck structures are displaced with the tongue falling back, causing an upper airway obstruction. This obstruction leads to apnea and increased levels of carbon dioxide. Respiratory acidosis stimulates neural centers in the brain, and the client awakens, takes a deep breath, and goes back to sleep. After the client returns to sleep, the cycle may be repeated as often as every 5 minutes as the airway is re-obstructed.Too much carbon dioxide, not a lack of oxygen, is the trigger that causes the client to awaken and breathe. Telling the client he is choking is not accurate. The loud snoring is caused by partial upper airway obstruction by the tongue. Also, telling the client he isn't really awakening that often minimizes the client's concern and is not correct. The client may be awakening every 5 minutes as the cycle repeats.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about prevention of complications? 1. "I am here to receive the yearly pneumonia shot again." 2. "I am here to get my yearly flu shot again." 3. "I should avoid large gatherings during cold and flu season." 4. "I should cough into my upper sleeve instead of my hand."

1. "I am here to receive the yearly pneumonia shot again." Rationale: The statement by the client, "I am here to receive the yearly pneumonia shot again" indicates a need for further teaching. The CDC recommends that adults older than 65 years be vaccinated with two vaccines, first with Prevnar 13 followed by Pneumovax about 6 to 12 months later. Adults who have already received the Pneumovax would have Prevnar 13 about a year or more later, but not annually.Older clients are encouraged to receive a flu shot annually because the vaccine is formulated annually, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. Recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? Select all that apply. 1. "I can only take baths, but no showers." 2. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." 3. "I should put cotton or foam over the tracheostomy hole." 4. "I will have to learn to suction myself." 5. "I will be unable to wear a necklace."

1. "I can only take baths, but no showers." 2. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." 3. "I should put cotton or foam over the tracheostomy hole." 5. "I will be unable to wear a necklace." Rationale: Need for teaching is indicated when the client says that only baths and no showers can be taken. The client is permitted to shower with the use of a shower shield over the tracheostomy, which prevents water from entering the airway. Also, the client does not instill anything into the artificial airway unless prescribed. The client would not put cotton or foam over the tracheostomy hole; this action may cause airway obstruction. The stoma may be covered loosely with a small cotton cloth to protect it during the day. This filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. Attractive coverings are available as cotton scarves, decorative collars, and jewelry including necklaces.The client is correct when commenting about learning to suction self, and will be taught clean suction technique to use at home.

Which statement by a client with chronic obstructive pulmonary disease (COPD) and a 10 pound (4.5 kg) weight loss indicates the need for additional follow-up instruction? 1. "I should consume plenty of fluids with my meal." 2. "I will try eating smaller more frequent meals." 3. "I will try to eat more protein." 4. "I will perform mouth care prior to eating."

1. "I should consume plenty of fluids with my meal." Rationale: The need for additional follow-up instruction is noted when the client states that he or she will drink more fluids before and during meals. This action will cause a sensation of fullness and limit adequate nourishment.Eating smaller, more frequent meals, trying to eat more protein, and performing mouth care before eating are all appropriate and positive client comments.

The nurse is providing preoperative teaching for the client with lung cancer for whom a lobectomy is planned. Which of these does the nurse include in the preoperative education session? Select all that apply. 1. "You will wake up with a drain in your chest which removes blood and allows the remaining lung to expand." 2. "You will be able to get out of bed after the chest tube is removed." 3. "Plan to request pain medication before your pain becomes severe." 4. "You may have a tube in your throat connected to a mechanical ventilator to assist you with breathing." 5. "You will need to lie on the operative side until the area of tissue removal heals."

1. "You will wake up with a drain in your chest which removes blood and allows the remaining lung to expand." 3. "Plan to request pain medication before your pain becomes severe." 4. "You may have a tube in your throat connected to a mechanical ventilator to assist you with breathing." Rationale: Preoperative teaching for a client scheduled to have a lobectomy for cancer includes telling the client that a chest drain will be in place, to request pain medication before the pain gets severe, and the possibility of having an endotracheal tube in the throat to assist with breathing.The nurse providing preoperative teaching for the lobectomy client would not tell the client that he or she will be able to get out of bed after the chest tube is removed. Bed rest may be necessary beyond the time the chest tube is removed in order to allow for proper healing; conversely the presence of the tube is not a contraindication for sitting in a chair. The nurse would not tell the client to lie on the operative side; this is typical after a pneumonectomy. Lying on either the operative or nonoperative side is a decision made by the surgeon.

The nurse is caring for a client who has had a lobectomy and placement of a chest tube 8 hours ago. When performing an initial assessment, which of these requires immediate follow up? 1. 200 mL red drainage from chest tube over 2 hours 2. Client sleepy but able to be aroused 3. 3 cm area of red drainage on the incisional dressing 4. Report of pain at the chest tube insertion site

1. 200 mL red drainage from chest tube over 2 hours Rationale: The nurse must immediately report 200 mL of red drainage over a 2 hour span of time. Chest drainage should slow down after surgery. More than 70 mL of drainage/hour must be reported to the surgeon.A client who had a surgical procedure, anesthesia, and analgesia may spend most of the day sleeping, but should be able to be aroused. A small amount of drainage after surgery is expected, such as a 3 cm area. The nurse should circle the area and report increasing amounts to the surgeon. Pain at the surgical and chest tube insertion site is expected and will be managed by the nurse in collaboration with the provider after airway, breathing, and circulation are ensured.

The nurse is caring for a group of clients on a medical surgical unit. Which client will the nurse assess first? 1. A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by Venturi mask 2. A client who has had a tracheostomy for 1 week, who has SpO2 of 95%-97% and foul-smelling drainage on the tracheostomy ties 3. A client who is being discharged with a new prescription for home oxygen therapy by nasal cannula 4. A client who was admitted yesterday with pneumonia and is receiving antibiotics and oxygen through a nasal cannula

1. A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by Venturi mask Rationale: The first client to assess is the newly admitted client with a long smoking history receiving 50% oxygen by Venturi mask. There is insufficient data to determine if this client is stable. The client is at an elevated risk for respiratory depression due to the hypoxic drive of respirations countered by high levels of oxygen and must be assessed frequently.The client with the tracheostomy is showing no signs or symptoms of respiratory compromise, and the client who meets discharge criteria do not require frequent assessment. Although the client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the client wearing the Venturi mask must be assessed first.

The nurse is caring for a group of clients on a Telemetry unit. When providing client education, which client will the nurse determine most needs information regarding preventing pulmonary embolism (PE)? 1. A woman who frequently flies to Europe 2. A man who works on a farm 3. A man admitted for a myocardial infarction 4. A woman with a bleeding disorder

1. A woman who frequently flies to Europe Rationale: Individuals who engage in prolonged and frequent air travel are at higher risk for PE due to the dependent position of the legs during long air flights.A 67-year-old man who works on a farm poses a low risk due to his active lifestyle. A myocardial infarction is caused by a thrombus or occlusion of the coronary arteries, not of the leg veins. If the MI client is on prolonged bedrest, the client's risk is increased. PE is a clotting disorder, not a bleeding disorder.

A client with chronic obstructive pulmonary disease (COPD) has a prescription to adjust oxygen to maintain SpO2 between 90% and 92%. Which action can be delegated to an unlicensed assistive personnel (UAP) under the supervision of an RN? 1. Adjust the position of the oxygen tubing. 2. Assess for signs and symptoms of hypoventilation. 3. Change the O2 flow rate to keep SpO2 as prescribed. 4. Select the O2 delivery device used for the client.

1. Adjust the position of the oxygen tubing. Rationale: The scope of a UAPs role includes positioning of oxygen tubing for client comfort.Assessing for signs and symptoms of hypoventilation, choosing which O2 delivery device to use, and changing the O2 flow rate are actions that are skills that should be performed by skilled personnel and are beyond the scope of practice for a UAP.

A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit? 1. Administering preoperative antibiotics and anxiolytics 2. Assessing the client's nutritional status and need for nutrition supplements 3. Having the client sign the operative consent form 4. Teaching the client about the need for tracheal suctioning after surgery

1. Administering preoperative antibiotics and anxiolytics Rationale: Administering medication is a skill within the LPN/LVN scope of practice. As a reminder, anxiolytics must be administered after the operative consent has been signed, or the consent will be invalid.The client's nutritional status and need for nutritional supplements should be assessed by the RN or a registered dietitian as part of the multidisciplinary care team. The surgeon is responsible for discussing the laryngectomy procedure, answering any questions, and having the client sign the operative consent form. Client teaching is the responsibility of the RN because it requires complex critical thinking skills.

A client with acute exacerbation of asthma has been admitted to the medical surgical unit for treatment. The client is reporting increased shortness of breath with inspiratory and expiratory wheezes. When planning care for this client, which medication will the nurse administer first? 1. Albuterol-2 inhalations 2. Fluticasone-2 inhalations 3. Ipratropium-2 inhalations 4. Salmeterol-2 inhalations

1. Albuterol-2 inhalations Rationale: The nurse first needs to administer Albuterol, which is a rescue medication, to treat the client with increased shortness of breath with inspiratory and expiratory wheezes. Albuterol is a rapidly acting beta2 agonist that promotes bronchodilation.Fluticasone is a corticosteroid and needs to be given after a bronchodilator is given to open the airways. It is used to prevent asthma attacks by decreasing airway inflammation, and is not used as a rescue medication. Ipratropium is an anticholinergic drug that allows the sympathetic system to dominate and cause bronchodilation. It is not immediately effective like a short acting a beta2 agonist, so it is not a first-line drug. Salmeterol is a long-acting beta2 agonist that must be used regularly over time and is not used as a rescue medication.

The community health nurse is providing education about risk factors for head and neck cancer? Which of these risks will be included in the teaching session? 1. Alcohol and smokeless tobacco use 2. Chronic laryngitis and voice abuse 3. Marijuana use and exposure to industrial chemicals 4. Poor oral hygiene and smoking cigarettes

1. Alcohol and smokeless tobacco use Rationale: The topic that must be included in the teaching session is that the combination of alcohol and tobacco use is one of the greatest risk factors for head and neck cancer. The same cancer-causing agents in smoking tobacco may be present in smokeless (chewing) tobacco.Chronic laryngitis and voice abuse in combination are not the greatest risk factors. However, each one individually is a risk factor for head and neck cancer. No large, randomized, controlled studies have identified a relationship between marijuana use and head and neck cancer. Exposure to industrial chemicals may increase a person's risk, but is not as great as the combination of alcohol and tobacco. Poor oral hygiene is a risk factor, as is smoking cigarettes. However, no studies have reported that a combination of the two will lead to increased risk.

A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? 1. Ask the client whether the mask fits tightly over the mouth and nose. 2. Discuss the use of autotitrating positive airway pressure (APAP). 3. Plan to teach the client about treatment with modafinil (Provigil). 4. Suggest that a nasal mask be used instead of a full facemask.

1. Ask the client whether the mask fits tightly over the mouth and nose. Rationale: Assessment is the first step of the nursing process. The nurse should assess whether the mask fits tightly over the mouth and nose and if the client has been consistently using CPAP at night, as initial adjustments to this therapy may be needed.With APAP, the pressures are adjusted continuously depending on the client's needs; this may be more comfortable for the client. Modafinil treats narcolepsy or daytime sleepiness; it does not correct the cause of sleep apnea, but may be used to help some of the side effects of obstructive sleep apnea. A nasal mask may be an option for the client if the facemask used with CPAP is uncomfortable.

When caring for the client returning from thoracotomy and placement of a chest tube, the client reports severe pain. What does the nurse do first? 1. Assess location and quality of pain. 2. Call for the Rapid Response Team (RRT). 3. Check the patency of the chest tubes. 4. Call the health care provider.

1. Assess location and quality of pain. Rationale: The nurse would assess the location, quality, radiation, severity of the pain, and the last time the client received pain medication before other actions are taken. Taking medication before pain becomes severe needs to be emphasized.The professional nurse is qualified to assess pain and provide pain medication when indicated. There is no information that suggests the client is unstable requiring the RRT to be called. The nurse will assess the chest drainage system at intervals, but pain is not typical when a chest tubes is blocked. The nurse would not call the health care provider before assessing the client's pain.

An adult resident with a C 6 spinal cord injury who resides in a long-term-care facility develops new onset of confusion, agitation and shouting, "Get out of here! You're trying to kill me!" Which action will the nurse take first? 1. Check the resident's oxygen saturation. 2. Do a complete neurologic assessment. 3. Administer the prescribed PRN lorazepam. 4. Perform a mini mental status exam.

1. Check the resident's oxygen saturation. Rationale: The nurse's first action is to assess the client's oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A common reason for sudden confusion in adult clients and those with spinal cord injury that may weaken respiratory muscles is hypoxemia caused by undiagnosed pneumonia or pulmonary embolism. A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation, but this will take several minutes to complete. Administering lorazepam may mask symptoms of hypoxemia, delaying treatment. Benzodiazepine medications may cause a paradoxical reaction, or opposite effect, in some older clients, enhancing agitation. A mini mental status exam determines cognitive function and may give direction to the diagnosis of Alzheimer's or traumatic brain injury.

The charge nurse in the emergency department (ED) is making assignments for the team including a new RN who has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? 1. Client on warfarin (Coumadin) with epistaxis with brisk bleeding 2. Client with facial burns caused by a mattress fire while sleeping 3. Client with possible facial fractures after a motor vehicle collision 4. Client with suspected bilateral vocal cord paralysis and stridor

1. Client on warfarin (Coumadin) with epistaxis with brisk bleeding Rationale: The initial treatment for epistaxis is upright positioning with direct lateral pressure to the nose. A nurse with minimal ED experience could be expected to safely provide care for this client. In addition, the new RN can facilitate obtaining laboratory studies to assess the client's ability to clot, given that the client is on warfarin (Coumadin).A client who has sustained facial burns in an enclosed setting is at high risk for airway burns or edema and requires observation by an experienced nurse. An experienced nurse should take care of a client with possible facial fractures after motor vehicle collision due to the potential for airway compromise from bleeding or swelling. Facial fractures may be accompanied by cervical spine fracture and/or spinal trauma that requires monitoring and evaluation by an RN with experience. Stridor is an indication of respiratory distress caused by airway obstruction; this requires an RN with experience.

When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? 1. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia 2. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain 3. Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94% 4. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs

1. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia Rationale: The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention.The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment. Calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications.

The nurse is caring for a group of clients on a medical surgical unit. Which clients will the nurse monitor closely for respiratory failure? Select all that apply. 1. Client with a brainstem tumor 2. Client with acute pancreatitis 3. Client with a C5 spinal cord injury 4. Client using client-controlled analgesia 5. Client experiencing cocaine intoxication

1. Client with a brainstem tumor 2. Client with acute pancreatitis 3. Client with a C5 spinal cord injury 4. Client using client-controlled analgesia Rationale: Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and intercostal muscles are affected. Opiates used in client controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing respiratory failure.Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

The charge nurse is making assignments for clients cared for on the intensive care stepdown unit. Which client will the charge nurse assign to the RN who has floated from the pediatric unit? 1. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask 2. Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour 3. Client with emphysema who requires instruction about correct use of oxygen at home 4. Client with lung cancer who has just been transferred from the intensive care unit after a left lower lobectomy yesterday

1. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask Rationale: The charge nurse would assign the asthma client to the float pediatric nurse. Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis.Although chronic pleural effusions can occur in the pediatric population, this diagnosis is more common in the adult population. If this client has not already received teaching for this procedure, he or she may have questions that the pediatric nurse would not be as comfortable answering as a nurse who is regularly assigned to the stepdown unit. Emphysema is a diagnosis associated with an adult population. Although an RN could instruct a client about home oxygen therapy, this client might have questions that would be better answered by an RN with adult experience. The adult client who has just had a lobectomy needs careful assessment from an RN with adult stepdown unit experience.

The home health nurse is assigned to visit these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule? 1. Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% 2. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test 3. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment 4. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

1. Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% Rationale: The best client for the nurse to reschedule for a home visit is the client with chronic emphysema who is on home oxygen and who has an appropriate SpO2 level. A SpO2 level of between 89% and 92% is appropriate and satisfactory.The client with a positive Mantoux test, in addition to a history of cough, weight loss, and night sweats, is highly suspicious for tuberculosis and needs to be seen that day. The nurse needs to perform follow-up assessment and coordinate follow up testing. The nurse may need to provide reporting to the public health department and to develop a plan for close personal contacts. A client with a newly diagnosed pleural effusion needs a complete and thorough admission and intake assessment to ensure that oxygenation and underlying needs are addressed. A percutaneous lung biopsy may be performed as an outpatient procedure. The client who had a percutaneous lung biopsy and is experiencing increased dyspnea needs to be assessed that day to determine whether a life-threatening pneumothorax or hemothorax has developed.

A client with respiratory failure has been intubated and placed on a ventilator with 100% oxygen delivery to maintain adequate saturation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds. The most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. What action will the nurse take next? 1. Collaborate with the provider to lower the FiO2 level. 2. Discuss the need for extubation due to the need for 100% oxygen. 3. Suggest noninvasive positive airway pressure techniques with oxygen. 4. Prepare to suction the client.

1. Collaborate with the provider to lower the FiO2 level. Rationale: Prompt identification and correction of the underlying disease process and potential oxygen toxicity may require delivery of a lower FiO2. The HCP needs to be notified when PaO2 levels are greater than 90 mmHg. Preventing oxygen toxicity and absorptive atelectasis (new onset of crackles and decreased breath sounds) are essential. Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung tissue present.The need for 100% oxygen delivery indicates that the client continues to require intubation and mechanical ventilation. Noninvasive positive airway pressure techniques are not used for clients requiring 100% oxygen. Suction is performed for rhonchi or noisy breath sounds on the anterior chest below the sternal notch (upper airway). Crackles and diminished breath sounds will be heard posteriorly reflecting fluid or poor exchange in the lower airway.

The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath sounds will the nurse assess? 1. Crackles 2. Rhonchi 3. Pleural friction rub 4. Wheeze

1. Crackles Rationale: When caring for a client with heart failure and acute kidney disease, the nurse would assess for crackles. Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways or areas of fluid.Rhonchi are low-pitched, coarse snoring sounds caused by thick secretions in larger airways. A pleural friction rub sounds grating, loud, or scratchy as inflamed surfaces of the pleura rub together. Wheezes are frequently referred to as musical or squeaky sounds caused by bronchospasm. They may occur on inspiration or on expiration as air rushes through narrowed airways.

When caring for a client who had a lobectomy the nurse notes small bubbles in the water seal chamber of the disposable chest drainage device during coughing. Which of these reflects the appropriate action by the nurse? 1. Document the finding in the medical record. 2. Check the tube for blood clots. 3. Briefly increase the amount of suction. 4. Add additional sterile water to the water seal chamber.

1. Document the finding in the medical record. Rationale: The nurse recognizes that gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. This indicates air is leaving the pleural space which is the intended purpose of the chest drain.Bubbling in the water seal chamber is absent if a kink or a blockage is present because air would not be able to escape from the chest cavity. Increasing the amount of suction without an order could damage lung tissue. There is no indication that the level of fluid in the water seal chamber is low.

A client is admitted to the medical floor with a new diagnosis of lung cancer. How will the nurse initially assist the client in managing the anxiety associated with the new diagnosis? 1. Encourage the client to ask questions and verbalize concerns. 2. Provide privacy for the client to be alone to deal with his or her own feelings. 3. Medicate the client with diazepam for anxiety every 8 hours. 4. Provide journals about cancer treatment.

1. Encourage the client to ask questions and verbalize concerns. Rationale: The best way for the nurse to initially assist the client in managing anxiety related to a new diagnosis of cancer is to encourage the client to ask questions and voice concerns. The availability of the nurse to answer questions and listen to the client's concerns will help to decrease anxiety.The client may choose to be alone, although this may be a maladaptive coping behavior. Diazepam every 8 hours will reduce the client's anxiety but not help to manage its cause such as fear of the unknown or fear of death. It is more important to work with the client to assist him or her in dealing with those issues first. Knowledge about cancer diagnosis and treatment may help relieve anxiety but the nurse must first assess the client's needs as well as the plan of care.

The emergency nurse is preparing to care for a client sustaining facial and neck injuries in a motor vehicle crash. Which of these is the priority at this time? 1. Ensure a tracheostomy tray is at the bedside 2. Place pressure on areas of hemorrhage 3. Assess the mastoid area for battle sign 4. Administer isotonic fluid replacement

1. Ensure a tracheostomy tray is at the bedside Rationale: The nurse should anticipate the need for an emergency airway through emergency intubation, tracheotomy, or cricothyroidotomy.Initial care focuses on establishing an airway, controlling hemorrhage, and assessing for the extent of injury. If shock is present, fluid resuscitation and identification of bleeding sites are started immediately. Assessing behind the ears (mastoid area) for extensive bruising, known as "battle sign," which is often associated with skull fracture and brain trauma is done last.

The nurse on a pulmonary unit is caring for a client who has had a tracheostomy placed earlier today. Which of these techniques representing best practice will use the nurse use when suctioning the client's tracheostomy tube? 1. Hyperoxygenate before and after suctioning. 2. Repeat suctioning until the tube is clear. 3. Apply suction during insertion of the tube. 4. Suction through the tracheostomy tube for 30 seconds.

1. Hyperoxygenate before and after suctioning. Rationale: The client needs to be preoxygenated/hyperoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client needs to be hyperoxygenated for 1 to 5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits.Repeat suctioning can be performed as needed for up to three total suction passes. Any additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult and is traumatic to the airway. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; a suction pass should last 10 to 15 seconds.

The nurse in the medical clinic is performing an assessment on an older adult client. Which finding requires further assessment by the nurse? 1. Inability to state name and date of birth 2. Slight kyphoscoliosis 3. Soft speaking voice 4. Need to rest after activity

1. Inability to state name and date of birth Rationale: The nurse would further assess the client who is unable to state name and date of birth. The older adult has a higher risk for hypoxemia than a younger client. The older adult can become confused during acute respiratory conditions, which requires additional investigation.Progressive Kyphoscoliosis occurs with aging because the thorax becomes shorter. With aging, laryngeal muscles lose elasticity, and airways lose cartilage causing the client's voice to become soft and difficult to understand. This is due to age-related changes in chest wall compliance and elasticity. Increased need for rest periods during exercise may occur.

The nurse is caring for a client who has just had radical neck surgery and is receiving mechanical ventilation. Which of these assessments takes priority? 1. Observing the dressing for bright-red blood 2. Monitoring for decreased level of consciousness 3. Evaluating the outcome of pain management strategies 4. Analyzing trends of urine output since surgery

1. Observing the dressing for bright-red blood Rationale: The nursing assessment that takes priority is the presence of bright-red blood on the dressing. Bright-red blood indicates leaking or rupture in the carotid artery and requires immediate activation of the Rapid Response Team.A ventilated postoperative client will likely be sedated with lingering effects of anesthesia, so a decreased level of consciousness is to be anticipated. Effective pain management must be evaluated during assessment, however airway breathing and circulation (bleeding) are the priority. Trends in urine output will be analyzed after airway, breathing and vital signs are assessed.

The intensive care nurse is working on a unit-based project to prevent intensive care unit (ICU) psychosis. Which intervention does the nurse recommend to best decrease the incidence of ICU psychosis? 1. Providing frequent explanations and reassurance 2. Keeping the lights on to promote orientation 3. Administering sedation 4. Providing television or radio for stimulation

1. Providing frequent explanations and reassurance Rationale: Clients with ICU psychosis need frequent, repeated explanations and reassurance. ICU psychosis or delirium can occur in clients undergoing mechanical ventilation in ICUs. It can also be minimized by encouraging sleep, and keeping to a regular routine.Keeping the lights on or providing TV or radio will not encourage sleep. Rather, these activities provide stimulation. Sedation can promote confusion and disorientation. It should be used when necessary to promote oxygenation and compliance with the ventilator.

When caring for a client with a pulmonary embolism, which priority intervention will the nurse use to reduce anxiety? 1. Remain with the client and provide oxygen in a calm manner. 2. Have the client breathe into a brown paper bag using pursed lips. 3. Offer the client a mild sedative. 4. Allow a family member to remain in the room.

1. Remain with the client and provide oxygen in a calm manner. Rationale: The priority nursing intervention is to correct hypoxemia, the underlying cause of anxiety. The nurse will stay with the client and provide oxygen in a calm manner. Anxiety, agitation, tachycardia, and restlessness are early symptoms of hypoxemia, which occurs with a PE. Oxygen will help to alleviate this problem. Remaining with the client in distress is also appropriate.Rebreathing from a brown paper bag is an intervention that increases PaCO2 during hyperventilation, as in a panic attack; it will not provide needed oxygen and tissue perfusion. Sedation and/or allowing a family member to stay may calm the client, but will not improve oxygenation and may delay appropriate treatment.

A registered nurse (RN) from the orthopedic unit has been assigned to the medical unit for the day. Which client assignment for the reassigned RN is the best? 1. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula 2. The client with chronic lung disease who is being evaluated for possible home oxygen use 3. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar 4. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

1. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula Rationale: The best client to assign this RN is the client with a pulmonary embolism. Orthopedic nurses are familiar with pulmonary emboli, a common complication of fractures and orthopedic surgery, as well as administration of oxygen through nasal cannulas.Orthopedic nurses do not specialize in chronic lung conditions. These clients are best assigned to an RN with experience in caring for clients with chronic lung diseases who require the use of home oxygen delivery devices and equipment. Orthopedic nurses generally do not have specific experience with airway surgery clients and clients being treated for chronic bronchitis. Care of these clients is best assigned to an RN with skills in postoperative tracheostomy care and chronic respiratory disease clients.

A client has just been admitted to the intensive care unit after having a left lower lobectomy via video-assisted thorascopic surgery. Which of these prescriptions will the nurse implement first? 1. Titrate oxygen flow rate to keep O2 saturation at or greater than 93%. 2. Administer 2 g of cephazolin IV now. 3. Give morphine sulfate 4 to 6 mg IV for pain. 4. Transfuse 1 unit of packed red blood cells (PRBCs) over 2 hours.

1. Titrate oxygen flow rate to keep O2 saturation at or greater than 93%. Rationale: Airway and oxygenation are main priorities in the immediate postoperative period. The client will likely be intubated, so coordination of care with respiratory therapy will be important.Although antibiotic therapy may be ordered, this is not a priority at this time. Pain management in the postoperative period is important, but is secondary to airway, breathing, and circulation. PRBCs to maintain the oxygen-carrying capacity of the blood will be performed after oxygenation. Pain medication and antibiotic administration will be performed last.

A client with COPD calls the pulmonary clinic reporting the last 24 hours the peak flow meter readings have been in the yellow range. Which of these interventions by the nurse is appropriate at this time? 1. Use your prescription for rescue medication and retest yourself. 2. This is a satisfactory reading, continue your present regimen. 3. Go to the nearest emergency department. 4. Increase your controller medication dose.

1. Use your prescription for rescue medication and retest yourself. Rationale: The nurse would tell the client to use the rescue medication and then retest. This instruction by the nurse is appropriate. Reliever drugs (also called "rescue" drugs) are used to stop an attack once it has started or when the peak flow meter is in the yellow range or 50%-80% of personal best range.The reading is not satisfactory. Frequent readings in the yellow zone indicate the need to reassess the asthma plan and the need to possibly change controller drugs. Satisfactory readings are in the green zone and are at least 80% of or better than the personal best readings. The client needs to seek care in the ED when the readings are in the red zone or below 50% of the personal best reading. Nurses do not prescribe medications or change dosing.

A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? 1. "But you know you need this to breathe, right?" 2. "Do you have a light scarf that you could place over it?" 3. "Your family and friends probably won't even care." 4. "It won't take you long to learn to manage."

2. "Do you have a light scarf that you could place over it?" Rationale: The nurse's best response is to suggest some strategies to cover the tracheostomy. This statement recognizes the client's concerns and explores options for dealing with the effects of the procedure.Reiterating the reason for the tracheostomy, suggesting that the client's loved ones won't care, and telling the client that he or she will learn to live with the tracheostomy are insensitive responses and minimize the client's concerns.

A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? 1. "I hope I can learn esophageal speech." 2. "I will have to take special care not to aspirate while eating." 3. "I won't be able to breathe through my nose anymore." 4. "It is hard to believe that I will never hear my own voice again."

2. "I will have to take special care not to aspirate while eating." Rationale: Aspiration cannot occur after a total laryngectomy because the airway is completely separated from the esophagus.The client will not be able to breathe through the nose. The client will be able to vocalize after working with a speech/language pathologist if he or she chooses; however, the voice will sound different than the client is used to. Esophageal or mechanical speech will permit the client to speak, but the voice will not sound like his or her own.

A client recently diagnosed with asthma has a prescription to use an inhaled medication with a spacer. The nurse evaluates the client has correct understanding of the use of an inhaler with a spacer when the client states which of these? Select all that apply. 1. "I don't have to wait a minute between the two puffs if I use a spacer." 2. "If the spacer makes a whistling sound, I am breathing in too rapidly." 3. "I should rinse my mouth and then swallow the water to get all of the medicine." 4. "I should shake the canister when I want to see whether it is empty." 5. "I should hold my breath for at least ten seconds after inhaling the medication."

2. "If the spacer makes a whistling sound, I am breathing in too rapidly." 5. "I should hold my breath for at least ten seconds after inhaling the medication." Rationale: Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client should hold the breath for at least 10 seconds, however attempting to hold the breath for a minute is unnecessary and could pose a threat to oxygenation.The client must wait 1 minute between puffs regardless of the method of delivery of the medication. The client should rinse the mouth but not swallow the water. The mouth needs to be rinsed after using an inhaler with or without a spacer. This is especially important if the inhaled medication is a corticosteroid; rinsing will help prevent the development of an oral fungal infection. An empty inhaler will float on its side in water while a full inhaler will sink. Shaking an inhaler helps ensure that the medication is dispersed and the same dose is delivered in each puff.

The nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements? 1. "The client will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." 2. "Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3." 3. "Once the health care provider orders warfarin (Coumadin), the intravenous heparin can be discontinued." 4. "If bleeding develops, we will give platelets to reverse the anticoagulant."

2. "Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3." Rationale: The nursing student correctly understands safety and effectiveness of Coumadin therapy when the student states that the international normalized ratio or INR reflects a therapeutic level when between 2 and 3. The INR is the diagnostic test used to measure effectiveness of anticoagulation with warfarin. Subtherapeutic levels below 2 pose a risk for clots to develop; values above 3 pose a risk for bleeding.Enoxaparin (Lovenox) is a low-molecular-weight heparin that is given by the subcutaneous, not intramuscular route. Heparin and warfarin are overlapped until the INR is in the therapeutic range, then the heparin can be discontinued. Fresh-frozen plasma is used as an antidote for anticoagulant therapy, not platelets.

The client says, "I hate this stupid COPD." What is the best response by the nurse? 1. "Stopping smoking will help your lungs heal." 2. "You sound fed up with managing your illness." 3. "Does anyone in your family have COPD?" 4. "Most clients get used to it after a few months."

2. "You sound fed up with managing your illness." Rationale: The best response by the nurse is "You sound fed up with managing your illness." This response encourages the client to express his or her feelings about the disease and its challenges.Lecturing the client regarding his smoking habits disregards the client's need for support. "Why" questions can seem accusatory and may make a client less likely to talk about what he or she is feeling. Asking the client if anyone in the family has COPD is a "yes" or "no" question and does not encourage the client to talk about his or her feelings. The client's feelings should never be minimized.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? 1. "You will not spread the disease unless you stop taking your medication." 2. "You will not pose an increased risk of disease to the people you have been living with." 3. "You will have to take these medications for at least 1 year." 4. "Your sputum may turn a rust color as your condition gets better."

2. "You will not pose an increased risk of disease to the people you have been living with." Rationale: The nurse tells the client that he/she will not be contagious to the people he/she lives with. The people the client has been living with have already been exposed and need to be tested. They cannot become at higher risk simply because the diagnosis has now been confirmed. The client with active tuberculosis is contagious, even while taking medication. However, the risk for transmission is reduced after the infectious person has received proper drug therapy for 2 to 3 weeks, clinical improvement occurs, and acid-fast bacilli (AFB) in the sputum are reduced. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

The nurse is reviewing the medical record of a client with pulmonary embolism (PE). What priority does the nurse set after reviewing the blood gas result below? pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L (26 mmol/L), PaO2 62 mm Hg 1. Have the client breathe rapidly and deeply 2. Apply oxygen 3. Administer sodium bicarbonate 4. Collaborate with the provider to increase the pH

2. Apply oxygen Rationale: The priority action taken by the nurse is to administer oxygen. Hypoxemia is present, demonstrated by PaO2below 75 mmHg. This is consistent with PE and supplementary oxygen is needed to improve tissue perfusion.Hyperventilation triggered by hypoxemia and pain first leads to respiratory alkalosis, indicated by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). Breathing more rapidly and deeply will continue to "blow off" CO2 and cause further alkalosis. The bicarbonate level (HCO3-) (26 mEq/L) (26 mmol/L) is normal and requires no intervention. The pH level is already high.

A client in the intensive care unit (ICU) who is receiving mechanical ventilation begins to pick at the bedcovers. Which action will the nurse take next? 1. Increase the sedation. 2. Assess for adequate oxygenation. 3. Explain that the tube in the client's throat helps with breathing. 4. Request that the family leave to decrease the client's agitation.

2. Assess for adequate oxygenation. Rationale: The next action by the nurse would be to assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia.Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease, not increase, the chances of "ICU psychosis" and anxiety.

The nurse coming on shift prepares to perform an initial assessment of a client receiving sedation and mechanical ventilation through a tracheostomy. Which are priorities for the nurse to carry out? Select all that apply. 1. Ask visitors to leave the room. 2. Assess the client's color and respirations. 3. Confirm alarms and ventilator settings. 4. Ensure that the tube is in proper position. 5. Auscultate for bilateral breath sounds. 6. Provide routine tracheostomy and mouth care.

2. Assess the client's color and respirations. 3. Confirm alarms and ventilator settings. 4. Ensure that the tube is in proper position. 5. Auscultate for bilateral breath sounds. Rationale: Initial priorities when assessing the critically ill client are to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Markings on the endotracheal tube should be compared to previous records to ensure the tube remains in appropriate position. Auscultating for equal bilateral breath sounds assists in confirming that the tube is in the proper position above the carina.It is not necessary to ask visitors to leave. Having visitors remain with the client may promote comfort and prevent confusion.Routine tracheostomy care, an intervention, is performed according to schedule and as needed, and is not necessarily part of an initial assessment.

The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which respiratory modality does the nurse suggest to the interdisciplinary team as an alternative to mechanical ventilation? 1. Oropharyngeal airway 2. Bi-level positive airway pressure (BiPAP) 3. Non-rebreather mask with 100% oxygen 4. Positive end-expiratory pressure (PEEP)

2. Bi-level positive airway pressure (BiPAP) Rationale: The nurse suggests bi-level positive airway pressure (BiPAP) because this type of ventilation provides noninvasive pressure support ventilation by nasal mask or facemask rather than by endotracheal intubation. Generally, it used for clients with sleep apnea but can also be used for clients with respiratory muscle fatigue or impending respiratory failure to avoid more invasive ventilation methods; this may provide short-term relief of an acute problem.An oropharyngeal airway is used to prevent the tongue from occluding the airway or the client from biting the endotracheal tube. A non-rebreather mask will assist with oxygenation; however, muscle fatigue and hypoventilation may occur as causes of respiratory failure. The need for PEEP indicates a severe gas-exchange problem. This modality is "dialed in" on the mechanical ventilator.

Which assessment finding in the client with exacerbation of emphysema requires intervention by the nurse? 1. Barrel-shaped chest 2. Bronchial breath sounds heard at the bases 3. Hyperresonance to percussion of the chest 4. Ribs lying horizontal

2. Bronchial breath sounds heard at the bases Rationale: The client with bronchial breath sounds needs intervention by the nurse. These sounds are not normally heard in the periphery and may indicate atelectasis or increased lung density, as might present with a tumor or an infectious process such as pneumonia.The anteroposterior diameter is the same as the lateral-to-lateral or side-to-side diameter in a client with emphysema, so the client will generally have a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to percussion. Air trapping causes the ribs in a client with emphysema to lie in a more horizontal direction.

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? 1. The left chest caves in on inspiration and "puffs out" on expiration. 2. Chest asymmetry and jugular vein distention are present. 3. The left lung field is dull to percussion with crackles present on auscultation. 4. The client has bloody sputum and wheezes.

2. Chest asymmetry and jugular vein distention are present. Rationale: Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. If not promptly detected and treated, tension pneumothorax is quickly fatal.Flail chest is generally the result of fractures of at least two neighboring ribs in two or more places and is manifested by paradoxical chest movement. This consists of "sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first? 1. Client with chronic obstructive pulmonary disease (COPD) who is ready for discharge, but is unable to afford prescribed medications. 2. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. 3. Hospice client with end-stage pulmonary fibrosis and an oxygen saturation level of 89%. 4. Client with lung cancer who needs an IV antibiotic administered before going to surgery.

2. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. Rationale: The client with CF with an elevated temperature and respiratory rate of 38 breaths/min is exhibiting signs of an exacerbation/infection and needs to be assessed first.The nurse will need to speak with the client who has COPD to help find a plan that will enable the client to obtain his or her prescribed medications. This may involve contacting case management or social services and discussing the discharge with the discharge health care provider. An oxygen saturation of 89% may be normal and expected for a hospice client with end-stage pulmonary fibrosis. There is no indication that this client is in distress. The nurse can delegate administration of the IV antibiotic to another RN, or it could be administered before the client is brought to the operating room.

The nurse is caring for a group of clients with respiratory disorders. For which of these clients does the nurse plan for immediate intubation? 1. Client who requires suctioning of oral secretions 2. Client with hypoventilation and decreased breath sounds 3. Client with O2 saturation of 90% 4. Client with thick, purulent secretions and crackles

2. Client with hypoventilation and decreased breath sounds Rationale: The nurse plans for immediate intubation for the client who demonstrates hypoventilation and has decreased breath sounds.There is no indication that the client with difficulty handling oral secretions or who has purulent sputum has hypoxemia or airway obstruction interfering with swallowing. Suctioning of oral secretions, rather than intubation, is indicated while continuing to monitor for hypoxemia, aspiration, and pneumonia. Intubation may be indicated for the client with an O2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia.

The registered nurse receives report on four clients on a medical-surgical unit. Which of these clients will the charge nurse assign to the LPN/LVN? 1. Client with group A beta-hemolytic streptococcal pharyngitis who has stridor 2. Client with pulmonary tuberculosis who is receiving multiple medications 3. Client with sinusitis who has just arrived after having endoscopic sinus surgery 4. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

2. Client with pulmonary tuberculosis who is receiving multiple medications Rationale: The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Each state designates which tasks may be safely delegated and assigned to nursing team members. Depending on the state's nurse practice act, licensed practical/vocational nurses (LPNs/LVNs) and technicians may be trained and undergo competency verification related to the skill of peripheral IV insertion and assistance with infusions. The RN is ultimately accountable for all aspects of infusion therapy and delegation of associated tasks (Infusion Nurses Society [INS], 2016; Weinstein & Hagle, 2014).Stridor, a harsh respiratory sound, is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful swallowing and respiratory assessment and monitoring by the RN.

The nurse is reviewing the admission assessment of an elderly client with pneumonia. For which symptom of pneumonia, typical to older adults, does the nurse assess? 1. Bradycardia 2. Confusion 3. Eupnea 4. Pale skin

2. Confusion Rationale: The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present. Symptoms of pneumonia include flushing, not pale skin, anxiety, chest pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, not bradycardia, dyspnea, tachypnea not eupnea, hemoptysis, and sputum production. Severe chest muscle weakness also may be present from sustained coughing. Crackles, wheezing may be heard over areas of fluid, decreased breath sounds are present and wheezing may be heard where the airways are narrowed by exudate.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the inner cannula and the tracheostomy tube. Which action should the nurse take first? 1. Auscultate the client's breath sounds while applying a nasal cannula. 2. Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask. 3. Apply a 100% non-rebreather mask while administering high-flow oxygen. 4. Replace the obturator while reinserting the tracheostomy tube.

2. Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask. Rationale: The nurse must first have someone call the RRT while attempting to resuscitate the client. Because a fresh tracheostomy stoma will collapse and airway patency lost, the nurse needs to ventilate the client through the mouth and nose while awaiting assistance to recannulate the client. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client.Auscultation of the client's breath sounds at this time will not improve the client's respiratory status. Effective use of a 100% non-rebreather mask requires a patent airway. During the first 72 hours following a tracheostomy, reinsertion of the tube is difficult and should not be attempted by the nurse but rather by the surgeon or an expert in this area such as a member of the RRT. The obturator aids in insertion of the tube and must be removed immediately or it will obstruct the airway.

A client with aspiration pneumonia occurring after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? 1. Administer levofloxacin (Levaquin) 500 mg IV. 2. Draw aerobic and anaerobic blood cultures. 3. Give lorazepam (Ativan) as needed for agitation. 4. Refer to social worker for alcohol counseling.

2. Draw aerobic and anaerobic blood cultures. Rationale: The nurse would first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed. Getting cultures to identify the causative organism before initiating an antibiotic could affect the results of the culture and the type of antibiotic used.Levofloxacin, an antibiotic, is a priority intervention, and would be done after cultures are drawn. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action. Other interventions to help control the agitation may be tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.

The community health nurse is collaborating with the local health department on containment of an anticipated pandemic influenza outbreak. The nurse advises the health department that the best method to prevent outbreaks of pandemic influenza is which of these? 1. Avoiding public gatherings at all times 2. Early recognition and quarantine of affected persons 3. Vaccinating community members with pneumonia vaccine 4. Widespread distribution of antiviral drugs

2. Early recognition and quarantine of affected persons Rationale: Early recognition and quarantine of affected persons is the best way to prevent outbreaks of pandemic influenza. The recommended approach to disease prevention consists of quick recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus.Public gatherings need to be avoided only in the case of widespread outbreak of influenza in the community. A vaccine (Vepacel) is available in case of H5N1 outbreaks, but is stockpiled and not part of general influenza vaccination. The pneumonia vaccine is recommended for high-risk populations because pneumonia may be a complication of influenza. The current influenza vaccine is updated, re-evaluated, and changed yearly to meet anticipated changes in the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.

The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential for the nurse to perform prior to the procedure? 1. Obtain informed consent. 2. Ensure the client has had nothing by mouth. 3. Review dietary and medication allergies. 4. Perform aggressive chest physiotherapy.

2. Ensure the client has had nothing by mouth. Rationale: When preparing a client for a diagnostic bronchoscopy, it is essential for the nurse to make sure the client is NPO for 4 to 8 hours before the procedure to reduce the risk for aspiration.It is important to verify allergies, however ensuring NPO status is maintained is essential to prevent aspiration, which can be life threatening. The nurse will verify that consent for the procedure was obtained. Until the client has a gag reflex and is fully alert, he or she should be maintained on NPO status to prevent aspiration. Aggressive chest physiotherapy is not indicated in a client who has had a bronchoscopy and may cause bleeding if biopsies have been obtained.

The standard perioperative laryngectomy plan of care includes these interventions. Which intervention will be most important for the nurse to accomplish preoperatively? 1. Educate the client about ways to avoid aspiration when swallowing after the surgery. 2. Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. 3. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. 4. Teach the client and significant others about how to suction and perform wound care of the stoma.

2. Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. Rationale: In the immediate postoperative period, relieving pain and anxiety is going to be a major priority. Because the client will be unable to communicate verbally, establishing a way to communicate before the surgery will help by having a plan in place.Aspiration is not a risk after a total laryngectomy because no connection is present between the mouth and the respiratory system. It will be several weeks before the client will need to address appropriate clothing; overloading the client with too much information before surgery is unnecessary. Suctioning and wound care are discharge teaching that can be started after the surgery, when the client and significant others are more likely to retain the information owing to decreased preoperative anxiety. The significant others can observe the care and then can begin to take over more of the care while the client is still in the hospital in a supervised environment.

The nurse is caring for the client who has had an open reduction and internal fixation (ORIF) with titanium plates to repair a LeFort III fracture. Which of these activities will the nurse include in the teaching plan? 1. Individuals with a titanium plate should not have an MRI and should carry a wallet card stating this. 2. It is important to have good oral hygiene using an irrigating device such as Waterpik. 3. Let the health care team know if you are experiencing any pain. 4. We will be checking behind your ear for any bruising to assess for additional trauma.

2. It is important to have good oral hygiene using an irrigating device such as Waterpik. Rationale: After surgery the client should be taught about oral care with an irrigating device, such as a Waterpik or SoniCare to prevent tooth infection or dental caries.Titanium plates do not interfere with an MRI study. Pain should be managed as with all clients. Le Fort III combines I and II plus an orbital-zygoma fracture, called "craniofacial disjunction" which may result in extensive bleeding and bruising. Checking behind the ears (mastoid area) for extensive bruising, known as the "battle sign," will help detect skull fracture and brain trauma, which may occur with facial trauma.

The nurse is educating the client with COPD who requires home oxygen therapy for discharge. Which of these teaching points takes the highest priority? 1. Correct performance when setting up the oxygen delivery system 2. Removing combustion hazards present in the home 3. Understanding the signs and symptoms of hypoxemia 4. Demonstrating how to use a pulse oximetry device

2. Removing combustion hazards present in the home Rationale: The highest priority of education is that oxygen is highly combustible. The nurse must ensure that no open flames or combustion hazards are present in a room where oxygen is in use.The oxygen delivery system in the home will be different than in the hospital. Therefore, this skill may be verified by the visiting nurse or company providing the oxygen. The client must be able to state signs and symptoms of hypoxemia, although safety is the priority. Pulse oximetry may be useful for monitoring the client's oxygenation status and the visiting nurse or respiratory therapy partner can assess this. The client needs to be able to state the signs and symptoms of hypoxemia and when to notify the health care provider.

When caring for a client who has just undergone thoracentesis, which of these interventions does the nurse perform first? 1. Encourage coughing and deep breathing. 2. Schedule an immediate chest x-ray. 3. Document the volume of removed fluid in the medical record. 4. Set up a water seal drainage unit.

2. Schedule an immediate chest x-ray. Rationale: After thoracentesis, the nurse first makes sure a chest x-ray is performed to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures toward one side).Coughing and deep breathing is done to promote lung expansion as part of the treatment for the underlying disorder. This can wait until a chest x-ray is completed. The volume of fluid will be recorded in the medical record, after the nurse schedules the x-ray to ensure a pneumothorax did not occur. Pigtail drain catheters may be left in place to a waterseal drainage system, rather than performing thoracentesis aspiration on a recurring basis, but this action is not standard.

The nurse is planning to provide tracheostomy care for a client with a soiled tracheostomy dressing. Which of these actions would be included in the plan of care? Select all that apply. 1. Cut a sterile 4 × 4 gauze to fit around the tracheostomy tube. 2. Suction the client if needed. 3. Cleanse the inner cannula with a mixture of peroxide and saline. 4. Replace the dressing with a sterile, folded 4 × 4 gauze. 5. Provide clean tracheostomy ties that fit snugly against the neck.

2. Suction the client if needed. 3. Cleanse the inner cannula with a mixture of peroxide and saline. 4. Replace the dressing with a sterile, folded 4 × 4 gauze. Rationale: The nurse needs to first suction the tracheostomy tube if necessary. Use half-strength hydrogen peroxide to clean the inner cannula and sterile saline to rinse it. Alternatively, remove a disposable inner cannula and replace it with a new one.Never cut tracheostomy tube dressings because small bits of gauze could then be aspirated through the tube. If specific tracheal tube dressings are not available, then fold a sterile 4 × 4 gauze to fit around the tube. Also, make sure tracheal ties do not fit snuggle to the neck. Secure new ties in place before removing soiled ones. Tie a square knot that is visible on the side of the neck which is snug against one finger placed between the tie tape and the neck.

A client with pneumonia is receiving 100% oxygen via a non-rebreather mask. Which of these situations requires immediate intervention by the nurse? 1. The client's skin has pink color. 2. The oxygen reservoir deflates during inspiration. 3. The client has crackles at the lung bases. 4. The client is expectorating rust colored sputum.

2. The oxygen reservoir deflates during inspiration. Rationale: The nurse intervene immediately if the reservoir bag is deflated. Suffocation can occur if the reservoir bag deflates, kinks, or if the oxygen source disconnects. The nurse needs to remove the device, refill the reservoir, and then reapply the mask.It is anticipated that the client's color is now pink. The client's color is expected to improve (from ashen or gray to pink) because of an increase in PaO2 level. Crackles in lung bases are an expected finding in a client with pneumonia, as is expectorating rust-colored sputum. Monitoring for adventitious breath sounds is important for the nurse to assess.

The nurse in the community health clinic is planning education related to tuberculosis (TB). Which of these groups will the nurse target? Select all that apply. 1. Breast cancer survivors 2. Those in the local prison 3. Homeless adults 4. Recent immigrants to the United States 5. Those who have received bacille Calmette-Guérin (BCG) vaccine

2. Those in the local prison 3. Homeless adults 4. Recent immigrants to the United States Rationale: The groups the nurse plans to educate include those adults who live in crowded areas such as prisons and homeless shelters, and those who are recent immigrants to the USA. Other groups at higher risk for tuberculosis include those who abuse injection drugs or alcohol and those groups of lower socioeconomic status.Breast cancer survivors who are no longer undergoing immunocomprising therapy have the same risk as the general population. Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.

The nurse in a life care community for geriatric clients is providing education to a group of residents on expected changes during aging. Which of these activities does the nurse encourage the older adult to perform to maintain respiratory function? 1. Stay in bed to prevent fatigue. 2. Walk as tolerated each day. 3. Consume adequate calcium. 4. Perform oral hygiene twice daily.

2. Walk as tolerated each day. Rationale: the best activity for the older adult to perform in order to maintain respiratory function is to try and walk each day. Ambulation to the client's ability is easily performed in an older adult facility as it does not require special equipment. Health and fitness help keep losses in respiratory functioning to a minimum.Older clients have less tolerance for exercise and may need increased rest periods during exercise. However, bedrest is not necessary or desirable. Encouraging adequate calcium intake to prevent osteoporosis is more helpful prior to menopause, and is less helpful with elderly clients. Oral hygiene aids in the removal of secretions when present, but is not the best intervention to maintain respiratory function.

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions? 1. "All asthma drugs help everybody breathe better." 2. "I must carry my emergency inhaler when activity is anticipated." 3. "I must have my emergency inhaler with me at all times." 4. "Preventive drugs can stop an attack."

3. "I must have my emergency inhaler with me at all times." Rationale: The statement by the client that indicates a correct understanding of the instructions is that the emergency inhaler must be with the client at all times. Because asthma attacks cannot always be predicted, clients with asthma must always carry a rescue inhaler such as a short-acting beta agonist (e.g., albuterol).Asthma medications are specific to the disease and to the client and should never be shared or used by anyone other than the person for whom they are prescribed. They are not always good for everyone and, in fact, may do harm. An emergency inhaler should be carried all the time and not just when activity is anticipated. Preventive drugs are those that are taken every day to help prevent an attack from occurring, and do not stop an attack once it begins.

The nurse is evaluating understanding of the treatment regimen for a client newly diagnosed with asthma. Which of these statements by the client indicates understanding of the regimen? 1. "I will take albuterol when I go to sleep." 2. "I will keep the rescue medication readily accessible on the first floor of my home." 3. "I will take the long acting beta agonist even when my breathing seems OK." 4. "I will immediately take the anti-inflammatory medication for an acute asthma attack."

3. "I will take the long acting beta agonist even when my breathing seems OK." Rationale: The client indicates understanding of the dosing regimen when stating, "I will take the long-acting beta agonist even when my breathing seems OK." Long-acting medications are useful in preventing an asthma attack but cannot stop an acute attack.Short-acting beta2 agonists (SABAs) provide rapid, short-term relief. These "rescue" type inhaled drugs are most useful when an attack begins (as relief) or as premedication when the client is about to begin an activity that is likely to induce an attack. They are not used on a regular schedule. The client must always carry the relief drug inhaler with him or her and ensure that they do not run out of this medication. Anti-inflammatory medications decrease airway inflammation and are considered controller medications. They are not used for acute attacks.

The nurse is providing education about the management of respiratory failure to the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse will communicate? 1. "Sedation is needed so your loved one does not rip the breathing tube out." 2. "Suctioning is important to remove organisms from the lower airway." 3. "Paralytics and sedatives help decrease the demand for oxygen." 4. "We are encouraging oral and IV fluids to keep your loved one hydrated."

3. "Paralytics and sedatives help decrease the demand for oxygen." Rationale: The nurse will tell the family that paralytics and sedation are administered to decrease oxygen demand and promote compliance with mechanical ventilation.Sedation is needed more for its effects on oxygenation than to prevent the client from ripping out the endotracheal tube. Suctioning is performed to remove upper airway secretions and maintain airway patency. Clients receiving mechanical ventilation typically receive hydration by enteral tube or parenteral route and not orally.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? 1. Client with bacterial pneumonia and a cough productive of green sputum 2. Client with neutropenia and pneumonia caused by Candida albicans 3. Client with possible H5N1 influenza who currently has epistaxis 4. Client with right empyema who has a chest tube and a fever of 103.2° F (39.6°C)

3. Client with possible H5N1 influenza who currently has epistaxis Rationale: A client with possible tuberculosis or H5N1 avian influenza would be admitted to the negative-airflow room to prevent airborne transmission of organisms from the client room to other clients/staff and areas of the hospital.A client with bacterial pneumonia does not require a negative-airflow room but should have airborne or Droplet Precautions in place. A client with neutropenia may be in a regular room with an emphasis on handwashing. The client with a right empyema who also has a chest tube and a fever would have Contact Precautions in place but does not require a negative-airflow room.

A local hunter is admitted to the intensive care unit with a diagnosis of fulminant stage inhalation anthrax. Which assessment findings does the nurse anticipate is present? Select all that apply. 1. Sore throat 2. Rhinorrhea 3. Harsh cough 4. Stridor 5. Low grade fever

3. Harsh cough 4. Stridor Rationale: The ICU nurse expects to find this client exhibiting a harsh cough and stridor. Inhalation anthrax has two stages: prodromal (or incubation period) and fulminant (with active disease). The fulminant phase of inhalation anthrax begins after the client feels a little better and includes high fever, sudden onset of severe illness, including respiratory distress, hematemesis (bloody vomit), dyspnea, diaphoresis, stridor, chest pain, and cyanosis. When infection occurs through the lungs, the disease is nearly 100% fatal without treatment (CDC, 2015b). Inhalation anthrax has two stages: prodromal (or incubation period) and fulminant (with active disease). Symptoms take up to 8 weeks to develop after exposure (Chart 31-4).The prodromal stage occurs early in the course of illness and includes low-grade fever, fatigue, mild chest pain, and a dry, harsh cough. It is not accompanied by upper respiratory symptoms of sore throat or rhinitis.

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? 1. Inadequate nutrition related to food-drug interactions with anticoagulant therapy 2. Risk for infection related to leukocytosis 3. Hypoxemia related to ventilation-perfusion mismatch 4. Insufficient knowledge related to the cause of PE

3. Hypoxemia related to ventilation-perfusion mismatch Rationale: The client problem given priority by the nurse is hypoxia related to ventilation-perfusion mismatch. Restoring adequate oxygenation and tissue perfusion takes priority. Obstruction of blood flow through the pulmonary artery or branches impairs ability of the alveolus to deliver oxygen to the left side of the heart; the resulting hypoxemia may be profound. Initially the client breathes more rapidly and eliminates CO2 causing respiratory alkalosis. A large PE causes hypoventilation and prolonged hyperventilation causes muscle fatigue and hypoventilation; hypoventilation leads to respiratory acidosis.Although nutrition must be addressed, priorities include airway, breathing, and circulation. The client has a leukocytosis, elevated WBC count, an expected response to lung inflammation. Leukopenia places clients at risk for infection, but neither is the priority at this time. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability are ensured.

The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action will the nurse take first? 1. Check the ventilator alarm settings. 2. Assess the set tidal volume. 3. Listen to the client's breath sounds. 4. Call the respiratory therapist.

3. Listen to the client's breath sounds. Rationale: The nurse will first listen to the client's breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax.The nurse is behind the assessment with the client, not with the ventilator or ventilator settings. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse's first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

The adult client with degenerative arthritis is admitted for surgery to create a tracheostomy. What is the best communication method for this client during the postoperative period? 1. Computer keyboard 2. Magic Slate 3. Picture board 4. Pen and paper

3. Picture board Rationale: A picture board is the best communication strategy for this client. It does not require very much dexterity for someone who has degenerative arthritis.A computer keyboard, Magic Slate, and pen and paper require dexterity that may be difficult and/or painful for a client with degenerative arthritis.

A client who has recently relocated to the United States from Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? 1. Contact the health care provider for tuberculosis (TB) medications. 2. Perform a TB skin test. 3. Place a respiratory mask on the client. 4. Test all family members for TB.

3. Place a respiratory mask on the client. Rationale: The nurse's first action is to place a respiratory mask on the client. The concern is that this client has a high risk for TB having recently immigrated from overseas. Client with symptoms consistent with TB should be considered infectious until the disease is ruled out. Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. Tell the client that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.

The interprofessional team is collaborating about using noninvasive positive-pressure ventilation (NPPV) for a confused client with pneumonia. What information is essential for the nurse to share with the team while making this decision? 1. The client requires frequent respiratory assessment. 2. NPPV uses positive pressure to keep the alveoli open. 3. The client is unable to cough and protect the airway. 4. A full face mask may not fit this client's small face well.

3. The client is unable to cough and protect the airway. Rationale: It is most essential to determine the client's respiratory status including ability to cough and presence of a gag reflex before beginning NPPV. NPPV may cause gastric insufflation that can lead to vomiting or aspiration. NPPV must only be used on clients who have the ability to protect their own airway.NPPV uses positive pressure to keep the alveoli open; function of the devices is not the most important consideration in this scenario. If NPPV is used, full face masks, nasal pillows, and nasal-oral masks are available in a variety of sizes. One may provide a better seal and comfort than the other.

The nurse is caring for four clients who came to the emergency department with a productive cough. Which of these clients requires immediate intervention by the nurse? 1. The client with blood in the sputum 2. The client with mucoid sputum 3. The client with pink, frothy sputum 4. The client with yellow sputum

3. The client with pink, frothy sputum Rationale: The nurse would immediately assess and interview the client with a productive cough and pink, frothy sputum. Pink, frothy sputum is common with pulmonary edema, a life-threatening exacerbation of heart failure. This client requires immediate assessment and intervention.Blood in the sputum may occur with chronic bronchitis or lung cancer. These conditions develop over time and therefore do not require immediate attention. Mucoid sputum may be related to smoking and does not require immediate attention. Although yellow sputum may indicate an infection that requires treatment, the condition is not life threatening.

The nurse in the radiation therapy department is teaching the client about use of fluoride gel trays during radiation treatments. How will the nurse explain the purpose of wearing fluoride gel trays during radiation therapy of the mouth? 1. They will keep the mouth moist during treatments. 2. They prevent yellow teeth after treatment. 3. They prevent radiation scatter from metal in the mouth. 4. They will protect the taste buds on the tongue.

3. They prevent radiation scatter from metal in the mouth. Rationale: The gel trays help prevent radiation scatter when the beam hits metal in the mouth and also prevent dental caries.The gel trays will not provide additional moisture to the mouth. Gel trays with fluoride are not used to prevent yellowing; fluoride is used to prevent demineralization and to help with uptake of calcium and phosphate ions by the teeth. Gel trays fit over the teeth and do not protect the taste buds on the tongue.

A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation for a mandibular fracture. Which of these does the nurse communicate as the priority? 1. "Make sure he gets enough calories each day." 2. "He can only consume milk and ice cream until the wires come off." 3. "He must brush his teeth every 2 hours." 4. "Make sure he always carries the wire cutters with him."

4. "Make sure he always carries the wire cutters with him." Rationale: It is essential that the client always have wire cutters in the event of emesis, so the wires can be cut to prevent aspiration. Remind the client to contact the surgeon as soon as possible if the wires have been cut, so that fixation can be re-established.Collaboration with the dietitian for teaching and support may be indicated, but is not the priority for education. Good nutrition, ensuring adequate protein intake for healing, must be maintained. A specific dental liquid diet will be reviewed with the client and significant others before surgery. Dental hygiene will be maintained with an irrigation device such as a Waterpik or SoniCare, not with a brush.

The clinic nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? 1. "Handwashing is the best way to prevent transmission." 2. "I should avoid kissing and shaking hands." 3. "It is best to cough and sneeze into my upper sleeve." 4. "The intranasal vaccine can be given to everybody in the family."

4. "The intranasal vaccine can be given to everybody in the family." Rationale: Further teaching is needed when the client states that the intranasal vaccine can be given to everybody in the family. The intranasal flu vaccine is approved for adult clients up to age 49 who are not pregnant.Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A recommendation from the Centers for Disease Control and Prevention for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand.

A client was intubated 30 minutes ago for acute respiratory distress syndrome (ARDS) and possible sepsis. The following prescriptions have been given for the client. In what sequence will the nurse perform these actions? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze post-intubation arterial blood gases (ABGs). 1. 2, 1, 3, 4 2. 4, 3, 1, 2 3. 3, 4, 2, 1 4. 4, 2, 1, 3

4. 4, 2, 1, 3 Rationale: ABGs which evaluate oxygenation, ventilation, and pH would be analyzed first before the other assessments/actions are carried out. A baseline of sputum cultures would then be obtained before anti-infective medications are administered. Then levofloxacin can be given. Client and family education on communication methods is important, but is the lowest priority.

The nurse on a medical surgical unit is planning bed assignments for a new admission who has cystic fibrosis (CF) and is infected with Burkholderia cepacia. Which of these room assignments is most appropriate for this client? 1. A room with laminar air flow 2. A room with a client who has Down syndrome and pneumonia 3. A room with another client who has cystic fibrosis 4. A private room with a bathroom

4. A private room with a bathroom Rationale: The most appropriate room for this client is a private room and separate bathroom. This provides maximum protection from organisms which can easily cause infection in the client with CF. A serious bacterial infection for clients with CF is Burkholderia cepacia, which is spread by casual contact from one CF client to another. To reduce spread of infection, measures include separating infected CF clients from noninfected CF clients on hospital units and seeing them in the clinic on different days.Laminar air flow is used in operating rooms and other areas where removing circulating air will provide for infection prevention. This is not required for those with CF. A client with Down syndrome may be unable to be careful with covering the mouth when coughing, using tissues, and handwashing, and would not be cohorted with a client who has high risk for infection.

The nurse is caring for a client with facial trauma who has recently developed restlessness. Which of these is the nurse's first priority? 1. Assess for bleeding on the drip moustache dressing. 2. Provide ventilation with a manual resuscitation bag. 3. Perform the abdominal thrust maneuver. 4. Apply oxygen.

4. Apply oxygen. Rationale: The nurse's first priority is to apply oxygen to any client who recently developed restlessness. Restlessness could be a sign of poor gas exchange and partial airway obstruction and requires immediate attention.Although bleeding is important in all trauma clients, it is not the first priority in assessing the "ABCs." The gauze drip pad (moustache dressing) is typically used after a rhinoplasty. There is no indication the client is experiencing hypoventilation or apnea requiring manual resuscitation. Abdominal thrust (formerly Heimlich maneuver) is performed for upper airway obstruction.

The nurse assesses that the flap created after laryngectomy in the immediate post-operative period appears dusky in color. What is the nurse's first action? 1. Apply moist heat over the flap site. 2. Massage the flap site vigorously. 3. Place a tight dressing over the flap. 4. Assess flow to the area using a Doppler device.

4. Assess flow to the area using a Doppler device. Rationale: A complete assessment of the area, including Doppler activity of major feeding vessels, needs to be completed and the surgeon must be notified; the client may have to be returned to the operating room immediately. Neither hot nor cold packs nor dressings (nor anything, for that matter) should be applied to the flap site. The site is delicate and should not be massaged.Neither hot nor cold packs nor dressings (nor anything, for that matter) should be applied to the flap site. The site is delicate and should not be massaged.

The nurse is caring for a client with COPD who has a prescription for supplemental oxygen. Which situation will cause the nurse to further assess the need to increase the fraction of inspired oxygen (FiO2)? 1. Client's last ECG showed atrial fibrillation at a rate of 82 2. Client's blood pressure is 106/80 3. Client has been cooperative with all treatments 4. Client has developed restlessness over the last hour

4. Client has developed restlessness over the last hour Rationale: The nurse needs to assess the client who has recently become restless for the need to increase this client's FiO2. This client may be exhibiting symptoms of hypoxemia including restlessness. Additional symptoms of hypoxemia include increased heart rate and blood pressure, oxygen desaturation, cyanosis, restlessness, and dysrhythmias.A client with controlled or treated atrial fibrillation with a pulse of 82 beats per minute is stable and not cause for alarm or a change in FiO2. A client with a blood pressure of 106/80 and a client cooperating with the treatment plan indicate positive outcomes to oxygen therapy. The nurse will continue to observe these clients.

Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? 1. Client with possible ulcer who just returned from an endoscopy 2. Client with emphysema who needs teaching about pulmonary function testing 3. Client with pancreatitis who needs a preoperative chest x-ray 4. Client who had 1200 mL of pleural fluid removed by thoracentesis

4. Client who had 1200 mL of pleural fluid removed by thoracentesis Rationale: A nurse working in the PACU would be most familiar with assessing vital signs and respiratory status for a postoperative client after an invasive procedure such as thoracentesis. When a large volume of fluid has been removed, there is a greater risk for instability. This client is within this nurse's skill set.Endoscopy is typically performed with sedation, not general anesthesia, which will not require the critical rescue skills of the PACU nurse. Pulmonary function testing is not a procedure the PACU nurse would typically encounter nor will it require the skill level of the PACU nurse. Although a client with pancreatitis is seriously ill and would require a chest x-ray before undergoing operative procedures, a nurse with a PACU monitoring skill set would not be required.

The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client needs to be evaluated first by the nurse? 1. Client who is short of breath after walking up two flights of stairs 2. Client with a 10 mm area of redness on the arm after receiving purified protein derivative (Mantoux) skin test 3. Client with sore throat and fever of 102.2°F (39°C) oral 4. Client who is speaking in three-word sentences and has an SpO2 of 90%

4. Client who is speaking in three-word sentences and has an SpO2 of 90% Rationale: The client that requires first and immediate evaluation by the nurse is the client who is speaking in three-word sentences and displaying dyspnea. This, coupled with an SpO2 of 90%, indicates hypoxemia.The client displaying shortness of breath after walking up two flights of stairs may be displaying signs/symptoms of underlying cardiopulmonary disease. This is not an emergency as there is no indication of dyspnea at rest. Induration, not redness, reflects a positive Mantoux test with possible TB. This develops slowly and will not take priority over airway and breathing. Sore throat and fever are symptoms of infection that require further evaluation, but not emergently.

The nurse is developing the plan of care to reduce risk for aspiration for a client with a tracheostomy. Which nursing interventions would be included in the plan of care? Select all that apply. 1. Encourage frequent sipping from a cup. 2. Encourage water with meals. 3. Inflate the tracheostomy cuff during meals. 4. Maintain the client upright for 30 minutes after eating. 5. Provide small, frequent meals. 6. Teach the client to "tuck" the chin down in the forward position to swallow.

4. Maintain the client upright for 30 minutes after eating. 5. Provide small, frequent meals. 6. Teach the client to "tuck" the chin down in the forward position to swallow. Rationale: Interventions that must be noted in the client's plan of care include having the client remain upright for at least 30 minutes after eating to reduce the chance of aspiration. Also, making sure that small frequent meals are available for the client. Shorter and more frequent intervals of eating tire the client less and also reduce the chance of aspiration. Teaching the client how to tuck the chin down in the forward position helps to open the upper esophageal sphincter and again reduces the risk of aspiration.Sipping from a cup is contraindicated. Liquids are consumed using a spoon to ensure that the client is attempting to swallow only small volumes of liquid. Controlled small amounts of thickened liquids are given. Thin liquids such as water should be avoided because they are easily aspirated. The tracheostomy cuff needs to be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.

The nurse is providing education to a client with chronic bronchitis who has a new prescription for a mucolytic. Which of these will the nurse teach the client about the purpose of the medication? 1. Mucolytics decrease secretion production. 2. Mucolytics increase gas exchange in the lower airways. 3. Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease. 4. Mucolytics thin secretions, allowing for easier expectoration.

4. Mucolytics thin secretions, allowing for easier expectoration. Rationale: Client with chronic bronchitis typically produces large amounts of thick mucus interfering with gas exchange. Mucolytic means "breaking down mucus," resulting in thinner secretions which are easier to expectorate.Mucolytics do not decrease secretion production. Mucolytics may increase gas exchange as secretions are cleared, but this is an indirect property and is not the main function. Mucolytics do not have any bronchodilation properties.

The nurse enters the room while the client is eating breakfast and recognizes that the client has an upper airway obstruction with signs of hypoxemia. What is the nurse's first action? 1. Attempt to remove the obstruction. 2. Call the Rapid Response Team (RRT). 3. Apply oxygen by non-rebreathing mask. 4. Perform the abdominal thrust maneuver.

4. Perform the abdominal thrust maneuver. Rationale: The first step the nurse needs to take after noting the foreign body upper airway obstruction is to perform the abdominal thrust maneuver (formerly known as the Heimlich maneuver). This must be done immediately to restore oxygenation.No attempt would be made to remove the obstruction, unless the foreign body obstruction is visible and close to the mouth. Although notifying the Rapid Response Team for intubation is important, this is not the first action. Oxygen will not be effective unless a patent airway is established.

The RN and the LPN/LVN are working together to provide care for a group of clients on a medical surgical unit. Which of these actions is most appropriate for the RN to perform? 1. Administer purified protein derivative (PPD) for tuberculosis testing. 2. Assess vital signs and the puncture site one day post thoracentesis. 3. Monitor oxygen saturation using pulse oximetry every 4 hours. 4. Plan client and family teaching regarding upcoming pulmonary function testing.

4. Plan client and family teaching regarding upcoming pulmonary function testing. Rationale: The most appropriate action for the RN to perform is developing the teaching plan for upcoming pulmonary function test. These skills are complex, requiring use of the nursing process, and are not in the scope of practice of the LPN/LVN.Medication administration and monitoring of vital signs and client status after procedures can be accomplished by the LPN/LVN. Monitoring of oxygen saturation by pulse oximetry can also be included in the vital signs assessment.

The nurse is preparing to assess an adult client who was just admitted with pertussis. Which symptom does the nurse anticipate finding in this client? 1. "Whooping" after a cough 2. Hemoptysis 3. Mild cold-like symptoms 4. Severe coughing spasms

4. Severe coughing spasms Rationale: Clients with pertussis will have severe coughing spasms. Paroxysms of coughing will often be followed by changes in color and/or vomiting.Adults do not usually have the characteristic whooping sound associated with coughing exhibited by children with pertussis. Hemoptysis may occur after the acute phase when changes in the respiratory mucosa occur. Mild, cold-like symptoms occur in the initial stages of pertussis and generally do not require hospitalization.

An elderly client is admitted to the emergency department (ED) with symptoms of possible seasonal influenza accompanied by vomiting and high fever. Which of these actions is the nurse's first priority? 1. Ensure that ED staff members receive oseltamivir (Tamiflu). 2. Administer IM influenza vaccination. 3. Place the client in a negative air pressure room. 4. Start an IV line and begin intravenous hydration.

4. Start an IV line and begin intravenous hydration. Rationale: The nurse's first priority is to start an IV line and begin intravenous hydration. Elderly clients with influenza symptoms can develop dehydration quickly because of fever, vomiting and possible diarrhea. Initiating intravenous rehydration is a priority to maintain tissue perfusion. The ED staff would have received annual seasonal influenza vaccine, however if not, they can be given antiviral agents. A negative airflow room is not required in the ED, however a mask would be worn. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority as it takes weeks for full immunity to develop.

The nurse is caring for a client with laryngeal trauma. Which sign/symptom does the nurse determine is most critical to report to the provider? 1. Aphonia 2. Hoarseness 3. Loud snoring 4. Stridor

4. Stridor Rationale: Stridor, representing airway obstruction is the most critical sign/symptom exhibited by the client with laryngeal trauma. Other signs/symptoms of airway obstruction include shortness of breath, dyspnea, anxiety, restlessness, hypoxia, hypercarbia (elevated blood levels of carbon dioxide), decreased oxygen saturation, cyanosis, and loss of consciousness. Oxygen must be applied to any client exhibiting stridor.Aphonia (the inability to produce sound) is a manifestation of laryngeal trauma and may be caused by nerve damage, swelling, cartilage fracture, or other events. It does not require immediate action by the nurse. Hoarseness is commonly associated with laryngeal trauma, but does not require immediate attention. Loud snoring is associated with obstructive sleep apnea and indicates obstruction of the airway by the tongue. This is also not considered an emergency situation.

The respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tubing is clear. What is the best immediate action by the nurse? 1. Humidify the oxygen source 2. Increase provided oxygenation 3. Remove the inner cannula of the tracheostomy 4. Suction the tracheostomy tube

4. Suction the tracheostomy tube Rationale: The best immediate action by the nurse is to suction the tracheostomy tube. This will likely result in clear lung sounds and lower peak pressure, and the appearance of the sputum will indicate whether bleeding is a concern. Humidifying the oxygen source may help mobilize secretions, but an active cough response is also required to clear the airway; a sedated client has a weak cough. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.Humidifying the oxygen source will help mobilize secretions, but an active cough response is required to clear the airway. This client is sedated and has a weak cough. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.

The home care nurse is caring for an elderly client with streptococcal pneumonia. Which of these findings indicate a positive outcome to treatment? Select all that apply. 1. The client states she will complete the entire dose of antibiotic prescribed. 2. The client reports fatigue and malaise. 3. White blood cell count is 16, 000 cells/cubic mm (16 × 109/L). 4. The client has been afebrile for 48 hours.

4. The client has been afebrile for 48 hours. Rationale: A positive outcome been afebrile for 48 hours.Expected outcomes to treatment include negative blood and sputum cultures, normal WBC count and differential, and absence of fever.Fatigue may persist for several weeks. The normal WBC count is 5000-10,000 mm3 (5-10 × 109/L). A WBC count of 16,000 mm3 (16 × 109/L) indicates infection. The client stating compliance with treatment is positive, but is not an objective measurement of eradicating the infecting organism.

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who has hypoxemia and hypercarbia. The nurse recognizes that a positive outcome to therapy has been achieved by which of these findings? 1. The pCO2 is within normal range. 2. The client's face is very pink. 3. The client reports decreased distress. 4. The oxygen saturation is between 88% and 90%.

4. The oxygen saturation is between 88% and 90%. Rationale: Clients with hypoxemia, even those with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and maintain SpO2 levels between 88% and 92%.Gases diffuse independently, therefore applying oxygen will not decrease the carbon dioxide level; hypoxemia may still be present. Flushing of the face can be a symptom of hypercarbia. A report of less distress is appropriate. The nurse, in any case, needs to use an objective measure of oxygenation such as pulse oximetry or blood gas results.

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? 1. Combination medication therapy is effective in eliminating cough and fever. 2. Combination medication therapy improves adherence. 3. Combination medication therapy has fewer side effects, particularly liver damage. 4. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.

4. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms. Rationale: The nurse tells the client that multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Combination drug therapy is the most effective method for treating TB and preventing transmission.As the disease responds to treatment, the symptoms will decrease, but they are not eliminated. Combination drug therapy does not improve adherence to drug therapy. Isoniazid, rifampin, and pyrazinamide may cause liver damage.

The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks is appropriate to delegate to a nursing assistant? 1. Administering throat-numbing lozenges 2. Assessing the mouth for inflammation and infection 3. Teaching about skin care while receiving radiation 4. Washing the skin with plain soap and water

4. Washing the skin with plain soap and water Rationale: Personal hygiene is within the scope of practice of the nursing assistant.Throat-numbing lozenges are medications and should not be administered by nursing assistants because they are outside the scope of practice. Assessment is a complex task that must be completed by licensed nursing staff. Educating the client is the responsibility of licensed nursing staff and is an ongoing part of the client's care.

The nurse is caring for a client with severe acute respiratory syndrome (SARS). What is the most important infection control precaution that the nurse takes when preparing to suction this client? 1. Keeping the door to the client room closed 2. Performing oral care after suctioning the oropharynx 3. Washing hands and donning gloves prior to the procedure 4. Wearing a disposable particulate mask respirator

4. Wearing a disposable particulate mask respirator Rationale: The most important infection control precaution the nurse must take before suctioning a client is to wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. The door to the room needs to be closed during care of the client with SARS and other instances of airborne precautions. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure.