Med-Surg Exam 2

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 should the nurse use initially? A. Face tent B. Venturi mask C. Nasal cannula D. Non-rebreather mask

A A client with smoke inhalation and facial burns who requires high-flow oxygen should 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 require snug fitting on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? A. Check the resident's oxygen saturation. B. Do a complete neurologic assessment. C. Give the prescribed PRN lorazepam (Ativan). D. Notify the resident's primary care provider.

A A common reason for sudden confusion in older clients is hypoxemia caused by undiagnosed pneumonia. The nurse's first action should be to assess oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation; this will take several minutes to complete. Administering lorazepam may make the client more confused and agitated because antianxiety drugs may cause a paradoxical reaction, or opposite effect, in some older clients. Depending on the results of the client's pulse oximetry and neurologic examination, notifying the primary care provider may be an appropriate next step.

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? A. Administering preoperative antibiotics and anxiolytics B. Assessing the client's nutritional status and need for nutrition supplements C. Having the client sign the operative consent form D. Teaching the client about the need for tracheal suctioning after surgery

A 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 asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest? A. Adventitious breath sounds B. Fremitus C. Oxygenation status D. Respiratory excursion

A Adventitious sounds are additional breath sounds superimposed on normal sounds. They indicate pathologic changes in the lung. Fremitus is vibration and is not detected by auscultation. Oxygenation status cannot be detected specifically by auscultation. Respiratory excursion is detected by both observation of the movement of the chest and palpation as the client inhales and exhales.

A client has just been admitted to the intensive care unit after having a left lower lobectomy with a video-assisted thoracoscopic surgery. Which of these requests will the nurse implement first? A. Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. B. Administer 2 g of cephalothin (Keflin) IV now. C. Give morphine sulfate 4 to 6 mg IV for pain. D. Infuse 1 unit of packed red blood cells (PRBCs) over the next 2 hours.

A 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; a minimally invasive technique will be less painful than an open technique, but is still painful. Pain management is not the first priority, however. PRBCs may or may not need to be infused to maintain the oxygen-carrying capacity of the blood. Less blood is lost during minimally invasive techniques than during open surgical procedures.

A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first? A. Albuterol (Proventil) 2 inhalations B. Fluticasone (Flovent) 2 inhalations C. Ipratropium (Atrovent) 2 inhalations D. Salmeterol (Serevent) 2 inhalations

A Albuterol is a beta2 agonist that acts rapidly as a bronchodilator. Fluticasone is a corticosteroid; it is used to prevent asthma attacks 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 as effective as 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; this client needs a rescue medication

A client is admitted to the medical floor with a new diagnosis of lung cancer. How does the nurse assist the client initially with the anxiety associated with the new diagnosis? A. Encourage the client to ask questions and verbalize concerns. B. Leave the client alone to deal with his or her own feelings. C. Medicate the client with diazepam (Valium) for anxiety every 8 hours. D. Provide journals about cancer treatment.

A Anxiety causes increased oxygen consumption, and oxygen availability is limited in lung cancer; the availability of the nurse to answer questions and listen to the client's concerns will decrease anxiety. The client may choose to be alone, although this may be a maladaptive coping behavior. Scheduled medication does not solve the anxiety associated with the new diagnosis, although administering Valium (diazepam) every 8 hours will assist with reducing the anxiety; it is more important to work with the client to determine the cause of the anxiety and assist him or her in dealing with those issues first. Knowledge about cancer may help relieve anxiety but is not the best initial step in a newly diagnosed client. The nurse must first assess how the client learns best and what the client's needs are. The nurse also must be aware of the plan of care for the client.

All of these clients are being cared for on the intensive care stepdown unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit? A. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. B. Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour. C. Client with emphysema who requires instruction about correct use of oxygen at home. D. Client with lung cancer who has just been transferred from the intensive care unit after having a left lower lobectomy the previous day.

A 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 nursing assistant has taken vital signs of the ventilated postoperative client who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for? A. Continuous oozing of bright-red blood B. Decreased level of consciousness C. Effective pain management D. Heart rate and blood pressure trending up over several hours

A Bright-red blood indicates a rupture in the carotid artery and requires immediate attention. A ventilated postoperative client will be sedated, so a decreased level of consciousness is to be anticipated. Effective pain management should be evaluated during assessment of vital signs and that information relayed to the nurse. Changes in vital signs, including trends, need to be reported to the nurse responsible for the client's care. Increasing heart rate and blood pressure can be an indication that the client is not adequately sedated or is in pain or anxious, for example.

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? A. Crackles B. Rhonchi C. Pleural friction rub D. Wheeze

A Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways. The airways have been deflated due to the presence of fluids in the lungs, and crackles should be considered to be a sign of fluid overload. Rhonchi are low-pitched, coarse snoring sounds caused by fluid or 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; they may occur on inspiration or on expiration and may be heard without a stethoscope as air rushes through narrowed airways.

An emergency nurse is preparing to care for a client arriving by ambulance after a motor vehicle crash. The client has severe facial and neck injuries and emergency airway measures have been taken. Which type of airway does the nurse prepare for? A. Cricothyroidotomy B. Endotracheal intubation C. Nasal bi-level positive airway pressure (BiPAP) D. Tracheotomy

A Cricothyroidotomy is an emergency procedure performed by emergency medical personnel to hold an airway open until a tracheotomy may be performed. Endotracheal intubation is not likely in a client with severe head and neck injuries. Nasal BiPAP depends on a patent upper airway. Tracheotomy is a surgical procedure, not a field procedure.

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? A. "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." B. "Because your body isn't getting enough oxygen. Not getting enough oxygen is what stimulates you to wake up and breathe." C. "Because your tongue may be blocking your throat, and you wake up because you are choking." D. "It isn't really that often. It just feels that way."

A 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. Technically the client is not choking. Telling the client he or she isn't really awakening that often minimizes the client's concern and is not accurate. The client may be awakening every 5 minutes as the cycle repeats.

While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do? A. Calmly continues talking B. Checks the tube for blocks or kinks C. Immediately calls the health care provider D. Strips the chest tube

A Gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. Any bubbling that is occurring would stop if a kink or a blockage is present in the chest tube. The chest tube is functioning normally; there is no need to notify the health care provider. "Stripping the chest tube" greatly increases pressure inside the chest and could potentially damage lung tissue; any excessive manipulation should be avoided.

A client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question? A. "Give ibuprofen 800 mg every 8 hours as needed for pain." B. "Encourage bedrest, with the head of the bed elevated 45 to 60 degrees." C. "Provide humidified air." D. "Suction at the bedside.

A Ibuprofen is contraindicated in a client with a nosebleed because nonsteroidal anti-inflammatory drugs inhibit clotting. At least initially, bedrest is suggested because significant amounts of blood may have been lost owing to a posterior nosebleed; 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 is a cause of epistaxis (nosebleed). Any client who is admitted for epistaxis needs suction at the bedside in the event of further bleeding.

In the older adult client, which respiratory change requires no further assessment by the nurse? A. Increased anteroposterior (AP) diameter B. Increased respiratory rate C. Shortness of breath D. Sputum production

A Increased AP diameter is normal with aging. Increased respiratory rate is not a normal finding with aging and may be an indication of pain or infection; it needs to be evaluated further by the nurse. Shortness of breath is not associated with aging and needs to be evaluated further, because it may be related to infection, tumor, or cardiac issues, for example. Sputum production is not related to the aging process; although it may be chronic in nature, it should be assessed further. It is important to note the character and quantity of the sputum, as well as the duration of sputum production.

Which assessment finding is associated with obstructive lung disease and not with interstitial lung disease? A. Barrel chest B. Cough C. Dyspnea D. Reduced gas exchange

A Interstitial lung diseases are restrictive, not obstructive, so they do not cause barrel chest, which is the result of air trapping. Both types of pulmonary disease cause cough, dyspnea, and reduced gas exchange.

A "do not resuscitate" (DNR) client has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? A. Ensure that the tubing is patent and that oxygen flow is high. B. Notify the chaplain and the family member of record. C. Call the Rapid Response Team and prepare to intubate. D. Comfort the client and confirm that signed DNR orders are in the chart.

A 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 should not be notified, because death is not imminent at this time. Equipment malfunction must be ruled out before intubation of the client is performed. Additionally, the client may not want to be intubated, as indicated in the DNR orders. Troubleshooting and reversal of nonresuscitative equipment is the standard of care; DNR does not mean "do not treat."

A client who has had a recent laryngectomy continues to report pain. Which medication would be best used as an adjunct to a narcotic once the client can take oral nutrition? A. Liquid nonsteroidal anti-inflammatory drugs (NSAIDs) B. Liquid steroids C. Opioid antagonists D. Oral diazepam

A NSAIDs are an excellent adjunct when used with narcotics or opioid analgesia. Steroids will not help in pain relief and will delay healing. An opioid antagonist will reverse the effect of the narcotic. Diazepam has no pain-relieving properties.

An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best? A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula B. The client with chronic lung disease who is being evaluated for possible home oxygen use C. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar D. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

A Orthopedic nurses are familiar with pulmonary emboli and with administration of oxygen through nasal cannulas. Orthopedic nurses do not specialize in chronic lung conditions; such care is best assigned to an RN with experience in chronic lung conditions and in the use of various home oxygen delivery devices and the use of various types of oxygen delivery equipment. Orthopedic nurses do not specialize in airway surgery; such care is best assigned to an RN with experience in postoperative tracheost

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? A. "I can only take baths, but no showers." B. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." C. "I should put cotton or foam over the tracheostomy hole." D. "I will have to learn to suction myself."

A The client does not understand that he or she can shower with the use of a shower shield over the tracheostomy tube to prevent water from entering the airway. Additional teaching is necessary. Normal saline should be instilled into the artificial airway 10 to 15 times a day, as prescribed. The stoma should be covered with cotton or foam to protect it during the day; this filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. Clients with tracheostomies should be taught clean suction technique.

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? A. Hyperoxygenate before and after suctioning. B. Repeat suctioning until the tube is clear. C. Apply suction during insertion of the tube. D. Suction for 30 seconds.

A The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1 to 5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits. Repeat suctioning as needed for up to three total suction passes; additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult/traumatic. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; never suction longer than 10 to 15 seconds.

The home health nurse is assigned to visit all of 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 would be best to reschedule? A. Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% B. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test C. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment D. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

A The client with emphysema has an appropriate SpO2 for home oxygen use. A positive Mantoux test, in addition to a history of cough, weight loss, and night sweats, is highly suspicious for tuberculosis and needs follow-up and reporting, because this becomes a public and a personal health issue. A client with a newly diagnosed pleural effusion needs a complete and thorough admission and intake assessment to ensure that he has adequate respiratory function to meet his basic oxygenation needs. Although a percutaneous lung biopsy may be an outpatient procedure, pneumothorax or hemothorax is a possible life-threatening complication of this procedure that would cause dyspnea and requires assessment in a timely manner by the home health nurse.

Which two factors in combination are the greatest risk factors for head and neck cancer? A. Alcohol and tobacco use B. Chronic laryngitis and voice abuse C. Marijuana use and exposure to industrial chemicals D. Poor oral hygiene and use of chewing tobacco

A The combination of alcohol and tobacco use is one of the greatest risk factors for head and neck cancer. 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. Poor oral hygiene is a risk factor, as is chewing tobacco; however, no studies have reported that a combination of the two will lead to increased risk. The same cancer-causing agents in smoking tobacco may be present in smokeless (chewing) tobacco.

A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? A. Client on warfarin (Coumadin) with epistaxis with profuse bleeding B. Client with facial burns caused by a mattress fire while sleeping C. Client with possible facial fractures after a motor vehicle collision (MVC) D. Client with suspected bilateral vocal cord paralysis and stridor

A 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, laboratory work should be obtained 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 involvement and requires observation by an experienced nurse. An experienced nurse should take care of a client with possible facial fractures after an MVC 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; this requires an RN with experience.

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? A. Ask the client whether CPAP has been used consistently at night. B. Discuss the use of autotitrating positive airway pressure (APAP). C. Plan to teach the client about treatment with modafinil (Provigil). D. Suggest that a nasal mask be used instead of a full facemask.

A The nurse should assess whether the client has actually consistently been using CPAP at night, because clients may have difficulty with the initial adjustment to this therapy. 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 treat 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 he or she is finding the facemask used with CPAP uncomfortable.

Which client has the most urgent need for frequent nursing assessment? A. An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year, 2-pack-per-day smoking history and is receiving 50% oxygen through a Venturi mask B. A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 at percentages in the upper 90s, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties C. An older adult client who is eager to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy D. A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

A The older adult with a long history of smoking and chronic lung disease is at elevated risk for respiratory depression owing to the hypoxic drive of respirations countered by high levels of oxygen; this client must be assessed frequently while receiving high-flow oxygen. The young client with no signs or symptoms of respiratory compromise, and the client who meets discharge criteria, do not require frequent assessment. Although the middle-aged client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the older client on higher-flow oxygen is at greater risk for respiratory demise and therefore needs frequent assessment more urgently.

A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? A. Adjust the position of the oxygen tubing. B. Assess for signs and symptoms of hypoventilation. C. Change the O2 flow rate to keep SpO2 as prescribed. D. Choose which O2 delivery device should be used for the client.

A The scope of a nursing assistant's work 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 beyond the scope of practice for unlicensed personnel.

People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilation? (Select all that apply.) A. Bakers B. Coal miners C. Electricians D. Furniture refinishers E. Plumbers F. Potters

A,B D, F Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. Coal miners are at risk to develop pneumoconiosis as the result of inhalation of coal dust. Owing to the chemicals used to refinish furniture (paint strippers, solvents), 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.

Which statement by a client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction? A. "I don't need to use my oxygen all the time." B. "I don't need to get a flu shot." C. "I need to eat more protein." D. "It is normal to feel more tired than I used to."

B An annual influenza vaccine (flu shot) is important for all clients with COPD. At the same time, a pneumonia vaccine could be offered, since pneumonia is one of the most common complications of COPD. The client who is hypoxemic and also has chronic hypercarbia requires lower levels of oxygen delivery, and may not need it all the time. Increased work of breathing in a client with COPD raises calorie and protein needs, which can lead to protein-calorie malnutrition. Clients with COPD often have chronic fatigue.

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

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

B Because a fresh tracheostomy stoma will collapse, the client will lose airway patency, which will require the nurse to ventilate the client through the mouth and nose while waiting for 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 and will be ineffective until airway patency is restored. Further, auscultation should not be done while a nasal cannula is simultaneously applied. 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. Reinsertion of the tracheostomy tube should be done once a Rapid Response Team is available to accomplish this.

Which assessment finding is of greatest concern in a client with emphysema? A. Barrel-shaped chest B. Bronchial breath sounds heard at the bases C. Hyperresonance to percussion of the chest D. Ribs lying horizontal

B Bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or an infective 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 he will generally have a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to percussion. Air trapping causes the lungs in a client with emphysema to lie in a horizontal direction.

The client says, "I hate this stupid COPD." What is the best response by the nurse? A. "Then you need to stop smoking." B. "What is bothering you?" C. "Why do you feel this way?" D. "You will get used to it."

B Encourage the client, and the family, to express their feelings about limitations on their lifestyle and about disease progression. This is not the time to lecture the client regarding his smoking habits; the client is expressing a need for support. "Why" questions can seem accusatory and may make a client less likely to talk about what he or she is feeling. The client's feelings should never be minimized.

A client who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. All of these health care provider requests are received. Which action will the nurse take first? A. Give oxygen to keep O2 saturation greater than 93%. B. Immobilize the neck with a cervical collar. C. Infuse normal saline by large-bore IV catheter. D. Obtain computed tomography (CT) scan of head, neck, and chest.

B If the cervical spine has not already been stabilized by emergency medical services, this is the nurse's top priority. The neck should be held in place manually until a properly fitted cervical collar can be applied. Innervation of the diaphragm is between cervical spine levels C3 and C5. Oxygen administration is important; however, this is not the nurse's first priority and is considered separate from establishing an airway. Two large-bore (16- or 18-gauge) IV catheter lines should be established, and an isotonic fluid such as normal saline should be infused at a rate determined by the client's condition and vital signs. CT scans are not the top priority and should be based on the client's reported problems and condition.

The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery? A. Educate the client about ways to avoid aspiration when swallowing after the surgery. B. Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. C. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. D. Teach the client and significant others about how to suction and do wound care of the stoma.

B 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 is 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

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

B Obtaining aerobic and anaerobic cultures is the first action the nurse should perform and is standard procedure in a febrile client for whom antibiotics have been requested. Levofloxacin, an antibiotic, is important to administer, but blood cultures should be drawn before antibiotics are started. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action; the question indicates that the client is agitated but does not indicate whether other attempts to control agitation have been tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge; this client is febrile and agitated, and a referral is not the immediate concern.

What does the nurse do first when setting up a safe environment for the new client on oxygen? A. Ensures that staff members wear protective clothing B. Ensures that no combustion hazards are present in the room C. Sets the oxygen delivery to maintain no fewer than 16 breaths/min D. Uses a pulse oximetry unit

B Oxygen is highly flammable. The nurse must ensure that no open flames or combustion hazards are present in a room where oxygen is in use. Protective clothing is not necessary for a client who requires oxygen therapy other than the use of Standard Precautions. The oxygen delivery setting is usually determined in conjunction with the respiratory therapy care partner. Although the setting is important for safe administration, it is not necessary for a safe environment. Pulse oximetry would be useful for monitoring the client's oxygenation status, but is not necessary for a safe environment.

A client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the health care provider requests oxygen via nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention? A. Increasing carbon dioxide levels B. Decreasing respiratory rate C. Increasing adventitious breath sounds D. Increased coughing

B Respiratory rate and depth should be monitored closely while the client receives oxygen, because hypoventilation is seen during the first 30 minutes of oxygen therapy in clients with hypoxic drive for respiration. The client's color will improve (from ashen or gray to pink) because of an increase in PaO2 level before apnea or respiratory arrest occurs from loss of the hypoxic drive. The COPD client is not sensitive to PaCO2; oxygen administration can cause high PaO2 levels. Monitoring for adventitious breath sounds is important, but these would not be a result of the oxygen that the client is receiving. The ability to cough and breathe deeply is a positive sign.

The nurse is teaching a client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques? A. Hair loss B.Increased risk for sunburn C. Loss of appetite D. Pain at site of treatment

B Skin in the path of radiation is more sensitive to sun damage; therefore, clients must avoid direct skin exposure to the sun during treatment and for at least 1 year after radiation is completed. Alopecia, or hair loss, is a side effect of chemotherapy, not of radiation. Loss of appetite is not specific to radiation therapy. Radiation therapy itself is painless and sensation-free; however, the skin may become sore and prone to breakdown over the course of treatment.

A client has been diagnosed with asthma. Which statement below indicates that the client correctly understands how to use an inhaler with a spacer? A. "I don't have to wait between the two puffs if I use a spacer." B. "If the spacer makes a whistling sound, I am breathing in too rapidly." C. "I should rinse my mouth and then swallow the water to get all of the medicine." D. "I should shake the inhaler only if I want to see whether it is empty."

B 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 must wait 1 minute between puffs. 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, to prevent the development of an oral fungal infection. An empty inhaler will float on its side in water; a full inhaler will sink. Shaking an inhaler helps ensure that the same dose is delivered in each puff.

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? A. "But you know you need this to breathe, right?" B. "Do you have a scarf or a large loose collar that you could place over it?" C. "Your family and friends probably won't even care." D. "It won't take you long to learn to manage."

B Suggesting strategies to cover the tracheostomy recognizes client 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.

In assessing the client's respiratory status, arterial blood gas (ABG) test results reveal pH of 7.50, PaO2 of 99 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 22 mEq/L. What action does the nurse need to take first? A. Call the health care provider. B. Encourage the client to slow his breathing rate. C. Nothing; these results are within the normal range. D. Provide oxygen support.

B The ABGs indicate respiratory alkalosis, which is commonly caused by hyperventilation; encouraging the client to slow down his breathing rate may help the client return to normal breathing and may correct this abnormality. This situation is not an emergency condition and does not require that the health care provider be called or that oxygen be given. The client's PaO2 is within normal limits, but it is important for the nurse to assess the client and not just look at the numbers.

Where does gas exchange occur? A. Acinus B. Alveolus C. Bronchus D. Carina

B The alveolus is the structural unit of the lung where gas exchange occurs. The acinus is a structural unit that includes a bronchiole, an alveolar duct, and an alveolar sac. The bronchus (plural, bronchi) is similar in structure to the trachea, which allows passage of air into the lungs. The carina is the junction where the trachea branches into the left and right bronchi.

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first? A. Client with chronic obstructive pulmonary disease (COPD) who is ready for discharge, but is not able to pay for prescribed home medications. B. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. C. Hospice client with terminal pulmonary fibrosis and an oxygen saturation level of 89%. D. Client with lung cancer who needs an IV antibiotic administered before going to surgery.

B The client with CF with an elevated temperature and respiratory rate is exhibiting signs of an exacerbation 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 for a hospice client with terminal pulmonary fibrosis; not enough information is provided to determine whether this client is in distress. The client who needs an IV antibiotic could have the medication administered by another RN, or it could be administered in the operating room.

What is the function of the turbinates? A. They decrease the weight of the skull on the neck. B. They increase the surface area of the nose for heating and filtering. C. They move inspired particles from nose to throat for removal. D. They separate two nasal passages down the middle.

B The turbinates increase the surface area of the nose, so that more heating, filtering, and humidifying of inspired air can occur before air passes into the nasopharynx. The paranasal sinuses are air-filled cavities that decrease the weight of the skull. The cilia are responsible for moving inspired particles to the throat so they can be swallowed or expectorated. The septum is the cartilage that separates the nasal cavity into two passages.

The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer? A. Class I, can perform manual labor B. Class II, can perform desk job C. Class III, minimally employable D. Class IV, must remain at home

B This client is dyspneic when climbing stairs or walking on an incline, but not on level walking; therefore, this client is considered class II and employable only for a sedentary job or under special circumstances. If the client had class I dyspnea, the dyspnea would only occur on more-than-normal or strenuous exertion; this client's dyspnea occurs beyond normal or strenuous exertion, so he or she would not be able to perform manual labor. The client's dyspnea does not occur on minimal exertion (class III), and does not prevent him or her from performing essential activities of daily living (class IV), so the client is still employable in some capacity

The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? A. Assess the puncture site for drainage. B. Implement nothing-by-mouth (NPO) status. C. Monitor for signs of anaphylaxis. D. Perform aggressive chest physiotherapy.

B Until the client has a gag reflex and is fully alert, he or she should be maintained on NPO status to prevent aspiration. No external puncture site is needed for bronchoscopy. Although the client will have received medications during the bronchoscopy, an anaphylactic reaction will occur immediately, not in a client who has returned to the medical unit. Aggressive chest physiotherapy is not indicated in a client who has had a bronchoscopy and may cause bleeding if biopsies have been obtained.

Which value indicates clinical hypoxemia and the need to increase oxygen delivery? A. Hemoglobin of 22 g/dL B. PaCO2 of 30 mm Hg C. PaO2 of 65 mm Hg D. Oxygen saturation of 88%

C A PaO2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is considered hypoxemia. Hemoglobin measures oxygen-carrying capacity. PaCO2 of 30 mm Hg indicates low carbon dioxide levels in the blood. Oxygen saturation measures tissue perfusion.

A client has a fever of 104° F (40° C). In which direction, if any, does this shift the oxygen-hemoglobin dissociation curve? A. Down B. To the left C. To the right D. Will not shift

C A client with fever has a higher demand for oxygen, so the curve will shift to the right for easier dissociation. The curve does not move up or down on the vertical axis. Moving to the left would cause hemoglobin to dissociate oxygen less easily.

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? A. Client with bacterial pneumonia and a cough productive of green sputum B. Client with neutropenia and pneumonia caused by Candida albicans C. Client with possible pulmonary tuberculosis who currently has hemoptysis D. Client with right empyema who has a chest tube and a fever of 103.2° F

C A client with possible tuberculosis should be admitted to the negative-airflow room to prevent airborne transmission of tuberculosis. A client with bacterial pneumonia does not require a negative-airflow room but should be placed in Droplet Precautions. A client with neutropenia should be in a room with positive airflow. The client with a right empyema who also has a chest tube and a fever should be placed in Contact Precautions but does not require a negative-airflow room.

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period? A. Computer keyboard B. Magic Slate C. Picture board D. Pen and paper

C A picture board does not require very much dexterity for communication. Dexterity can be limited to the extent the client finds comfortable. 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 had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? A. Abscess B. Pneumonia C. Pneumothorax D. Pulmonary embolism

C A pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms. Although it is possible that an abscess has formed, this is not the most likely diagnosis because it would not cause a great deal of shortness of breath. It is not likely that pneumonia would develop this rapidly, causing this level of symptoms. Thoracentesis is not a cause of pulmonary emboli.

A client who had an earlier bronchoscopy has the following vital signs: heart rate 132 beats/min, respiratory rate 26 breaths/min, and blood pressure 98/50 mm Hg. The client is anxious and his skin is cyanotic. What is the nurse's first action? A. Call the Rapid Response Team. B. Give methylene blue 1% 1 to 2 mg/kg by IV injection. C. Administer oxygen. D. Notify the health care provider immediately.

C Administering oxygen and reassessing vital signs to observe for improvement is the first action. Administration of oxygen by itself may help relieve the client's anxiety. The Rapid Response Team should be called if the client has any symptoms of methemoglobinemia; calling a rapid response will not be the nurse's first action because abnormal vital signs can result from many causes. Methylene blue is given for treatment of methemoglobinemia; information is insufficient for the nurse to determine whether the client has this condition. The health care provider will receive an update of the client's condition; however, this is not the highest priority at this time.

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? A. "Asthma drugs help everybody breathe better." B. "I must carry my emergency inhaler only when activity is anticipated." C. "I must have my emergency inhaler with me at all times." D. "Preventive drugs can stop an attack."

C 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 [Proventil]). Asthma medications are specific to the disease and should never be shared or used by anyone other than the person for whom they are prescribed. An emergency inhaler should be carried when activity is anticipated, as well as at other times. Preventive drugs are those that are taken every day to help prevent an attack from occurring. They are not able to stop an attack once it begins.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test does the nurse expect to help confirm the diagnosis? A. Bronchoscopy B. Chest x-ray C. Computed tomography (CT) scan D. Thoracoscopy

C CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli. The client has a pulmonary embolism; bronchoscopy will not help to confirm this diagnosis. A chest x-ray will rule out other causes of the symptoms but is not specific for pulmonary embolism. Thoracoscopy is not used to detect pulmonary emboli.

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse? A. Pain on deep inspiration B. Pain on palpation C. Pain radiating to the shoulder D. Pain that is rubbing in nature

C Chest pain radiating to the shoulder should be assumed to be cardiac in origin until proven otherwise; this requires the immediate attention of the nurse. Pain on inspiration and chest pain that is rubbing in nature are usually pulmonary in origin but do not require immediate attention. Pain on palpation is not usually pulmonary in nature; it may be due to trauma or may be referred from another source, such as the gastrointestinal tract.

What is the greatest risk factor for lung cancer? A. Alcohol consumption B. Asbestos exposure C. Cigarette smoking D. Smoking marijuana

C Cigarette smoking 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. Although asbestos is carcinogenic and some components of marijuana are carcinogenic, neither is the major risk factor for lung cancer.

A client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? A. The low PaO2 level may result in oxygen toxicity. B. The 100% oxygen delivery requirement indicates immediate extubation. C. Lung sounds may indicate absorption atelectasis. D. The level of oxygen delivery may indicate absorption atelectasis.

C High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated. High PaO2 levels may result in oxygen toxicity. The need for 100% oxygen delivery does not suggest that the client should be extubated; rather, it suggests that the client continues to require intubation and mechanical ventilation. Although high levels of oxygen delivery can result in absorption atelectasis, this is not an indicator; rather, it is a cause.

Which nursing intervention is the priority in preparing a client for pulmonary function testing (PFT)? A. Administer bronchodilator medication on call. B. Encourage clear fluid intake 12 hours before the procedure. C. Ensure no smoking 6 hours before the test. D. Provide supplemental oxygen as testing begins.

C If the client has been smoking, this may 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. Fluid intake does not have an effect on PFT testing. Unless the client develops distress during testing, supplemental oxygen is not required and will alter the results of PFT.

A client is 1 day postoperative from a total laryngectomy for cancer. He has indicated to the nurse that he is experiencing pain. Pain management for him is best achieved with which medication? A. IV ketorolac (Toradol) B. IV midazolam (Versed) C. IV morphine sulfate (Morphine) D. Oral acetaminophen (Tylenol)

C Lorazepam is a short-acting antianxiety medication that would be the most appropriate choice for this client. Amitriptyline is a tricyclic antidepressant that would not be used specifically for this client's anxiety. Although diazepam is an effective medication for anxiety, it is more likely to cause respiratory depression; the location of this tumor makes diazepam not the best choice for anxiety. Ketorolac is a nonsteroidal anti-inflammatory drug and should not be used before surgery. Ketorolac should be used with caution, or not at all, if the client is taking medication for anxiety.

The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success? A. Peak flowmeter readings that are yellow after the third reading B. Productive cough C. SpO2 level of 92% after ambulating 50 feet D. Stable arterial blood gases (ABGs)

C Maintaining a baseline SpO2 of 92% after ambulating 50 feet is an excellent indicator that the client has achieved better airflow, and that the nurse's teaching has been effective. A yellow reading means "caution," which indicates narrowing airways. Although a productive cough may be an indication of success, it can also be an indication of infection. ABGs are invasive, costly, and painful and are not the most effective indicator of successful teaching in this situation.

A client has asthma that gets worse during the summer. She tells the nurse that she takes a medication every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client? A. Albuterol (Proventil) inhaler B. Guaifenesin (Organidin) C. Montelukast (Singulair) D. Omalizumab (Xolair)

C Montelukast is a leukotriene antagonist that works well for asthma that occurs during certain seasons. It is taken on a daily basis as a preventive medication. Albuterol inhalers are beta2 agonists that are rescue medications used on an as-needed basis only. Guaifenesin is a mucolytic that does not provide any bronchodilation; it may or may not be taken daily. Omalizumab is an immunomodulator that is injected subcutaneously every 2 to 3 weeks; it is not commonly used because a high rate of anaphylaxis is associated with it.

A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? A. Blood in the sputum B. Mucoid sputum C. Pink, frothy sputum D. Yellow sputum

C Pink, frothy sputum is common with pulmonary edema and requires immediate attention and intervention to prevent the client's condition from getting worse. Blood in the sputum may occur with chronic bronchitis or lung cancer; because this condition is chronic, the situation does 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 emergent.

A client has just arrived in the postanesthesia care unit following a successful tracheostomy procedure. Which nursing action must be taken first? A. Suction as needed. B. Clean the tracheostomy inner cannula and stoma. C. Listen to lung sounds. D. Change the tracheostomy dressing as needed.

C The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs. Suction is not needed if the lungs are clear to auscultation. Although cleanliness is a priority, the nurse must assess the client's respiratory status before cleaning or performing a dressing change.

What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth? A. Keep the mouth moist during treatments B. Keep the teeth from turning yellow after treatment C. Prevent radiation scatter when the beam hits metal in the mouth D. Protect the taste buds on the tongue

C The gel trays help prevent radiation scatter when the beam hits metal in the mouth. They 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 new client arrives in the medical-surgical unit with a flap after a total laryngectomy. The flap appears dusky in color. What is the nurse's first action? A. Apply a hot pack over the flap site. B. Massage the flap site vigorously. C. Place a tight dressing over the flap. D. Use a Doppler device to assess flow to the area.

D A complete assessment of the area, including Doppler activity of major feeding vessels, needs to be completed and the surgeon must be notified, because 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.

Which client does the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU) A. Client with allergic rhinitis scheduled for skin testing B. Client with emphysema who needs teaching about pulmonary function testing C. Client with pancreatitis who needs a preoperative chest x-ray D. Client with pleural effusion who has had 1200 mL removed by thoracentesis

D A nurse working in the PACU would be familiar with assessing vital signs and respiratory status after procedures such as thoracentesis. Skin testing is performed in the outpatient setting. Pulmonary function testing is not a procedure that requires PACU care. 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.

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral diazepam (Valium) 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress? A. The client is not being treated for asthma. B. The client has a mental disorder. C. The client received a dose of Valium. D. The client is receiving oxygen at 4 L/min.

D A simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath, which has low levels of oxygen and can eventually suffocate the client. The client had a panic attack, not an asthma attack. A panic attack is not a definitive diagnostic indicator of a mental disorder. A small dose of Valium does not place a client at increased risk for respiratory distress; a large dose is required to place a client at high risk.

The RN and the LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which action is best accomplished by the RN? A. Administer the purified protein derivative for tuberculosis testing. B. Assess vital signs and the puncture site after thoracentesis. C. Monitor oxygen saturation using pulse oximetry every 4 hours. D. Plan client and family teaching regarding upcoming pulmonary function testing.

D Developing the teaching plan is the most complex of the skills listed and requires RN education and licensure. 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 be included in the vital signs assessment.

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who is hypoxemic and hypercarbic. How will the nurse administer the oxygen for this client? A. By nasal cannula at a rate of no more than 1 to 3 L/min B. By nasal cannula at a rate of no more than 2 to 4 L/min C. By Venturi mask at a rate of at least 60% D. By maintaining oxygen saturations greater than 88%

D In the past, a client with COPD was thought to be at risk for extreme hypoventilation with oxygen therapy because of a decreased drive to breathe as blood oxygen levels increased. However, recent evidence does not support this; this idea has been responsible for ineffective management of hypoxia in clients with COPD. All hypoxic clients, even those with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and bring SpO2 levels up between 88% and 92%

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 completed as an outpatient. What does the nurse tell her? A. "Give him Phenergan (promethazine) by rectum around the clock so he does not vomit." B. "He can only drink milk and eat ice cream until the wires come off." C. "He must brush his teeth every 2 hours." D. "Make sure he always has wire cutters with him."

D It is extremely important 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. Antiemetics such as promethazine, ondansetron (Zofran), and prochlorperazine (Compazine) are prescribed by a health care provider on an as-needed basis only for nausea. 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.

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

D 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 is 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 it. 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 has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client had been very anxious about his surgery. Which medications does the nurse expect to find on his home medication list? A. Amitriptyline (Elavil) B. Diazepam (Valium) C. Ketorolac (Toradol) D. Lorazepam (Ativan)

D Lorazepam is a short-acting antianxiety medication that would be the most appropriate choice for this client. Amitriptyline is a tricyclic antidepressant that would not be used specifically for this client's anxiety. Although diazepam is an effective medication for anxiety, it is more likely to cause respiratory depression; the location of this tumor makes diazepam not the best choice for anxiety. Ketorolac is a nonsteroidal anti-inflammatory drug and should not be used before surgery. Ketorolac should be used with caution, or not at all, if the client is taking medication for anxiety.

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 will be best to delegate to a nursing assistant? A. Administering throat-numbing lozenges B. Assessing the mouth for inflammation and infection C. Teaching about skin care while receiving radiation D. Washing the skin with soap and water

D Personal hygiene is within the scope of practice of the nursing assistant. Throat-numbing lozenges should not be administered by nursing assistants because they are medication, and administering medication is out of 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.

he client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler? A. Corticosteroids B. Long-acting beta agonists C. Nonsteroidal anti-inflammatory drugs (NSAIDs) D. Short-acting beta agonists

D Short-acting beta agonist medications have a rapid onset and cause bronchodilation; they would be excellent for marathon running because some types of asthma may be exercise-induced. Corticosteroids disrupt production pathways of inflammatory mediators. Maximum effectiveness requires 48 to 72 hours of continued use; therefore, they are not appropriate as a rescue medication. Long-acting beta agonists do cause bronchodilation, but have a slow onset; they are not used as rescue inhalers. NSAIDs stabilize the membranes of mast cells and prevent release of inflammatory mediators. They have a slow onset of action and are used for prevention of symptoms, not as rescue medication.

A newly diagnosed client with asthma says that his peak flowmeter is reading 82% of his personal best. What does the nurse do? A. Nothing. This is in the green zone. B. Provide the rescue drug and reassess. C. Provide the rescue drug and seek emergency help. D. Repeat the peak flow test

D Since the client is newly diagnosed with asthma, this would be an excellent opportunity for the nurse to observe the client using the peak flowmeter to ensure that the client is using it properly, so readings are accurate and in the green zone, at least 80% of the client's personal best. The result of 82% is in the green zone, but this is not the best answer for a newly diagnosed client. Rescue drugs should be used only in the yellow zone, between 50% and 80% of the client's personal best. They should not be used in this situation, and the nurse does not need to seek emergency help until readings are in the red zone, or below 50% of the client's personal best.

Which clinical manifestation in the client with facial trauma is the nurse's first priority? A. Bleeding B. Decreased visual acuity C. Pain D. Stridor

D Stridor is an indication of a 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 question does not specify where the bleeding is occurring. The type (venous or arterial) and quantity of the bleeding need to be noted. Visual acuity will be assessed in the secondary survey because it is not considered life-threatening. Pain must be addressed to fully evaluate a client and complete a reliable examination; however, it is not the nurse's first priority.

Respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? A. Humidifying the oxygen source B. Increasing oxygenation C. Removing the inner cannula of the tracheostomy D. Suctioning the client

D Suctioning the client 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 will 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.

Which clinical manifestation requires immediate action by the nurse for a client with laryngeal trauma? A. Aphonia B. Hemoptysis C. Hoarseness D. Tachypnea

D Tachypnea is a sign of respiratory distress that may accompany laryngeal trauma; this requires immediate action on the part of the nurse. 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. Hemoptysis (bleeding from the airway) may occur as the result of laryngeal trauma. The quantity needs to be observed; an increase in the amount of bleeding can become an emergency because it affects airway patency. Hoarseness is commonly associated with laryngeal trauma, but does not require immediate attention.

An environmental assessment of a factory finds inhalation exposure with a high level of particulate matter. What does the factory nurse do to generate the quickest compliance? A. Encourages proper building ventilation B. Refers workers to a tobacco cessation program C. Suggests that workers find another job D. Teaches workers how to use a mask

D Teaching everyone to use a mask when working in areas with high levels of particulate matter can reduce individual exposure. Proper building ventilation often requires work orders, reconstruction, time, and money; this will need to be implemented, but it will not occur quickly. Particulate matter can be emitted from a variety of sources; smoking may be unrelated to the question. Suggesting that workers find another job does not solve the problem of particulate matter in a rapid or safe manner.

A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders? A. It affects only young people. B. The client has dyspnea. C. The client is coughing. D. The client is symptom-free between exacerbations

D The client may be completely symptom-free between exacerbations. Asthma affects people of all ages. Dyspnea is a common symptom of many chronic lung diseases. Coughing occurs in many acute and chronic lung diseases.

The nurse answers a client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action? A. Attempt to remove the obstruction. B. Call the Rapid Response Team to intubate immediately. C. Call the Rapid Response Team to perform an emergency cricothyroidotomy. D. Determine the cause of the obstruction.

D The first step the nurse should take is to determine the cause of the obstruction. After the cause has been determined (e.g., tongue, food, inflammation), the nurse can decide the next course of action. The obstruction cannot be removed until its origin has been determined. Although notifying the Rapid Response Team is important and the client may require intubation, this is not the first action. An emergency cricothyroidotomy is not the first step to take in relieving an upper airway obstruction. This is an invasive procedure that requires specialized training and equipment that is not readily available at the bedside.

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? A. "You can quit when you are ready." B. "It's never too late to quit." C. "Just turn off your oxygen when you smoke." D. "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."

D The nurse should 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 OK 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 encourages the client to remove his or her oxygen source, which could harm the client.

A client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client? A. Mucolytics decrease secretion production. B. Mucolytics increase gas exchange in the lower airways. C. Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease. D. Mucolytics thin secretions, making them easier to expectorate.

D The term mucolytic means "breaking down mucus." Mucolytics cause secretions to thin, making them easier to expectorate; this is important for a client with chronic bronchitis. Mucolytics do not decrease secretion production. Mucolytics may increase gas exchange, but this is an indirect property and is not the main function. Mucolytics do not have any bronchodilation properties.

The nurse is caring for a client with severe acute respiratory syndrome. What is the most important precaution the nurse should take when preparing to suction this client? A. Keeping the head of the bed elevated 30 to 45 degrees B. Performing oral care after suctioning the oropharynx C. Washing hands and donning gloves prior to the procedure D. Wearing a disposable particulate mask respirator and protective eyewear

D To protect health care workers during procedures that induce coughing or promote aerosolization of particles, nurses should wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. Keeping the head of the bed elevated 30 to 45 degrees is not the most important precaution. Performing oral care is a comfort measure. Washing hands and donning gloves is necessary, but not the most important measure.

A client with a new tracheostomy has a soiled dressing. What is the best nursing intervention? A. Cut a sterile 4 × 4 gauze to fit around the tracheostomy tube. B. Reinforce the dressing with a sterile 4 × 4 gauze. C. Replace the dressing with a clean, folded 4 × 4 gauze. D. Replace the dressing with a sterile, folded 4 × 4 gauze.

D Tracheostomy dressings may be used to keep the tracheostomy clean and dry. These dressings resemble a 4 × 4 gauze pad with an area removed to fit around the tube. If tracheostomy dressings are not available, fold standard sterile 4 × 4s to fit around the tube. The dressing should never be cut because small bits of gauze could then be aspirated through the tube. Dressings should be changed often, not reinforced, because moist dressings provide a medium for bacterial growth, leading to infection.

A client with a tracheostomy is at increased risk for aspiration. Which nursing interventions will reduce this risk? (Select all that apply.) A. Encourage frequent sipping from a cup. B. Encourage water with meals. C. Inflate the tracheostomy cuff during meals. D. Maintain the client upright for 30 minutes after eating. E. Provide small, frequent meals. F. Teach the client to "tuck" the chin down in the forward position to swallow.

D,E,F At least 30 minutes is required for thinner liquids in the stomach to be thickened in combination with stomach contents and/or removed from the stomach; this reduces the chance of aspiration. Eating requires significant time and energy; when the client becomes tired, he is more likely to aspirate. Shorter and more frequent intervals of eating tire the client less and reduce the chance of aspiration. Tucking the chin downward helps to open the upper esophageal sphincter. Liquids should not be given frequently and should be taken using a spoon to ensure that the client is attempting to swallow only small volumes of liquid; thin liquids such as water are easily aspirated. The tracheostomy cuff should be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.

What is the follow up care for a patient who just had a lung biopsy preformed?

-Assess vital signs, breath sounds at least every 4 hours for 24 hours -Asses for respiratory distress -Report reduced/absent breath sounds immediately -Monitor for hemoptysis

A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer? A. The client will be treated for 5 to 7 days. B. The client will require IV antibiotics for 7 to 10 days. C. The client will complete 6 days of therapy. D. The client must be afebrile for 24 hours.

A Anti-infectives usually are used for 5 to 7 days in uncomplicated community-acquired pneumonia, and for up to 21 days in an immunocompromised client or one with hospital-acquired pneumonia. A client may become afebrile early in the course of treatment with anti-infective medications; this may cause many clients to fail to complete their course of treatment.

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? A. Urine output of 20 mL over 2 hours B. Blood pressure of 106/58 mm Hg C. Absent bowel sounds D. +3 pedal pulses

A Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria. Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output (think ABCs). +3 pedal pulses is a normal physical assessment finding.

The peak pressure alarm is sounding on the ventilator of a client with a recent tracheostomy. What intervention should be done first? A. Assess the client's respiratory status. B. Decrease the sensitivity of the alarm. C. Ensure that the connecting tubing is not kinked. D. Suction the client.

A The client must always be assessed before attention is turned to equipment. If the alarm is sounding as an indicator of worsening client condition, reducing the sensitivity is harmful. Suctioning the client may not even be needed; the client's respiratory status must be assessed before such a determination can be reached.

The nurse is caring for a frail, older patient in the hospital after surgery to repair a bowel obstruction. The patient has a nasogastric (NG) tube to suction, through which all her scheduled drugs are given, oxygen at 1 liter/nasal cannula at night (home order), an indwelling urinary catheter, and a saline lock. The patient is weak, fatigued, has pain not relieved by IV opioids, and is reluctant to participate in any activities. 1. The physician orders a chest x-ray, and the results show pneumonia. What actions by the nurse are most important?

Administer the prescribed antibiotics as soon as they are available, maintain oxygen saturation above 96%, monitor work of breathing, assist with effective coughing, provide fluids, and treat pain while being cautious to avoid respiratory depression and sedation.

Your patient is the 68-year-old man from the previous Clinical Judgment Challenge who had shortness of breath (SOB) for the past 2 to 3 days. His clinical condition deteriorated further, requiring intubation. The health care provider orders a CT scan of the chest. 3. A large fluid collection on the left side is found during the CT scan, and a thoracentesis is planned. What are your responsibilities in preparing for and assisting with this procedure?

An explanation of the procedure to the patient, verify that a consent has been obtained, determine allergies if a local anesthetic is to be used, and properly position the patient (although this may be modified from a nonintubated patient's position).

What is Thoracentesis?

An invasive procedure that aspirates the pleural fluid or air from the pleural space.

During nasotracheal suctioning, the client's heart rate changes from 78 beats/min to 48 beats/min. What is the nurse's best first action? A. Immediately stop suctioning. B. Gently pinch the client's cheek. C. Administer oxygen by mask at 2 L/min. D. Document the change as the only action.

Answer: A Rationale: The change in heart rate is a serious response to suctioning. The client is experiencing vagal stimulation and bradycardia from the presence of the suction catheter in the tracheopharyngeal area. Such stimulation can lead to severe hypotension, heart block, and asystole. Administering oxygen would be a good second action but the first action is to stop the activity causing the problem. The client's response is not related to a lack of being alert.

Which parameter indicates to the nurse that the short-acting beta-adrenergic agonist the client used 5 minutes ago for an acute asthma attack is effective? A. SpO2 decreased from 85% to 78% B. Peak expiratory flow increase from 50% to 70% C. The obvious use of accessory muscles during inhalation D. Active bubbling in the humidifier chamber of the oxygen delivery system

Answer: B Rationale: Peak flow measures the effectiveness of expiratory efforts. An increased peak flow rate indicates less obstruction and greater movement of air with expiratory effort. Decreased SpO2 would indicate a worsening of the condition, not effectiveness of the therapy. The use of accessory muscles indicates that the work of breathing has increased. The active bubbling in the humidification chamber is not related to the client's respiratory effort or the drug therapy's effectiveness.

Which precaution is most important for the nurse to teach a client who has cystic fibrosis? A. Report a weight change of 2 pounds to your health care provider immediately. B. Use supplemental oxygen whenever your oxygen saturation is less than 95%. C. Eat six small meals each day instead of only three larger ones. D. Avoid crowds and people who are ill.

Answer: D Rationale: The most common cause of death for a client with CF is respiratory failure from a respiratory infection. Avoiding infection in this population is critical for survival. Although many clients who have CF are underweight and need to maintain good nutrition, changes in weight and food intake patterns are not as critical as avoiding infection. Supplemental oxygen use is based on client manifestations. Its use is not as critical as avoiding infection.

A 71-year-old man is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. He is married but has no children. During your assessment, you observe that his color is pale, he is dyspneic, and he reports new onset of chest discomfort. Even though he has oxygen via nasal cannula at 2 L/min., you note that he seems a little confused and is oriented only to person. His oxygen saturation has decreased from 95% to 88%. 1. The patient's physician prescribes an initial dose of furosemide (Lasix) 40 mg IVP. What assessments will you perform to determine if the drug was effective?

Assess for dependent edema by measuring circumferences of the abdomen, ankles, and legs. This provides a baseline assessment against which further measurements can be compared to determine if the drug was effective.

The nurse is caring for a frail, older patient in the hospital after surgery to repair a bowel obstruction. The patient has a nasogastric (NG) tube to suction, through which all her scheduled drugs are given, oxygen at 1 liter/nasal cannula at night (home order), an indwelling urinary catheter, and a saline lock. The patient is weak, fatigued, has pain not relieved by IV opioids, and is reluctant to participate in any activities. 1. Two days later, the NG tube is removed and the patient is started on ice chips and other clear liquids. The patient swallows repeatedly when given sips of water. What action does the nurse perform?

Assess the patient for aspiration using an evidence-based aspiration screening tool and consult with the physician about formal speech therapy swallowing evaluation.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? A. Ejection fraction is 25%. B. Client states that she is able to sleep on one pillow. C. Client was hospitalized five times last year with pulmonary edema. D. Client reports that she experiences palpitations.

B mprovement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.

Your patient is the 68-year-old man from the previous Clinical Judgment Challenge who had shortness of breath (SOB) for the past 2 to 3 days. His clinical condition deteriorated further, requiring intubation. The health care provider orders a CT scan of the chest. 2. Why is it important to monitor your patient using capnography?

Capnography is a noninvasive measurement of carbon dioxide levels. This information provides information about CO2 production, alveolar function, and respiratory patterns. It reflects changes in breathing effectiveness before hypoxia occurs.

A nursing home administrator reports having severe headache and facial flushing for the past 3 weeks. He does not smoke but is overweight. Both of his parents have hypertension and cardiac disease. One of his nurses takes his blood pressure, which is 210/116. He states that he will see his primary care provider as soon as possible. At the physician's office, his heart rate is 88 beats/min, blood pressure is 190/110, and respiratory rate is 24 breaths/min. 1. What additional information will you need from his past and current family and personal history?

Collect data on patient's age and ethnic origin or race. Ask whether the patient has a history of kidney disease. Collect a full medication history because drugs can cause secondary hypertension. Ask about dietary habits, particularly regarding fat and sodium intake, and number of calories consumed daily. Determine whether the patient engages in exercise, and if so, what kind and how often. Ask when his parents developed hypertension, how they were managed, and if they are still living. If either or both parents have died, ask at what age they passed.

A nursing home administrator reports having severe headache and facial flushing for the past 3 weeks. He does not smoke but is overweight. Both of his parents have hypertension and cardiac disease. One of his nurses takes his blood pressure, which is 210/116. He states that he will see his primary care provider as soon as possible. At the physician's office, his heart rate is 88 beats/min, blood pressure is 190/110, and respiratory rate is 24 breaths/min. 1. What community resources are available to assist this patient to self-manage his hypertension?

Community resources that encourage healthy activities can assist this patient to self-manage his hypertension. Encourage the patient to seek out resources that encourage exercise and healthy cooking techniques.

The patient is a 68-year-old man who has had shortness of breath (SOB) for the past 2 to 3 days. His past medical history includes a 40-packyear smoking history, COPD, and heart failure. He reports that he became concerned when he woke from sleep because he could not breathe. Your physical assessment reveals crackles in the lower lobes bilaterally. His oxygen saturation (SpO2) is 84% without supplemental oxygen. 2. Who should you contact and why?

Contact this patient's primary health care provider and inform him or her of the patient's oxygen saturation. Contact respiratory therapy for additional support with an appropriate oxygen delivery method and to provide additional treatments as needed.

A client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? A. Chest x-ray B. Complete blood count (CBC) C. Tuberculosis (TB) skin test D. Throat culture

D A throat culture is important for distinguishing a viral infection from a group A beta-hemolytic streptococcal infection. A chest x-ray or TB skin test is not indicated by the symptoms given. A CBC might be indicated to evaluate infection and dehydration, but would not be the first action.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? A. Ensures that the client is wearing a mask B. Tells the visitor that the client cannot receive visitors at this time C. Provides a particulate air respirator to the visitor D. Provides a mask to the visitor

D 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 finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? A. Peptic ulcer disease B. Deep vein thrombosis (DVT) C. Osteoarthritis D. Marfan syndrome

D Marfan syndrome is a risk factor for cardiovascular disorders. Peptic ulcer disease is not a risk factor for AAA formation. AAA is an arterial problem; thus, DVT is not a related risk. Osteoarthritis is related to overuse of joints; it does not present a risk for AAA.

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? A. Assess preprocedure medications the client took that day. B. Have the client sign the consent form before the procedure is performed. C. Educate the client about the need to remain on bedrest after the procedure. D. Obtain client vital signs and a resting electrocardiogram (ECG).

D Vital signs and 12-lead ECGs can be obtained by UAP. The health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching should be done by the RN.

A patient who had a supraglottic partial laryngectomy with a right-sided radical neck dissection 4 weeks ago is now receiving radiation therapy. He has lost 24 pounds since his surgery, which makes him 15 pounds less than his ideal weight. He tells you that he has no appetite and that what food he does eat "has no taste." In addition, although he expresses that he is glad to be alive, he does not want friends to visit because it takes so much energy to interact with them. He also says that he can no longer play the piano because of difficulty moving his right arm and shoulder. 1. Should you press the issue of not wanting to visit with friends further? Why or why not?

Do not press him to visit with friends at this time. Remind him that as he heals, more of his energy will return.

A 71-year-old man is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. He is married but has no children. During your assessment, you observe that his color is pale, he is dyspneic, and he reports new onset of chest discomfort. Even though he has oxygen via nasal cannula at 2 L/min., you note that he seems a little confused and is oriented only to person. His oxygen saturation has decreased from 95% to 88%. 1. After two doses of Lasix, the patient's condition improves. What data will you document in the electronic medical record (EMR)?

Document findings from a complete head-to-toe assessment, including neurologic status; breath sounds; skin color; report of severity of chest pain (on a 0-10 scale); and circumferences of the abdomen, ankles, and legs.

The patient is a 60-year-old man who has just been diagnosed with non-small cell lung cancer. He smoked cigarettes for about 25 years starting when he was 16 years old and quit when he was 41 years old. His lung cancer is at stage I in the left lower lobe. He is distraught, saying that he can't die now because he has one child in college and two in high school. He also fears chemotherapy and seems bitter that he quit smoking and got lung cancer anyway. His next statement is: "Why couldn't I get prostate cancer like most men? At least they survive. No one beats lung cancer." 1. What can you tell him about the benefits of having quit smoking?

If he had continued to smoke, he may have had more advanced lung cancer at this time. In addition, his stamina and gas exchange are considerably better than they would be had he continued to smoke. He will better tolerate his cancer therapy with fewer complications because he does not now smoke. If he has surgery, he will have less problems with recovery from the surgery itself and the anesthesia.

Your patient is a 41-year-old woman with a significant closed head injury (CHI) from a motor vehicle crash (MVC). She is not anticipated to be able to be weaned from the ventilator, and the physicians have asked the patient's family for permission to perform a tracheostomy. The family is concerned that the patient will not be able to speak again. 1. What is your response?

Initially, the patient will not be able to speak. As she is weaned from the ventilator to supplemental oxygen, plans can be made to switch the tracheostomy to a fenestrated trachesotomy, which will allow her to talk.

What is Hypoxemia?

Low levels of oxygen in the blood

Your patient is an 81-year-old male with end-stage COPD who is admitted with pneumonia and COPD exacerbation. He has a 60-pack-year smoking history and has been hospitalized many times over the past year for respiratory distress. The admitting provider orders an arterial blood gas (ABG). The patient is not wearing oxygen. 1. What areas will be the focus of your assessment and documentation? Provide a rationale for your choice(s).

Mental status assessment is important. Declining level of consciousness can be indicative of worsening hypercarbia. The patient's skin color should gradually become pinker. Oxygen saturation should be assessed with the expectation of improvement. Assess the patient's respiratory distress, which should improve if therapy is effective. The fraction of inspired oxygen (FiO2) should be at the lowest amount needed to achieve an oxygen saturation of about 92%. It is not necessary to achieve higher saturations, and in fact, saturations as low as about 88% are often acceptable. Also assess respiratory rate and breath sounds. All of your assessment must be documented.

Your patient is a 41-year-old woman with a significant closed head injury (CHI) from a motor vehicle crash (MVC). She is not anticipated to be able to be weaned from the ventilator, and the physicians have asked the patient's family for permission to perform a tracheostomy. The family is concerned that the patient will not be able to speak again. 1. What can you do to minimize tracheal damage?

Monitor cuff pressure. Ideally, it should be less than 25 cm H2O. Check cuff pressures each shift. Minimize tube friction and movement by stabilizing the tube. Assess for adequate nutrition and hydration. Be aware if the patient is receiving medications (i.e., corticosteroids) that may be damaging to tissues.

The nurse is caring for a frail, older patient in the hospital after surgery to repair a bowel obstruction. The patient has a nasogastric (NG) tube to suction, through which all her scheduled drugs are given, oxygen at 1 liter/nasal cannula at night (home order), an indwelling urinary catheter, and a saline lock. The patient is weak, fatigued, has pain not relieved by IV opioids, and is reluctant to participate in any activities. 1. The nurse does hourly rounds on the patient, and the patient's daughter states, "Something is just not right with mom." What action should the nurse take first? What other actions should the nurse perform?

Obtain an oxygen saturation; assess other vital signs, including temperature; assess cognitive function; assess for pain; auscultate lung sounds; assess the quality and characteristics of urine; palpate the abdomen; assess the IV site; review the most recent laboratory values; document findings; and notify the physician.

A nursing home administrator reports having severe headache and facial flushing for the past 3 weeks. He does not smoke but is overweight. Both of his parents have hypertension and cardiac disease. One of his nurses takes his blood pressure, which is 210/116. He states that he will see his primary care provider as soon as possible. At the physician's office, his heart rate is 88 beats/min, blood pressure is 190/110, and respiratory rate is 24 breaths/min. 1. What physical assessment data will you collect as the office nurse?

Perform focused cardiovascular and neurological assessments. Collect blood pressure readings in both arms using an appropriate-sized cuff. To detect postural (orthostatic) changes, take readings with the patient in the supine (lying) or sitting position and at least 2 minutes later when standing.

Your patient is the 68-year-old man from the previous Clinical Judgment Challenge who had shortness of breath (SOB) for the past 2 to 3 days. His clinical condition deteriorated further, requiring intubation. The health care provider orders a CT scan of the chest. 4. Your patient was extubated after the left thoracentesis. Within 12 hours he again develops respiratory distress, decreased breath sounds, and a trachea that appears deviated to the right. What is your assessment?

Pneumothorax, partial or complete, is a complication that can occur within 24 hours of a thoracentesis. Tracheal deviation results as the thoracic structures are shifted away from the collapsed lung.

A patient who had a supraglottic partial laryngectomy with a right-sided radical neck dissection 4 weeks ago is now receiving radiation therapy. He has lost 24 pounds since his surgery, which makes him 15 pounds less than his ideal weight. He tells you that he has no appetite and that what food he does eat "has no taste." In addition, although he expresses that he is glad to be alive, he does not want friends to visit because it takes so much energy to interact with them. He also says that he can no longer play the piano because of difficulty moving his right arm and shoulder. 1. What factors are contributing to his fatigue?

Radiation therapy for cancer treatment causes some degree of fatigue in everyone who receives it (see Chapter 22). Not eating also contributes to fatigue because food is necessary to provide the nutrients needed for adequate cellular energy production and metabolism.

A middle-aged man is admitted to the cardiac unit after reports of a severe headache and flushing of the face. He is diagnosed with severe hypertension. The patient is alert and oriented; BP = 192/104 and HR = 88. You are the RN assigned to his care. There is an unlicensed nursing technician working with you. 1. What interventions will you implement to ensure this patient's safety?

Standard safety precautions should be put in place to ensure environmental safety. If the patient is to have invasive diagnostic testing, assess the patient for iodine-based contrast media allergies. Report any dysrhythmias immediately. Continually assess (and report) the patient's reports of pain, particularly when the patient's description of pain is descriptive of angina or myocardial infarction. Teach the patient about safety precautions regarding calling for assistance if the patient needs to ambulate to the bathroom because syncope can be associated with severe hypertension.

A nursing home administrator reports having severe headache and facial flushing for the past 3 weeks. He does not smoke but is overweight. Both of his parents have hypertension and cardiac disease. One of his nurses takes his blood pressure, which is 210/116. He states that he will see his primary care provider as soon as possible. At the physician's office, his heart rate is 88 beats/min, blood pressure is 190/110, and respiratory rate is 24 breaths/min. 1. What health teaching will you provide for the patient? What evidence do you have to support your answer?

Teach healthy dietary habits and appropriate forms of exercise that will address the patient's status of being overweight. Educate patient that hypertension can have genetic links, so it is important to engage in as many modifiable behaviors as possible.

A middle-aged man is admitted to the cardiac unit after reports of a severe headache and flushing of the face. He is diagnosed with severe hypertension. The patient is alert and oriented; BP = 192/104 and HR = 88. You are the RN assigned to his care. There is an unlicensed nursing technician working with you. 1. The patient's wife is very concerned about her husband returning to work as owner of a roofing company. What education will you provide the patient and his wife at this time? With what health care team members will you collaborate to ensure positive patient outcomes?

Teach the patient and wife methods for decreasing cardiovascular disease risk such as control of hypertension with medication, moderate physical activity, smoking cessation, decrease of psychological stressors, and diet modification. Collaborate with a dietician for nutrition planning, the primary care provider for medications that may assist with smoking cessation and community support systems that may assist with specific types of psychological stressors.

Your patient is an 81-year-old male with end-stage COPD who is admitted with pneumonia and COPD exacerbation. He has a 60-pack-year smoking history and has been hospitalized many times over the past year for respiratory distress. The admitting provider orders an arterial blood gas (ABG). The patient is not wearing oxygen. 1. Based on your understanding of his disease process (see Chapter 30), would you expect this patient to have a normal or altered arterial blood gases values, especially carbon dioxide (PaCO2) level?

The ABB analysis results would most likely be abnormal. Patients with a long history of chronic lung disease are likely to have an elevated PaCO2 level (hypercarbia).

Your patient is an 81-year-old male with end-stage COPD who is admitted with pneumonia and COPD exacerbation. He has a 60-pack-year smoking history and has been hospitalized many times over the past year for respiratory distress. The admitting provider orders an arterial blood gas (ABG). The patient is not wearing oxygen. 1. Your patient has continually increasing oxygen requirements. He is now wearing a simple mask, and one of your colleagues would like to switch to a non-rebreather mask to deliver 100% oxygen. What are other good options for this patient?

The best approach is to administer the lowest concentration of oxygen possible to prevent oxygen-induced hypercapnia. You should contact both the respiratory therapist and the provider and ask them to consider noninvasive positive-pressure ventilation. This may allow you to improve gas exchange at a lower FiO2. You should also be prepared to call the rapid response team for additional support.

At a recent staff meeting, the medical-surgical nurse manager reports that the rate of repeated hospitalizations for patients with chronic heart failure has increased 50% in the past 3 months. As a staff nurse, you agree to be part of the unit quality improvement (QI) team to examine the cause(s) of the increase and make evidence-based recommendations for improving the outcomes for this patient population. Specific patient data and summaries are available for the team to review as needed. 1. After your team assembles and analyzes the evidence to determine best practices, what will be done with the information?

The team must discern the evidence and determine how to best put this information into practice with the specific patient population. After an approach has been determined, the information must be disseminated to members of the collaborative health care team that cares for patients with chronic heart failure. Remember that the process of implementation needs to be systematic, shared, and consistent, which means that it must be followed strictly so that any outcomes that are achieved are actually based on the new EBP that is being implemented. Therefore, complete buy-in from the people who will be involved in implementing the new practice is essential.

Your patient is a 41-year-old woman with a significant closed head injury (CHI) from a motor vehicle crash (MVC). She is not anticipated to be able to be weaned from the ventilator, and the physicians have asked the patient's family for permission to perform a tracheostomy. The family is concerned that the patient will not be able to speak again. 2. What are some possible concerns for patient care in the immediate postoperative period?

The tracheostomy is not matured until at least 72 hours. During this period, decannulation is a possible surgical emergency. Meticulous care must be taken while turning or suctioning the patient. Many institutions have policies regarding the number of clinicians present to assist with turning and usually including a respiratory therapist. Other concerns include tube obstruction, pneumothorax, bleeding, and infection.

The nurse is caring for a frail, older patient in the hospital after surgery to repair a bowel obstruction. The patient has a nasogastric (NG) tube to suction, through which all her scheduled drugs are given, oxygen at 1 liter/nasal cannula at night (home order), an indwelling urinary catheter, and a saline lock. The patient is weak, fatigued, has pain not relieved by IV opioids, and is reluctant to participate in any activities. 1. What risk factors does this patient have for developing pneumonia?

These risk factors include advanced age; NG tube; presence of respiratory equipment; weakness, fatigue, and pain limiting activity; being in the hospital; and decreased physical status.

The patient is a 68-year-old man who has had shortness of breath (SOB) for the past 2 to 3 days. His past medical history includes a 40-packyear smoking history, COPD, and heart failure. He reports that he became concerned when he woke from sleep because he could not breathe. Your physical assessment reveals crackles in the lower lobes bilaterally. His oxygen saturation (SpO2) is 84% without supplemental oxygen. 4. What additional referrals might be appropriate for this patient?

This patient would benefit from a respiratory therapy consult for additional instruction with breathing exercises, evaluation for home oxygen therapy, and evaluation for possible pulmonary rehabilitation.

Your patient is an 81-year-old male with end-stage COPD who is admitted with pneumonia and COPD exacerbation. He has a 60-pack-year smoking history and has been hospitalized many times over the past year for respiratory distress. The admitting provider orders an arterial blood gas (ABG). The patient is not wearing oxygen. 1. The results of the ABG indicate hypoxemia (PaO2 of 40 mm Hg). Should you provide your patient with supplemental oxygen? Why or why not? If so, how much and which deliver method would be best?

Your patient is hypoxic and does need oxygen. You would start your patient on nasal oxygen and titrate to a saturation level of about 88% to 92% (assessing by either portable pulse oximetry or ABG results). A Venturi mask will deliver more precise concentrations of oxygen and may be preferable if your patient will tolerate a mask.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? A. Give the digoxin; reassess the heart rate in 30 minutes. B. Give the digoxin; document assessment findings in the medical record. C. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. D. Hold the digoxin, and obtain a prescription for a potassium supplement

d Digoxin causes bradycardia; hypokalemia potentiates digoxin. Because digoxin causes bradycardia, the medication should be held. Furosemide decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid volume excess at this time.

Because clients with cystic fibrosis (CF) are at increased risk for infection, what will the nurse advise the client with CF who is infected with Burkholderia cepacia to do? A. Avoid Cystic Fibrosis Foundation-sponsored events. B. Avoid the hospital. C. Stay at home most of the time. D. Use an antiseptic hand gel.

A A serious bacterial infection for clients with CF is Burkholderia cepacia, which is spread by casual contact from one CF client to another. For this reason, the Cystic Fibrosis Foundation bans infected clients (those who have had a positive sputum culture) from participating in any foundation-sponsored events. Avoiding the hospital completely is unrealistic, although special infection control procedures may be implemented, such as scheduling the client's office visits on different days or in different areas of the hospital. Social isolation is not needed for clients with CF and may be detrimental to the psychosocial well-being of the client. Hand hygiene is important, although this is not the best response.

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? A. Fatigue B. Swelling of one leg C. Slow heart rate D. Brown discoloration of lower extremities

A Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle. Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of long-standing venous stasis, such as occurs with varicose veins.

Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? A. Client with acute allergic reaction B. Client with dyspnea on exertion C. Client with lung cancer with cough D. Client with sinus infection and fever

A An acute allergic reaction can lead to immediate respiratory distress; this is an emergent situation that requires the immediate attention of the nurse. Dyspnea on exertion is a condition that will need further evaluation by the nurse, but is not usually an emergency. Coughing is a frequent symptom of lung cancer; although coughing may be related to something not associated with the client's cancer, this situation is not an emergency. Sinus infections are not considered emergencies.

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

A An oxygen saturation level less than 91% indicates hypoxemia and requires 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, if this was not already completed. The client who had a bronchoscopy 3 hours ago and has returned to the floor does not require the most immediate 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.

After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first? A. Assess the airway, breathing, and circulation. B. Call for the Rapid Response Team. C. Check the patency of the chest tubes. D. Listen for breath sounds.

A Assessing the "ABCs" is the priority to determine possible causes of burning in the client's chest. The client's situation does not require the Rapid Response Team to be called. The client's symptoms are not caused by a blockage of chest tubes. Listening for breath sounds would be an appropriate action for the nurse to take to evaluate the client's reported symptoms; however, this would not be the nurse's first action.

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment? A. Arrange for a health care worker to watch the client take the medication. B. Give the client written instructions about how to take prescribed medications. C. Have the client repeat medication names and side effects. D. Instruct the client about the possible consequences of nonadherence.

A Because this client is unlikely to adhere to long-term treatment unless directly supervised while taking medications, the best option is to arrange for directly observed therapy. 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. Also, the question does not indicate whether the client can read. 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 may be more concerned with obtaining shelter and food than with properly taking his or her medication.

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? A. Reproducible leg pain with exercise B. Unilateral swelling of affected leg C. Decreased pain when legs are elevated D. Pulse oximetry reading of 90%

A Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.

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 the disease? A. "I am here to receive the yearly pneumonia shot again." B. "I am here to get my yearly flu shot again." C. "I should avoid large gatherings during cold and flu season." D. "I should cough into my upper sleeve instead of my hand."

A Clients 65 years and older, as well as those who have chronic health problems, should be encouraged to receive the pneumonia vaccine, which is not given annually but only once. Older clients are encouraged to receive a flu shot annually because the vaccine changes, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. New 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.

Which component of a client's family history is of particular importance to the home health nurse who is assessing a new client with asthma? A. Brother is allergic to peanuts. B. Father is obese. C. Mother is diabetic. D. Sister is pregnant.

A Clients with asthma often have a family history of allergies; it will be important to assess whether this client has any allergies that may serve as triggers for an asthma attack. Obesity, diabetes, and pregnancy are not correlated with asthma.

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the provider immediately? A. Swelling and tenseness in the affected area B. Incisional pain and tenderness at the surgical site C. Pink, mobile fingers D. An order for heparin infusion

A Compartment syndrome may develop after an embolectomy; swelling of skeletal muscle fibers causes increasing pain, swelling, and tenseness. A fasciotomy may be needed to preserve the limb. Incisional pain is expected. Pink fingers and mobility are normal physical assessment findings. Heparin may be prescribed to maintain patency of the vessel after clot removal.

The nurse understands which symptom to be a hallmark subjective sign of lung disease? A. Cough B. Dyspnea C. Chest pain D. Sputum production

A Cough is a main sign of lung disease. Dyspnea (difficulty in breathing or breathlessness) is a subjective perception and varies among patients. A patient's feeling of dyspnea may not be consistent with the severity of the presenting problem. Sputum production may be associated with coughing and indicate an acute or chronic lung condition. Chest pain can occur with other health problems, as well as with lung problems.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? A. "I will call the provider if I have a cough lasting 3 or more days." B. "I will report to the provider weight loss of 2 to 3 pounds in a day." C. "I will try walking for 1 hour each day." D. "I should expect occasional chest pain."

A Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified. The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? A. "I should avoid eating hamburgers." B. "I must cut out bacon and canned foods." C. "I shouldn't put the salt shaker on the table anymore." D. "I should avoid lunchmeats but may cook my own turkey"

A Cutting out beef or hamburgers made at home is not necessary; however, fast-food hamburgers are to be avoided owing to higher sodium content. Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention; these are to be avoided. The client correctly understands that adding salt to food should be avoided.

A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? A. Ethambutol B. Isoniazid C. Pyrazinamide D. Rifampin

A Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Both isoniazid and pyrazinamide may cause liver failure; side effects of major concern include jaundice, bleeding, and abdominal pain. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless. Contact lenses will also be stained and oral contraceptives will be less effective.

Which client has the highest risk for cardiovascular disease? A. Man who smokes and whose father died at 49 of myocardial infarction (MI) B. Woman with abdominal obesity who exercises three times per week C. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL D. Man who is sedentary and reports four episodes of strep throat

A Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death. Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI; however, HDL cholesterol of 75 mg/dL is in the optimal range of greater than 55 mg/dL. Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease.

Which statement reflects correct cardiac physical assessment technique? A. Auscultate the aortic valve in the second intercostal space at the right sternal border. B. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. C. Palpate the apical pulse over the third intercostal space in the midclavicular line. D. Assess for carotid bruit by auscultating over the anterior neck.

A The aortic valve is auscultated at the second intercostal space at the right sternal border. Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck.

The nurse is assigned to all of these clients. Which client should be assessed first? A. The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago B. The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg C. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid D. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

A The client who had PTA should have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure. The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. The client with peripheral vascular disease is the most stable and can be seen last. The client who had a right femoral-popliteal bypass is not in need of immediate assessment; he can be assessed after the PTA client is seen.

A nursing home administrator reports having severe headache and facial flushing for the past 3 weeks. He does not smoke but is overweight. Both of his parents have hypertension and cardiac disease. One of his nurses takes his blood pressure, which is 210/116. He states that he will see his primary care provider as soon as possible. At the physician's office, his heart rate is 88 beats/min, blood pressure is 190/110, and respiratory rate is 24 breaths/min. 1. What members of the health care team may be involved in this patient's care?

A dietician may be helpful in assisting the patient with designing a healthy meal plan. The health care provider will need to be involved to monitor the patient's hypertension and response to medication therapy. Community resources can assist the patient in engaging in healthy activities.

Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.) A. Troponin 3.2 ng/mL B. Myoglobin 234 mcg/L C. C-reactive protein 13 mg/dL D. Triglycerides 400 mg/dL E. Lipoprotein-a 18 mg/dL

A, B Normal troponin should be less than 0.03 ng/mL. Normal myoglobin should be less than 90 mcg/L. Normal C-reactive protein should be less than 1 mg/dL; however, this tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides should be less than 150 mg/dL; however, this tests for risk for CAD, not ACS. Normal lipoprotein-a is 18 mg/dL; however, this tests for risk for CAD, not ACS.

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.) A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds since last seen in the clinic C. Cooks food in palm oil to save money D. Exercises once weekly E. Has cut down on caffeine

A,B,E Clients with hypertension should consume low-sodium foods and should avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure. Although palm oil may be cost-saving, it is higher in saturated fat than canola, sunflower, olive, or safflower oil. The goal is to exercise three times weekly.

When auscultating the client's breath sounds, the nurse hears soft rustling sounds at the lung edges. What is the nurse's best action? A. Listen again with the bell of the stethoscope rather than the diaphragm. B. Ask the client to cough and spit out any collected mucus. C. Document the finding as the only action. D. Notify the health care provider.

Answer: C Rationale: The sounds described are vesicular sounds, which are normally heard at the peripheral lung fields where air flows through smaller bronchioles and alveoli. Thus, this is a normal finding that does not require any action other than documentation.

A 71-year-old man is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. He is married but has no children. During your assessment, you observe that his color is pale, he is dyspneic, and he reports new onset of chest discomfort. Even though he has oxygen via nasal cannula at 2 L/min., you note that he seems a little confused and is oriented only to person. His oxygen saturation has decreased from 95% to 88%. 1. What evidence-based actions will you plan to implement at this time based on your observations? What is the source of the evidence?

Assess neck veins for distention, abdominal girth, hepatosplenomegaly, hepatojugular reflux, edema in ankles and legs, and ascites. Obtain the patient's weight and report of severity of chest pain (on a 0-10 scale). Monitor for electrolyte imbalances because these may occur from complications of heart failure or as side effects of drug therapy. Monitor respiratory rate, rhythm, and quality. Auscultate lung sounds. Recognize that ventilation assistance may be needed. Elevate the head of the bed to assist with oxygenation. Alert the client's health care provider. Sources of evidence may be found in credible databases such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Anticipate administration of diuretic.

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? A. Complete the referral form for a home health agency. B. Suction the tracheostomy using sterile technique. C. Teach the client and spouse about tracheostomy care. D. Consult with the health care provider about using a fenestrated tube.

B Complex sterile procedures are within the education and scope of practice of the experienced LPN/LVN. Completion of client referral forms, client and family teaching, and consulting with the health care provider are all actions that must be performed by an RN.

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? A. Calcium 8.5 mEq/L B. Potassium 3.0 mEq/L C. Magnesium 2.1 mEq/L D. International normalized ratio (INR) of 1.0

B Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations. A normal calcium level is 8.5 to 10.5 mEq/L. A normal magnesium level is 1.7 to 2.4 mEq/L. INR of 1.0 reflects a normal value.

Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? A. Client with group A beta-hemolytic streptococcal pharyngitis who has stridor B. Client with pulmonary tuberculosis who is receiving multiple medications C. Client with sinusitis who has just arrived after having endoscopic sinus surgery D. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

B The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Stridor 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 assessment and monitoring by the RN.

After a cardiac catheterization, the client should increase his or her fluid intake for which reason? A. NPO status will cause the client to be thirsty. B. The dye causes an osmotic diuresis. C. The dye contains a heavy sodium load. D. The pedal pulses will be more easily palpable.

B The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment. Although the client may report thirst while NPO, the reason to increase fluids is related to osmotic diuresis from the contrast medium. The contrast medium is iodine-based. Although maintaining fluid volume may make pulses more obvious, this is not the reason to encourage fluids.

Which signs and symptoms are seen with suspected pericarditis? (Select all that apply.) A. Squeezing, vise-like chest pain B. Chest pain relieved by sitting upright C. Chest and abdominal pain relieved by antacids D. Sudden-onset chest pain relieved by anti-inflammatory agents E. Pain in the chest described as sharp or stabbing

B,D,E The pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing; squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer.

What is the term for the opening between the vocal cords? A. Arytenoid cartilage B. Epiglottis C. Glottis D. Palatine tonsils

C The glottis is the opening of the vocal cords into which the endotracheal tube is passed during intubation for surgery. The arytenoid cartilages work with the thyroid cartilage to control the movement of the vocal cords. The epiglottis is a structure that prevents aspiration during swallowing. The palatine tonsils are part of the immune system and are located in the oropharynx

The nurse is working in an urgent care clinic. Which client needs to be evaluated first by the nurse? A. Client who is short of breath after walking up two flights of stairs B. Client with soreness of the arm after receiving purified protein derivative (Mantoux) skin test C. Client with sore throat and fever of 102.2° F (39° C) oral D. Client who is speaking in three-word sentences and has an SpO2 of 90% by pulse oximetry

D A client should be able to speak in sentences of more than three words, and an SpO2 of 90% indicates hypoxemia that requires intervention on the part of the nurse. Shortness of breath after walking up two flights of stairs may not be an emergency. Although not a usual finding, the arm may be sore after a skin test is performed. Sore throat and fever are symptoms of infection that require further evaluation but not emergently.

A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced nursing assistant working in the PACU? A. Assess breath sounds. B. Check gag reflex. C. Determine level of consciousness. D. Monitor blood pressure and pulse.

D A nursing assistant working in the PACU would have experience in taking client vital signs after the client has had conscious sedation or anesthesia. Evaluating breath sounds and gag reflex and determining level of consciousness require the skill and knowledge of a higher-level provider.

What is Hypoxia?

Decreased tissue oxygenation

A 67-year-old man recently lost his wife after being married for 42 years. He met his wife shortly after he returned from Vietnam as a combat soldier. He visits his physician and reports decreased appetite, moodiness, and extreme fatigue, even though he sleeps 10 to 12 hours a night. When giving his medical history, he admits that he drinks 4 or 5 beers and smokes marijuana almost every day. 1. With whom might you collaborate to develop his plan of care?

Depending on resources in your agency or physician's office, you may be able to collaborate with or refer the patient to an alcoholism counselor or community resources such as Alcoholics Anonymous. A social worker or case manager may also be helpful for this man to function productively in the community.

Your patient is the 68-year-old man from the previous Clinical Judgment Challenge who had shortness of breath (SOB) for the past 2 to 3 days. His clinical condition deteriorated further, requiring intubation. The health care provider orders a CT scan of the chest. 1. What are your responsibilities when preparing the patient for the CT scan?

Determine patient sensitivity to intravenous contrast; allergies to iodine or shellfish; and renal function, including baseline creatinine level.

A 71-year-old man is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. He is married but has no children. During your assessment, you observe that his color is pale, he is dyspneic, and he reports new onset of chest discomfort. Even though he has oxygen via nasal cannula at 2 L/min., you note that he seems a little confused and is oriented only to person. His oxygen saturation has decreased from 95% to 88%. 1. What will you tell the patient's wife about his condition at this time? Should the patient's wife be present during his emergency treatment? Why or why not?

Explain that right-sided heart failure affects the body systemically and that the client is in need of diuresis. Anxiety may increase symptoms of dyspnea and chest pain. Brain hypoxia (decreased oxygen to the brain) can cause confusion. Depending on the wife's psychosocial presentation, the nurse may determine that it is better for her to be present or compassionately removed from the room during emergency treatment. If the wife remains present, the nurse should ensure that she will not interfere with resuscitative efforts, and have someone present with the wife to explain what is taking place. If the wife needs to be compassionately removed from the room, the nurse should arrange for someone to accompany her and to provide regular updates regarding her husband's condition.

The patient is a 64-year-old man with COPD who lives with his wife of 35 years. He retired 2 years ago when his disease interfered with his with his job as a carpenter. He also quit smoking a year ago. Since then, his disease has remained stable; however, he now reports that he thinks his wife is preparing for widowhood by taking over all the home chores that he always performed (including driving and bill paying), limiting his interaction with friends, and making all decisions. He is angry and depressed. Routine assessment with pulmonary function testing show his FEV1 to be 40% of his predicted value, which is an improvement over the 32% value of FEV1 last year. 1. What severity classification is his COPD? Provide a rationale for your choice.

He meets the GOLD 3 criteria for severe COPD in that his FEV1 is less than 50% of predicted but greater than 30% of predicted. The fact that his FEV1 has improved during the past year is a positive sign, probably related to quitting smoking.

The patient is a 60-year-old man who has just been diagnosed with non-small cell lung cancer. He smoked cigarettes for about 25 years starting when he was 16 years old and quit when he was 41 years old. His lung cancer is at stage I in the left lower lobe. He is distraught, saying that he can't die now because he has one child in college and two in high school. He also fears chemotherapy and seems bitter that he quit smoking and got lung cancer anyway. His next statement is: "Why couldn't I get prostate cancer like most men? At least they survive. No one beats lung cancer." 1. What can you tell him about lung cancer survival?

Help him understand that diagnosing lung cancer, especially NSCLC, at an early stage is "beatable."

The nurse is caring for a frail, older patient in the hospital after surgery to repair a bowel obstruction. The patient has a nasogastric (NG) tube to suction, through which all her scheduled drugs are given, oxygen at 1 liter/nasal cannula at night (home order), an indwelling urinary catheter, and a saline lock. The patient is weak, fatigued, has pain not relieved by IV opioids, and is reluctant to participate in any activities. 1. What actions does the nurse take to decrease the patient's risk of pneumonia?

Irrigate the NG tube using sterile water after medication administration, ensure oxygen equipment is changed per agency policy, consult with physician to manage pain better, provide pain medication on a schedule instead of waiting for the patient to ask for it, encourage use of a spirometer, teach the patient to splint the incision for coughing, mobilize the patient, turn the patient every 2 hours while in bed, elevate the head of the bed, provide oral care, consult with the physician about fluids (the patient only has a saline lock) and how nutrition is being addressed, consult with the physician about removing the catheter, and ensure the patient has received the pneumonia vaccination or gets an order to administer one during the hospital stay.

The patient is a 60-year-old man who has just been diagnosed with non-small cell lung cancer. He smoked cigarettes for about 25 years starting when he was 16 years old and quit when he was 41 years old. His lung cancer is at stage I in the left lower lobe. He is distraught, saying that he can't die now because he has one child in college and two in high school. He also fears chemotherapy and seems bitter that he quit smoking and got lung cancer anyway. His next statement is: "Why couldn't I get prostate cancer like most men? At least they survive. No one beats lung cancer." 1. What resources could you recommend to help him at this time?

The American Cancer Society, Canadian Cancer Society, and American Lung Association have information regarding the positive outcome of lung cancer treated appropriately at this time. Also, the National Cancer Institute has patient information and education resources that can be downloaded from the website.

At a recent staff meeting, the medical-surgical nurse manager reports that the rate of repeated hospitalizations for patients with chronic heart failure has increased 50% in the past 3 months. As a staff nurse, you agree to be part of the unit quality improvement (QI) team to examine the cause(s) of the increase and make evidence-based recommendations for improving the outcomes for this patient population. Specific patient data and summaries are available for the team to review as needed. 1. How will your team interpret and use the evidence that you obtain? (See Chapter 5 for assistance.)

The key to this step is a collaborative team effort. One effective strategy is to have each member of an evidence-based practice (EBP) team take responsibility for summarizing and critically appraising a select number of articles (depending, of course, on the number of relevant articles your search revealed) and then presenting a written summary and review to all team members. This allows collegial critique of the evidence, helps clarify areas of uncertainty, and helps the team come to consensus on what the best evidence is to answer the clinical question. In addition, critiquing and summarizing each piece of relevant evidence makes it easier to synthesize all the relevant evidence into a succinct summary of the evidence is telling you about your clinical question. After you have reviewed, critically appraised, and synthesized all the relevant evidence, you are ready to make practice recommendations in a written report to whoever needs to review them for potential approval. After the approval has been obtained, implementation will follow.

The patient is a 67-year-old man with moderate emphysema. He has just been admitted to the medical unit with a diagnosis of shortness of breath related to influenza. In the emergency department he received a chest x-ray and a nebulizer treatment with albuterol. He also had a saline lock placed and arterial blood gases were sent to the laboratory. Vital signs before transfer were: BP 158/92; HR 92; RR 32; T 101.4° F. The health care provider wrote the following orders: • Obtain admission vital signs • Schedule pulmonary function tests • Tylenol 650 mg orally as needed • Oxygen at 2 L per nasal cannula • Nebulizer treatment with albuterol every 6 hours • Intravenous antibiotic administration • Use of an incentive spirometer hourly • Drawing blood for a culture and sensitivity 1. The patient's SaO2 is 90% on admission. What action would you take at this time? Provide a rationale for your choice.

The only action required is to document the patient's admission SaO2. An SaO2 of 90% or higher, although lower than the normal range, is acceptable and desirable for a patient with emphysema.

At a recent staff meeting, the medical-surgical nurse manager reports that the rate of repeated hospitalizations for patients with chronic heart failure has increased 50% in the past 3 months. As a staff nurse, you agree to be part of the unit quality improvement (QI) team to examine the cause(s) of the increase and make evidence-based recommendations for improving the outcomes for this patient population. Specific patient data and summaries are available for the team to review as needed. 1. Where will your team begin with this process during the first meeting of the team?

The team should begin with formulation of a PICOT question that is designed to develop an answerable research problem. PICOT questions may vary depending on whether intervention, etiology, diagnosis, prevention, meaning, or prognosis is being studied.

At a recent staff meeting, the medical-surgical nurse manager reports that the rate of repeated hospitalizations for patients with chronic heart failure has increased 50% in the past 3 months. As a staff nurse, you agree to be part of the unit quality improvement (QI) team to examine the cause(s) of the increase and make evidence-based recommendations for improving the outcomes for this patient population. Specific patient data and summaries are available for the team to review as needed. 1. How will you know if the plan of action to improve care was effective?

The team will need to return to the PICOT question that is formulated to compare the number of repeated hospitalizations within a 90-day period after implementation of the best practices that were identified. Analysis of this number (of repeat hospitalizations) will provide the team with baseline information regarding whether the plan of action to improve care was effective.

At a recent staff meeting, the medical-surgical nurse manager reports that the rate of repeated hospitalizations for patients with chronic heart failure has increased 50% in the past 3 months. As a staff nurse, you agree to be part of the unit quality improvement (QI) team to examine the cause(s) of the increase and make evidence-based recommendations for improving the outcomes for this patient population. Specific patient data and summaries are available for the team to review as needed. 1. What Internet sites will your team use to determine best practices for decreasing repeated hospital stays and why?

The team will want to reference The Joint Commission and the Agency for Healthcare Research and Quality websites, as well as the "fantastic four" databases (below) to begin determining best practices for decreasing repeated hospital stays. These are recognized, credible sources of information. a. Cochrane Library of Systematic Reviews b. Joanna Briggs Institute (JBI) systematic reviews c. Medline (or PubMed) d. CINAHL

Your patient is a 41-year-old woman with a significant closed head injury (CHI) from a motor vehicle crash (MVC). She is not anticipated to be able to be weaned from the ventilator, and the physicians have asked the patient's family for permission to perform a tracheostomy. The family is concerned that the patient will not be able to speak again. 1. The patient's family is concerned that the tracheostomy will be permanent and they are worried about her image. How do you respond?

Tracheostomies do not need to be permanent. It is possible for the patient to be fully weaned from mechanical ventilation and supplemental oxygen. After that is accomplished, the tracheostomy size is decreased and then removed completely. Loose-fitting clothing or a scarf can be worn while the stoma closes and heals. The patient will be left with only a modest scar. It is important to support the patient and her family through all of these discussions.

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.) A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL B. Smoking C. Aspirin (acetylsalicylic acid [ASA]) consumption D. Type 2 diabetes E. Vegetarian diet

A,B,D Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), the client is advised to modify diet and exercise. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease. ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. A diet high in whole grains, fruits, and vegetables is desirable to prevent atherosclerosis; vegetarians usually consume fruits, vegetables, and nonanimal sources of protein.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? A. Ibuprofen (Motrin) B. Hydrochlorothiazide (HydroDIURIL) C. NPH insulin D. Levothyroxine (Synthroid)

A Long-term use of nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF. A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism; it does not cause HF.

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? A. "My leg might turn very white after the surgery." B. "I should be concerned if my foot turns blue." C. "I should report a fever or any drainage." D. "Warmness, redness, and swelling are expected."

A Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis. The foot turning blue is a sign of poor perfusion. Fever or drainage would indicate an infection. Warmness, redness, and swelling indicate reperfusion, which is a good sign.

After receiving change-of-shift report about these four clients, which client should the nurse assess first? A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions B. A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% C. A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths D. A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

A The 46-year-old's premature ventricular contractions may be indicative of digoxin toxicity; further assessment for clinical manifestations of digoxin toxicity should be done and the health care provider notified about the dysrhythmia. The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis; this type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia; this client may be seen after the client with aortic stenosis.

A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? (Select all that apply.) A. Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B. The medications may cause nausea. The client should take them at bedtime. C. The client is generally not contagious after 2 to 3 consecutive weeks of treatment. D. These medications must be taken for 2 years. E. These medications may cause kidney failure.

A,B Combination drug therapy is the most effective method for treating TB and preventing transmission. Multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Although combination drug therapy will decrease the required length of time for treatment, the length of treatment is decreased to 6 months from 6 to 12 months.

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? (Select all that apply.) A. Combination drug therapy is effective in preventing transmission. B. Combination drug therapy is the most effective method of treating TB. C. Combination drug therapy will decrease the length of required treatment to 2 months. D. Multiple drug regimens destroy organisms as quickly as possible. E. The use of multiple drugs reduces the emergence of drug-resistant organisms.

A,B,D,E Combination drug therapy is the most effective method for treating TB and preventing transmission. Multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Although combination drug therapy will decrease the required length of time for treatment, the length of treatment is decreased to 6 months from 6 to 12 months.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? (Select all that apply.) A. Chest discomfort or pain B. Tachycardia C. Expectorating thick, yellow sputum D. Sleeping on back without a pillow E. Fatigue

A,B,E Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure. Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom; Clients usually find it difficult to lie flat because of dyspnea symptoms.

A 67-year-old man recently lost his wife after being married for 42 years. He met his wife shortly after he returned from Vietnam as a combat soldier. He visits his physician and reports decreased appetite, moodiness, and extreme fatigue, even though he sleeps 10 to 12 hours a night. When giving his medical history, he admits that he drinks 4 or 5 beers and smokes marijuana almost every day. 1. As this man's office nurse, what other assessment data do you need to collect? What screening tools might you use?

Additional assessment data include needing to know more about his family and health history. For example, does he have family members with depression or substance use? Did he have any mental health issues as a result of serving in Vietnam as a combat soldier? If so, was he treated by a health care professional? Also ask the patient more about his presenting clinical manifestations. How much does he eat each day? Has he had weight loss? If so, how much weight has he lost over what period of time? Does he prepare meals? Is there family support? Is he retired, or does he have a job? If he is retired, what does he do to keep busy during the day? Does he exercise? Does he volunteer? Does he have a hobby? If he works, what type of work does he do, and is it fulfilling? How many hours does he work each week? How much marijuana does he smoke each day? Does he drive when he drinks or smokes marijuana? Depending on agency policy, you could use an alcohol screening assessment tool to gather more specific information about his substance use. These tools include the CAGE questionnaire, Short Michigan Alcoholism Test—Geriatric Version (SMAST—G), and Short Alcohol Related Problems Survey (shARPS).

A patient who had a supraglottic partial laryngectomy with a right-sided radical neck dissection 4 weeks ago is now receiving radiation therapy. He has lost 24 pounds since his surgery, which makes him 15 pounds less than his ideal weight. He tells you that he has no appetite and that what food he does eat "has no taste." In addition, although he expresses that he is glad to be alive, he does not want friends to visit because it takes so much energy to interact with them. He also says that he can no longer play the piano because of difficulty moving his right arm and shoulder. 1. What other health care professionals or resources would be appropriate at this time?

An occupational therapist and a speech and language pathologist could be very helpful at this time. The speech and language pathologist can suggests ways to communicate that may require less energy. The occupational therapist can help him improve the muscle tone in his right arm and shoulder and may even have suggestions for how to continue to enjoy the piano. Other resources might include a visit from someone who has had the same surgery and experienced similar problems. This person could be a source of inspiration for how much activity he may be able to participate in as time passes. Pastoral care may also be helpful.

A client who recently had a heart valve replacement is taking warfarin (Coumadin) as prescribed. What statement by the client indicates that the nurse will need to do additional health teaching? A. "I will take my pulse every day, and call my doctor if it is below 60." B. "I will eat foods that are high in vitamin K, such as kale and spinach." C. "I will weigh myself every day in the morning using the same scale." D. "I will take my blood pressure every day and call if it is too high or low."

Answer: B Rationale: Patients taking warfarin (Coumadin) should be taught to avoid foods that are high in vitamin K, as well as herbs such as ginger, ginseng, goldenseal, Ginkgo biloba, and St. John's wort, because all of these may interfere with the drug's action. Spinach and kale are high in vitamin K.

A nurse is caring for an 89-year-old client admitted with pneumonia. He has an IV of normal saline running at 100 mL/hr and antibiotics that were initiated in the emergency department 3 hours ago. He has oxygen at 2 liters/nasal cannula. What assessment finding by the nurse indicates that goals for a priority diagnosis have been met for this client? A. The client is alert and oriented to person, place, and time. B. Blood pressure is within normal limits and client's baseline. C. Skin behind the ears demonstrates no redness or irritation. D. Urine output has been >30 mL/hr per Foley catheter.

Answer: A Rationale: One of the first manifestations of pneumonia in an older adult is acute confusion as a result of impaired gas exchange. A client with pneumonia who is alert and oriented to person, place, and time is responding well to appropriate therapy for the disorder. The blood pressure is not an indicator of effective management of pneumonia, and neither is urine output. The skin behind his ears being intact is important and desirable but is not an outcome indicator for pneumonia management.

A client diagnosed with atherosclerosis has been prescribed lovastatin (Mevacor). Which statement by the client indicates a need for further teaching? A. "I won't need to change my diet because now I'm taking a pill." B. "I'll follow up with my nurse practitioner on a regular basis." C. "I need to quit smoking as soon as I possibly can." D. "I shouldn't drink grapefruit juice while on this drug."

Answer: A Rationale: Clients should engage in lifestyle modifications to lower cholesterol and decrease their risk for atherosclerosis. Drug therapy alone is not enough. The client should appropriately continue to follow up with the health care provider; quit smoking; and avoid grapefruit juice, which can interfere with drug efficacy.

The nurse is caring for a client with chronic venous stasis ulcers. Which statement by the client indicates a need for further health teaching? A. "I'll wear compression stockings at night." B. "I'll keep my affected leg above my heart." C. "I'll eat protein and vitamin C foods to help heal the ulcer" D. "I'll change my dressing every 3 to 5 days as needed."

Answer: A Rationale: Compression stockings should be worn during the day and the evening rather than just at night. Teach the patient to elevate his or her legs for at least 20 minutes four or five times per day. When the patient is in bed, remind him or her to elevate the legs above the level of the heart. Food rich in protein and vitamin C can assist with healing processes. Hydrocolloid dressings are left in place for a minimum of 3 to 5 days for best effect.

For which problem does the nurse assess the client who cannot breathe through the nose because of a severe septal deviation? A. Dry respiratory tract membranes B. Frequent episodes of tonsillitis C. Development of nasal polyps D. Difficulty swallowing

Answer: A Rationale: When inspired air passes through the nose, it is filtered, warmed, and humidified. When a person is unable to breathe through the nose because of an anatomical obstruction, he or she is at risk for excessive drying of the respiratory mucous membranes. This anatomical problem does not influence the development of tonsillitis or difficulty swallowing. Nasal polyps can contribute to nasal obstruction but is not caused by a septal deviation.

A client has been admitted to the hospital with suspected TB. What drugs should the nurse plan to teach the client about before discharge? Select all that apply. A. Rifampin (Rifadin); contact lenses can become stained orange B. Isoniazid (INH); report yellowing of the skin or darkened urine C. Pyrazinamide (PZA); maintain a fluid restriction of 1200 mL/day D. Ethambutol (Myambutol); report any changes in vision E. Amoxicillin (Amoxil); take this drug with food or milk

Answer: A, B, D Rationale: Amoxicillin is not prescribed for TB. Pyrazinamide, although prescribed for TB, calls for an increase in fluids, not fluid restriction. Rifampin, isoniazid, and ethambutol are first-line drugs for TB therapy and have side effects. The side effects listed with these drugs are appropriate to teach the client.

An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is admitted to the emergency department (ED) with an apical pulse of 48. A family member states that the client has reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action? A. Call the ED physician immediately. B. Draw a serum digoxin level. C. Assess for signs of hypokalemia. D. Establish the client's airway.

Answer: B Rationale: The clinical manifestations of digoxin toxicity are often vague and nonspecific and include anorexia, fatigue, blurred vision, and changes in mental status, especially in older adults. Older adults are more likely than other patients to become toxic because of decreased renal excretion.

The charge nurse at an assisted living facility receives report from an emergency department (ED) nurse about one of the resident clients. The client was sent to the ED with a fever, chills, muscle aches, and headache. The ED nurse reports the client's rapid influenza report came back from the laboratory positive for influenza A. What action by the nurse at the assisted living facility is most appropriate? A. Prepare to administer antibiotics. B. Have the resident eat meals in his room. C. Provide oseltamivir (Tamiflu) to the staff. D. Arrange a follow up chest x-ray in 2 weeks.

Answer: B Rationale: This client is most likely going to be managed at the assisted living facility. Influenza is highly contagious. Keeping the client in his room rather than having him go to the dining room and eat with other residents helps prevent infection spread. Antibiotics are not used for influenza. The staff should not, at this time, require oseltamivir unless they have manifestations of influenza. This is not a pandemic influenza, and oseltamivir is not used for prophylaxis in this situation. Unless the client develops manifestations of pneumonia, radiography is not indicated.

The nurse is caring for a client with lower extremity peripheral arterial disease. Which statement made by the client regarding self-management requires further health teaching? A. "I need to quit smoking as soon as I can." B. "I will elevate my legs above the level of my heart." C. "I will use a heating pad to promote circulation." D. "I will avoid crossing my legs at all times."

Answer: B Rationale: This patient should avoid raising his or her legs above the heart level because extreme elevation slows arterial blood flow to the feet. Smoking cessation, gently warming the extremity, and avoiding crossing the legs (which interferes with blood flow) can assist in management of peripheral arterial disease.

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Breathlessness D. Ascites E. Tachypnea

Answer: B, C, E Rationale: Clients with left-sided heart failure will exhibit symptoms such as fatigue, dyspnea or breathlessness, and crackles on auscultation of breath sounds. Peripheral edema and ascites are associated with right-sided heart failure.

For which activity does the nurse teach the client who is receiving oxygen by a transtracheal oxygen (TTO) delivery system to switch to a nasal cannula oxygen delivery system? A. Eating a meal B. Sleeping at night C. Cleaning the catheter D. Performing mouth care

Answer: C Rationale: A TTO delivery system involves passing a catheter into the trachea through a small incision with the patient under local anesthesia, delivering oxygen directly to the lungs. Thus, the mouth is not involved, and this delivery is not disrupted by eating, drinking, or performing oral care. If the catheter is properly attached to the client, it is no more likely to become dislodged during sleep than is a nasal cannula. To maintain adequate gas exchange and oxygenation, the client should receive supplemental oxygen through a nasal cannula delivery system whenever the transtracheal catheter is not in place for any reason, such as when cleaning it.

The chest tube of a client 16 hours postoperative from a lobectomy is accidentally pulled out by a portable x-ray machine. What is the nurse's best first action? A. Clamp the tubing with padded clamps as close as possible to the insertion site. B. Reposition the client on the nonoperative side and support the tube(s) with pillows. C. Cover the insertion site with a sterile occlusive dressing and tape down on three sides. D. Don sterile gloves and attempt to reinsert the chest tube at the original insertion site.

Answer: C Rationale: Although the client had a pneumonectomy and sometimes chest tubes are not even used, the insertion site should be covered immediately to prevent infection. If this were a chest tube placed for any other reason, the action of covering the insertion site is still the best first action to prevent air from being sucked into the chest cavity. Clamping the tubing that has already fallen out of the chest does nothing to help the client or prevent a problem. Repositioning the client would cause neither harm nor benefit. Reinserting a contaminated chest tube is wrong and beyond the scope of nursing practice.

What is the effect of age-related decreased skeletal muscle strength on the effectiveness of gas exchange? A. Reduced gas exchange as a result of decreased alveolar surface B. Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles. C. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity. D. Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue

Answer: C Rationale: Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased, and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.

Which statement by an older adult regarding diet and exercise indicates a need for further teaching by the nurse? A. "I need to include more fiber in my diet like whole grains, raw vegetables, and fruits." B. "I just joined our local fitness center and plan to go there three times a week" C. "I will stop drinking fluids after 4 PM to prevent getting up during the night." D. "I drink prune juice every day and that keeps my bowels very regular."

Answer: C Rationale: Older adults need to drink adequate fluids to prevent constipation and dehydration. Therefore, the nurse needs to provide health teaching about this important healthy behavior.

A client is admitted to the telemetry unit after a right-sided cardiac catheterization. What is the nurse's priority when caring for this client? A. Assess the intensity and quality of the client's pain. B. Position the client in a sitting position to improve breathing. C. Check the client's arterial insertion site. D. Apply oxygen at 2 L/min via nasal cannula.

Answer: C Rationale: Patients who have had cardiac catheterization should be restricted to short-term bedrest, and the insertion site extremity should be kept straight. The nurse should assess the insertion site for bloody drainage or hematoma formation because complications with vascular closure devices are not common but can be very serious.

A home care nurse conducts an assessment of an older woman's medications and herbal/ nutritional supplements. Which supplement is most likely to cause an interaction with prescribed medications? A. Calcium B. Vitamin C C. St. John's wort D. Vitamin B complex

Answer: C Rationale: St. John's wort interacts with many prescribed drugs by either decreasing their effectiveness or increasing drug action. Examples of prescribed drugs that interact with this herb include antihistamines, antidepressants, digoxin, sedatives, immune suppressing agents, warfarin, and anti-allergy medications. Calcium and vitamin B complex do not commonly interact with most prescribed medication. Excessive vitamin C could cause bleeding and bruising, but as a water-soluble vitamin, this supplement is relatively safe to use.

The client is a woman with severe angioedema and tongue swelling from exposure to seafood. She has stridor, and her oxygen saturation is 70%. For which type of respiratory support does the nurse prepare? A. Nasal BiPAP B. Tracheotomy C. Cricothyroidotomy D. Endotracheal intubation

Answer: C Rationale: Stridor is a sound made from a laryngeal obstruction, not just an oral obstruction. The fact that her oxygen saturation is so low indicates that this is a critical emergence and that her airway is going to become completely obstructed very soon. Nasal biPAP is not at all helpful here, and it is unlikely that endotracheal intubation would be successful with this much edema. A tracheotomy would work but takes more time. Also, because this is a temporary condition that should respond well to anaphylaxis therapy, the cricothyroidotomy is the best choice, and this is what the nurse should have prepared for the rapid response team.

A client is prescribed enalapril (Vasotec) for control of hypertension. What health teaching will the nurse provide before the client begins therapy? A. "You may develop a higher pulse rate." B. "You may notice some swelling in your feet." C. "You may develop a nagging cough." D. "Your diet should include foods high in sodium."

Answer: C Rationale: The most common side effect of angiotensin-converting enzyme inhibitors such as enalapril (Vasotec) is a nagging, dry cough. Teach clients to report this problem to their health care provider as soon as possible. If a cough develops, the drug is usually discontinued.

Which precaution is most important for the nurse to teach a client, who is a secretary and just had nasal tubes removed after a posterior nasal bleed? A. Avoid NSAIDs for at least 1 week. B. Wait 4 weeks before returning to work. C. If bleeding recurs, call 911 immediately. D. Do not blow your nose for at least a month.

Answer: C Rationale: The most important of all these precautions is to get emergency treatment as soon as any rebleeding occurs. The tissue is fragile and could rebleed easily and excessively. It is important for the client to avoid the issues that could lead to bleeding, such as nose blowing and the use of NSAIDs, but it is more important to stop the bleeding as soon as possible. Because this client's occupation is sedentary (being a secretary), he or she could return to work within a day or two as long as the usual precaution regarding heavy lifting is observed.

The nurse is providing care to a client who has started warfarin after being diagnosed with a deep vein thrombosis. What health teaching will the nurse provide to the client related to self-management of warfarin therapy? A. "You must have your partial thromboplastin time checked every 2 weeks." B. "Massage the injection site after the warfarin is injected." C. "Eat plenty of dark green leafy vegetables while taking warfarin." D. "Report any signs of bleeding to your primary care provider."

Answer: D Rationale: Any signs of bleeding should be immediately reported to the primary care provider. The client's international normalized ratio will be monitored while the patient is taking warfarin. Injection sites should not be massaged because this could dislodge a clot. Clients who are on warfarin therapy should avoid foods with high concentrations of vitamin K, especially dark, green, leafy vegetables, because they can interfere with the action of warfarin.

A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2 mEq/L. What is the nurse's best action at this time? A. Assess the client's oxygen saturation level. B. Ask the laboratory to retest the potassium level. C. Give potassium as an IV infusion. D. Check the client's serum creatinine.

Answer: D Rationale: Clients who are hyperkalemic (those with an elevated serum potassium level) may also be in renal failure. The client's serum creatinine should be reviewed to determine if it is greater than 1.8 mg/dL, at which time the health care provider should be notified before administering any supplemental potassium.

The nurse is providing education to help reduce cardiovascular risks for a women's book club. Which statement made by a participant indicates a need for further teaching? A. "We are more likely to die from cardiovascular disease than men." B. "We need to walk or do other exercise every day for 30 minutes." C. "We need to stay away from people who smoke." D. "We should take hormones for menopause to decrease the risk for heart attack."

Answer: D Rationale: Medications used in hormone therapy can cause an increased incidence of myocardial infarction or stroke in women.

The 62-year-old client whose brother was just diagnosed with head and neck cancer asks the nurse what he could do to reduce his risk for also developing this cancer. What is the nurse's best response? A. "Because head and neck cancer has a strong hereditary component, participating in screening twice yearly is critical for you." B. "Always wear sunscreen with a 50% or greater protection factor whenever you are out doors." C. "Avoid shouting and singing to prevent stress to your vocal cords and larynx." D. "Stop smoking and drink alcohol only in moderation."

Answer: D Rationale: No hereditary component has been identified to increase the risk for head and neck cancer. Although many head and neck cancers are squamous cell, which is a type of skin cancer, these cancers develop inside the oropharyngeal area and are not associated with external skin cancers on the head or the neck. Vocal cord abuse is associated with some types of head and neck cancer; however, the two most important risk factors for head and neck cancer are tobacco and alcohol use, especially in combination. Other risk factors include chronic laryngitis, exposure to chemicals, dusts, poor oral hygiene, long-term or severe gastroesophageal reflux disease, and oral infection with the human papillomavirus. Of all the cancer prevention activities this client could perform, smoking cessation and reduction of alcohol intake (or elimination of alcohol intake) are the most effective.

Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours alerts the nurse to the possibility of oxygen toxicity? A. Oxygen saturation greater than 100% B. Decreased rate and depth of respiration C. Wheezing on inhalation and exhalation D. Discomfort or pain under the sternum

Answer: D Rationale: Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. Initial manifestations include dyspnea, nonproductive cough, chest pain beneath the sternum, and gastrointestinal upset. Oxygen saturation falls, not increases. Breathing becomes more rapid with the sensation of dyspnea. Wheezing represents airway obstruction, not damage to the alveolar membrane.

An older adult returns to the orthopedic unit after an open reduction, internal fixation surgery for a fractured hip. Upon admission, she is combative and screaming profane language. What is the nurse's first action? A. Increase the client's rate of intravenous fluids. B. Give the client IV morphine stat. C. Start oxygen via mask at 6 L/min. D. Assess for risk factors that could cause her behaviors.

Answer: D Rationale: The client's behaviors are consistent with delirium, or short-term acute confusion. This problem is common after surgery in older adults, especially hip repairs. The nurse needs to determine the cause of the delirium to manage it. Oxygen therapy may not be needed. Increasing IV fluids might cause fluid overload. Morphine often causes delirium in older adults.

A client with chronic obstructive pulmonary disease (COPD) prescribed a long-acting inhaled beta2 agonist reports hating the inhaler and asks why the drug can't be taken as a pill. What is the nurse's best response? A. "Drugs taken by inhaler work more slowly and remain in the system longer." B. "Drugs taken by inhaler have no side effects and are less expensive." C. "Drugs taken by mouth are more expensive because they must be sterile." D. "Drugs taken by mouth have systemic side effects and are harder to control."

Answer: D Rationale: When used as prescribed, inhaler drugs go more to the site where the intended responses are needed (the airways), and less drug is absorbed systemically. Thus, inhaled drugs have fewer side effects (but still have side effects). Oral drugs always have systemic side effects.

The patient is a 64-year-old man with COPD who lives with his wife of 35 years. He retired 2 years ago when his disease interfered with his with his job as a carpenter. He also quit smoking a year ago. Since then, his disease has remained stable; however, he now reports that he thinks his wife is preparing for widowhood by taking over all the home chores that he always performed (including driving and bill paying), limiting his interaction with friends, and making all decisions. He is angry and depressed. Routine assessment with pulmonary function testing show his FEV1 to be 40% of his predicted value, which is an improvement over the 32% value of FEV1 last year. 1. How should you respond to his statement about the wife probably preparing for widowhood?

Ask him if he thinks there might be any other reason for her to take over chores, limit social interactions, and make all the decision. Try to steer the conversation for him to understand his wife's concern for him.

The patient is a 68-year-old man who has had shortness of breath (SOB) for the past 2 to 3 days. His past medical history includes a 40-packyear smoking history, COPD, and heart failure. He reports that he became concerned when he woke from sleep because he could not breathe. Your physical assessment reveals crackles in the lower lobes bilaterally. His oxygen saturation (SpO2) is 84% without supplemental oxygen. 1. What are some areas of focus to assess as part of this patient's current history?

Ask the patient to describe the onset of manifestations and any actions that exacerbate or alleviate them. Ask about the paroxysmal nocturnal dyspnea (PND), if the patient experiences orthopnea, and if so, how many pillows does he require in order to sleep. Ask about his endurance, how far he can walk, and if his SOB has affected his ability to complete his activities of daily living. Your history should also include all current over-the-counter and prescription medications as well as herbal supplements. Does the patient use oxygen at home? Is the patient working? If so, what type of work? Is there exposure to toxins? Does he have a cough? You should inquire about his smoking history; if he is currently smoking, does he have a plan to stop smoking? Smoking cessation counseling should be offered, and if agreeable to the patient, drugs for smoking cessation should be considered. Ask about other smokers in the home.

The patient is a 64-year-old man with COPD who lives with his wife of 35 years. He retired 2 years ago when his disease interfered with his with his job as a carpenter. He also quit smoking a year ago. Since then, his disease has remained stable; however, he now reports that he thinks his wife is preparing for widowhood by taking over all the home chores that he always performed (including driving and bill paying), limiting his interaction with friends, and making all decisions. He is angry and depressed. Routine assessment with pulmonary function testing show his FEV1 to be 40% of his predicted value, which is an improvement over the 32% value of FEV1 last year. 1. What psychosocial assessment of this patient and his situation should you make?

Ask the patient to rank, in terms of importance to him, the chores, activities, and decisions he wants to continue to perform.

An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? A. It would not be beneficial for this client. B. It would help decrease the bronchospasm. C. It would clear up the density in the bases of the client's lungs. D. It would decrease the client's pain on inspiration.

B A bronchodilator would help decrease bronchospasm and would open up the airways, so it would be beneficial for this client. It would decrease dyspnea and feelings of shortness of breath. A bronchodilator would not be able to clear up the density in the bases of the client's lung. The cause of the density is unknown; however, an infection such as pneumonia is likely, which bronchodilators do not treat. Although a bronchodilator would help a client breathe easier, it does not have any analgesic properties.

Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? A. "I don't know how I am going to change my lifestyle." B. "I don't need to change. It hasn't killed me yet." C. "I don't think it is as bad as the doctors say." D. "I will have to change my diet and exercise more."

B A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care. The statement about not changing because "it hasn't killed me yet" indicates maladaptive denial. Not knowing how to change indicates that the client is overwhelmed, not in denial. Not thinking it is that bad indicates denial, but not maladaptive denial. Changing diet and exercising more indicates a willingness to change.

The nurse is planning care for the non-English-speaking client who is on complete voice rest. What alternative method of communication does the nurse implement? A. Alphabet board B. Picture board C. Translator at the bedside D. Word board

B A picture board overcomes language barriers and can be used to communicate with 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. Unless the nurse is able to read the language the client speaks, a word board would not be beneficial.

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? A. No intervention is needed; this is a normal reading. B. Collaborate with the health care provider to administer a positive inotropic agent. C. Administer a STAT dose of metoprolol (Lopressor). D. Ask the client to perform the Valsalva maneuver.

B A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility; cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output.

The nurse is caring for a client with dark-colored toe ulcers and blood pressure of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? A. Assess leg ulcers for evidence of infection. B. Administer a clonidine patch for hypertension. C. Obtain a request from the health care provider for a dietary consult. D. Develop a plan for discharge, and assess home care needs.

B Administering medication is within the scope of practice for the LPN/LVN. The RN is responsible for physical assessments, making referrals for other services, and developing the plan of care for the hospitalized client.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? A. The client's ability to understand medication teaching B. The risk for hypotension C. The potential for bradycardia D. Liver function tests

B Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, understanding of teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? A. Assess the client for peripheral edema. B. Auscultate the client's posterior breath sounds. C. Notify the health care provider about the client's weight gain. D. Remind the client about dietary sodium restrictions.

B Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds. Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse should notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

Which medication, when given in heart failure, may improve morbidity and mortality? A. Dobutamine (Dobutrex) B. Carvedilol (Coreg) C. Digoxin (Lanoxin) D. Bumetanide (Bumex)

B Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; this category of pharmacologic agents improves morbidity, mortality, and quality of life. Dobutamine and digoxin are inotropic agents used to improve myocardial contractility but have not been directly associated with improving morbidity and mortality. Bumetanide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? A. Serum sodium level of 135 mEq/L B. Serum potassium level of 2.8 mEq/L C. Serum creatinine of 1.0 mg/dL D. Serum magnesium level of 1.9 mEq/L

B Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy. A serum sodium level of 135 mEq/L is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L represents a normal value.

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? A. Heart rate 52 beats/min B. Blood pressure 192/102 mm Hg C. Report of constipation D. Anxiety

B Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture. The nurse must consider the client's usual pulse; however, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection; however, a potential problem should not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious; however, the elevated blood pressure is an immediate risk.

Which statement about diagnostic cardiovascular testing is correct? A. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. B. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. C. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. D. The left side of the heart is catheterized first and may be the only side examined.

B Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing. Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing.

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? A. Increase red meat in the diet. B. Consume melons and baked potatoes. C. Add several portions of dairy products each day. D. Try replacing your usual breakfast with oatmeal or Cream of Wheat.

B Melons and baked potatoes contain potassium. Red meat is high in saturated fat and is to be consumed sparingly. Dairy products are high in calcium. Cereals are fortified with iron; oatmeal contains fiber but not potassium.

Which symptom of pneumonia may present differently in the older adult than in the younger adult? A. Crackles on auscultation B. Fever C. Headache D. Wheezing

B Older adults may not have fever and may have a lower-than-normal temperature with pneumonia. Crackles on auscultation may be present in all age groups as the result of fluid in the lungs. All age ranges may have a headache with pneumonia. Wheezing is an indication of narrowed airways and can be found in all age groups.

The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what percent of oxygen dissociate from the hemoglobin molecule? A. 25% B. 50% C. 75% D. 100%

B Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules when blood perfuses tissues that have an oxygen tension (concentration) of 26 mm Hg. This is considered a "normal" point at which 50% of hemoglobin molecules are no longer saturated with oxygen.

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? A. Less than 30% of the daily caloric intake should be derived from proteins. B. Use canola oil rather than palm oil. C. Consume 10 mg of fiber daily. D. Work toward lowering your high-density lipoprotein (HDL) cholesterol levels.

B Palm oil is higher in saturated fats and should be avoided. Less than 30% of daily calories should come from fats. Clients should be encouraged to consume 30 g of dietary fiber daily. A higher HDL cholesterol level (good cholesterol) is more desirable; clients should strive to reduce low-density lipoprotein cholesterol (bad cholesterol) when elevated.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? A. "I feel my heart beating in my abdominal area." B. "I just started to feel a tearing pain in my belly." C. "I have a headache. May I have some acetaminophen?" D. "I have had hoarseness for a few weeks."

B Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA. The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.

Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? A. Client with abdominal pain and belching B. Client with pressure in the mid-abdomen and profound diaphoresis C. Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows D. Client with claudication and fatigue

B Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety. Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.

Which client should the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? A. Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted B. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes C. Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain D. Client who has many questions about the electrophysiology studies (EPS) scheduled for today

B The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN. An experienced critical care nurse is needed to assist with insertion of a pulmonary artery catheter for hemodynamic monitoring. A client with electrocardiographic changes is potentially unstable; the experienced nurse will need to monitor the electrocardiogram, administer nitroglycerin, and identify additional interventions as needed. The experienced critical care nurse needs to provide extensive teaching about the invasive procedure of EPS; the newly licensed nurse just off orientation may not have the depth of knowledge to perform this teaching independently.

A client who is to undergo cardiac catheterization should be taught which essential information by the nurse? A. "Monitor the pulses in your feet when you get home." B. "Keep your affected leg straight for 2 to 6 hours." C. "Do not take your blood pressure medications on the day of the procedure." D. "Take your oral hypoglycemic with a sip of water on the morning of the procedure."

B The client will remain in bed and the affected leg must remain straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding. The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure; therefore, antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating; they are not taken when the client is NPO for procedures or surgery.

Which client is best to assign to an LPN/LVN working on the telemetry unit? A. Client with heart failure who is receiving dobutamine (Dobutrex) B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea C. Client with pericarditis who has a paradoxical pulse and distended jugular veins D. Client with rheumatic fever who has a new systolic murmur

B The client with dilated cardiomyopathy who needs oxygen only with exertion is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the RN.

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the health care provider before the procedure begins? A. The client has had intermittent substernal chest pain for 6 months. B. The client develops wheezes and dyspnea after eating crab or lobster. C. The client reports that a previous arteriogram was negative for coronary artery disease. D. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.

B The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure. The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain; the intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time; it is nice to know, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure; they can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? A. "You are not contagious unless you stop taking your medication." B. "You will not be contagious to the people you have been living with." C. "You will have to take these medications for at least 1 year." D. "Your sputum may turn a rust color as your condition gets better."

B The people the client has been living with have already been exposed and need to be tested. They cannot be re-exposed simply because the diagnosis has now been confirmed. The client with active tuberculosis is contagious, even while taking medication. 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.

Which method is the best way to prevent outbreaks of pandemic influenza? A. Avoiding public gatherings at all times B. Early recognition and quarantine C. Vaccinating everyone with pneumonia vaccine D. Widespread distribution of antiviral drugs

B The recommended approach to disease prevention consists of early recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus. Public gatherings should be avoided only if a widespread outbreak has occurred in a community. No vaccine is available for pandemic influenza. 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.

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN? A. A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures B. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index C. A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging D. A client with acute coronary syndrome who has just been admitted and needs an admission assessment

B The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and lower extremity. The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing client education; the LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care; the LPN/LVN may implement the plan.

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? A. Calls the family to lift the client's spirits B. Considers further assessment for depression C. Sedates the client to decrease myocardial oxygen demand D. Tells the client that things will get better

B This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done. Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope, and ignores the client's feelings.

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? A. Right atrial pressure is 4 mm Hg. B. Mean arterial pressure (MAP) is 58 mm Hg. C. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. D. PO2 is reported as 78 mm Hg.

B To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain. An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg.

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the provider? A. Partial thromboplastin time (PTT) 60 seconds B. Platelets 32,000/mm3 C. White blood cells 11,000/mm3 D. Hemoglobin 12.2 g/dL

B UFH can also decrease platelet counts. Notify the provider if the platelet count is below 100,000 to 120,000/mm3. Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000/mm3. A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL reflects a normal reading.

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? A. "I can use an electric razor or a regular razor." B. "Eating foods like green beans won't interfere with my Coumadin therapy." C. "If I notice I am bleeding a lot, I should stop taking Coumadin right away." D. "When taking Coumadin, I may notice some blood in my urine."

B Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin. Warfarin "thins" the blood; the risk for cutting oneself and bleeding is very high with the use of a regular razor, so the client should use an electric razor. Clients should apply pressure to bleeding wounds and should seek medical assistance immediately, but they should not discontinue warfarin therapy. Blood in the urine of a client taking warfarin therapy is not a side effect; the client should notify the health care provider immediately if this occurs

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? (Select all that apply.) A. Hypokalemia B. Sinus bradycardia C. Fatigue D. Serum digoxin level of 1.5 E. Anorexia

B,C,E Digoxin toxicity may cause bradycardia. Fatigue and anorexia are symptoms of digoxin toxicity. Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. A serum digoxin level between 0.8 and 2.0 is considered normal and is not a symptom.

Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.) A. Consuming a diet rich in fiber B. Elevated C-reactive protein levels C. Low blood pressure D. Elevated high-density lipoprotein (HDL) cholesterol level E. Smoking

B,E Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease. A diet rich in fiber is not a risk factor for cardiovascular disease; rather, it is a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis; elevated HDL cholesterol is desirable and may be cardioprotective.

A 71-year-old man is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. He is married but has no children. During your assessment, you observe that his color is pale, he is dyspneic, and he reports new onset of chest discomfort. Even though he has oxygen via nasal cannula at 2 L/min., you note that he seems a little confused and is oriented only to person. His oxygen saturation has decreased from 95% to 88%. 1. What lung sounds do you expect to hear and why?

Because the client has a history of COPD, you may hear wheezing, whistling, gurgling, or rattling sounds when auscultating the lungs. Wheezing is consistent with partial airway obstruction caused by mucus or inflammation. Gurgling or rattling sounds suggest the presence of fluid in the lungs.

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? A. Dietary consult B. Sodium restriction C. Daily weight monitoring D. Restricted activity

C A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent. The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions.

Which statement best reflects correct client education for a client with a blood pressure of 136/86 mm Hg? A. This blood pressure is good because it is a normal reading. B. This blood pressure indicates that the client has hypertension or high blood pressure. C. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. D. This blood pressure seems a little low; the client should be further assessed for orthostatic hypotension.

C Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. Hypertension is defined as blood pressure greater than 140/90 mm Hg. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. Orthostatic hypotension is defined as blood pressure less than 90/60 mm Hg.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? A. Serum potassium level of 3.2 mEq/L B. Ejection fraction of 60% C. B-type natriuretic peptide (BNP) of 760 ng/dL D. Chest x-ray report showing right middle lobe consolidation

C BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia may occur in response to diuretic therapy for HF, but may also occur with other conditions; it is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.

A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? A. Maintains NPO (nothing by mouth) until this resolves B. Calls in another nurse for a second opinion C. Performs a complete neurologic assessment and notifies the health care provider D. Explains to the client and family that this is expected after sedation

C Based on this assessment, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness should be reported immediately for prompt intervention. Be confident in this decision; this assessment does not warrant a second opinion. Keeping the client NPO and waiting for symptoms to resolve is not appropriate. Slurred speech is not expected after sedation.

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? A. Completing the antibiotic medication regimen B. Taking pain medications every 4 to 6 hours C. Contacting the provider if the throat feels more swollen D. Using warm saline gargles and irrigations

C Clients with peritonsillar abscess are at risk for airway obstruction due to swelling and should notify the provider if signs of obstruction occur, such as stridor or drooling. It is important to complete the antibiotics to treat the infection, and to adhere to comfort measures such as analgesic medications and saline gargles, but none of these is the most important thing to teach the client.

Which sign/symptom is essential for the nurse to report to the provider when caring for a client with Raynaud's phenomenon? A. Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. B. The client's extremity became white, then red temporarily. C. The affected extremity becomes purple and cold. D. The client states that the digits are painful when they are white.

C Cold, mottled extremities are indicative of occlusion, which could lead to gangrene. Vasodilating drugs are administered as treatment and may lower the blood pressure; this is not a significant drop. In severe cases, the attack lasts longer, and gangrene of the digits can occur. Pain, numbness, and cold are typical findings in Raynaud's phenomenon.

Which nursing action may be delegated to a nursing assistant working on the medical unit? A. Determine the usual alcohol intake for a client with cardiomyopathy. B. Monitor the pain level for a client with acute pericarditis. C. Obtain daily weights for several clients with class IV heart failure. D. Check for peripheral edema in a client with endocarditis.

C Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments; determining alcohol intake, monitoring pain level, and assessing for peripheral edema should not be delegated.

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? A. White blood cell count B. Low-density lipoproteins C. Serum troponin I level D. C-reactive protein

C Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications. The white blood cell count does not reflect ACS; a mild leukocytosis may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem.

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? A. Ecchymosis B. Edema C. Excessive swallowing D. Sore throat

C Excessive swallowing in a client who has undergone a nasoseptoplasty may indicate posterior nasal bleeding and requires immediate attention. Because of the very vascular nature of the face, ecchymosis is a normal finding in the client who has undergone a nasoseptoplasty. 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 side effect of endotracheal intubation.

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? A. "Elevate your legs above heart level to prevent swelling." B. "Inspect your legs daily for brownish discoloration around the ankles." C. "Walk to the point of leg pain, then rest, resuming when pain stops." D. "Apply a heating pad to the legs if they feel cold."

C Exercise may improve arterial blood flow by building collateral circulation; instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther. Elevating the legs in PAD decreases blood flow and increases ischemia. Brown discoloration around the ankles is characteristic of venous occlusive disease. Application of heat should be avoided in clients with PAD owing to lack of sensation and possible burns.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? A. Monitor pulse oximetry and cardiac rate and rhythm. B. Reassure the client that his distress can be relieved with proper intervention. C. Place the client in high-Fowler's position with the legs down. D. Ask a family member to remain with the client

C High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? A. "How does this make you feel?" B. "This can be caused by taking performance-enhancing drugs." C. "This may be caused by a genetic trait." D. "Just imagine how bad it would be if you weren't in good shape."

C Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait. Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? A. Ensure that ED staff members receive oseltamivir (Tamiflu). B. Obtain specimens for the H5 polymerase chain reaction test. C. Place the client in a negative air pressure room. D. Start an IV line and administer rehydration therapy.

C If a client is exhibiting symptoms of avian flu or any other pandemic influenza, he or she is assumed to be contagious until proven otherwise. Preventing the spread of disease to the community is the top priority, so placing the client in a negative air pressure room is the nurse's first action. If avian influenza is diagnosed, it is important that those exposed receive oseltamivir or zanamivir (Relenza) within 48 hours of contact with the client. Obtaining specimens will be important to determine whether the client has avian influenza; this test takes approximately 40 minutes to complete. A client with avian flu will become dehydrated because of diarrhea, so starting an IV to administer rehydration fluid is important, but is not the first priority.

A local hunter is admitted to the intensive care unit with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the health care provider will order? A. Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours B. Ceftriaxone (Rocephin) 2 g IV every 8 hours C. Ciprofloxacin (Cipro) 400 mg IV every 12 hours D. Pyrazinamide (Zinamide) 1000 to 2000 mg orally every day

C Intravenous ciprofloxacin (Cipro) is a first-line drug for treatment of inhaled anthrax. A dose of 400 mg IV every 12 hours is typically used for treatment of anthrax, while a dose of 500 mg orally twice daily is usually prescribed for anthrax prophylaxis. Oral doses of amoxicillin are used only as prophylaxis, not as treatment, for inhaled anthrax. Cephalosporins such as ceftriaxone are not used for treatment of anthrax. Pyrazinamide (Zinamide) is used for treatment of tuberculosis.

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? A. "Are you afraid you will not be able to work?" B. "If you control your diabetes, you can avoid amputation." C. "Your concerns are valid; we can review some steps to limit disease progression." D. "What about the situation concerns you most?"

C It is important to validate the client's concern and offer needed information. Asking the client if he is afraid may identify fear but does not allow the client to discuss his specific concern. Controlling diabetes may help prevent amputation, but the nurse cannot state this with certainty. Asking the client about what concerns him the most is not as open-ended a question as the others; plus, the client has already stated his concern.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? A. The client ambulates around the nursing unit with a walker. B. The nurse monitors the client's pulse and blood pressure frequently. C. The nurse obtains a bedside commode before administering furosemide. D. The nurse returns the client to bed when he becomes tachycardic.

C Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? A. Ankle-brachial index B. Dye allergy C. Pedal pulses D. Gag reflex

C Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring for distal pulses. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses). Ankle-brachial index is a diagnostic study used to detect the presence of PAD; this is not necessary after PTA, which is an intervention to treat PAD. It is imperative to assess for dye allergy before performing PTA. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy); the femoral artery is generally the access site for PTA.

Which symptom reported by a client who has had a total hip replacement requires emergency action? A. Localized swelling of one of the lower extremities B. Positive Homans' sign C. Shortness of breath and chest pain D. Tenderness and redness at the IV site

C Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for deep vein thrombosis (DVT) and PE. Although localized swelling is a symptom of DVT, it is not emergent. Pain in the calf on dorsiflexion of the foot (positive Homans' sign) appears in only a small percentage of clients with DVT, and false-positive findings are common; therefore, assessing for Homans' sign is not advised. Tenderness and redness at the IV site indicate phlebitis and are not emergent, but should be attended to after the emergency.

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? A. Friction rub auscultated at the left lower sternal border B. Pain aggravated by breathing, coughing, and swallowing C. Splinter hemorrhages D. Thickening of the endocardium

C Splinter hemorrhages are indicative of infective endocarditis. Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

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

C The concern is that this client has TB. A respiratory mask should be placed on the client immediately. 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. It is important to remember to let the client know 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.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? A. Auscultation of crackles B. Pedal edema C. Weight loss of 6 pounds since the last visit D. Reports sucking on ice chips all day for dry mouth

C Weight loss in this client indicates effective fluid restriction and diuretic drug therapy. Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.

The nurse understands that the expected assessment for the older adult related to the natural aging process of the respiratory system includes which finding? A. Tightening of the vocal cords B. Decrease in residual volume C. Decrease in the anteroposterior diameter D. Decrease in respiratory muscle strength

D As a person ages, vocal cords become slack, changing the quality and strength of the voice; the anteroposterior diameter increases; respiratory muscle strength decreases; and the residual volume increases.

Which vascular assessment by the student nurse requires intervention by the supervising nurse? A. Measuring capillary refill in the fingertips B. Assessing pedal pulses by Doppler C. Measuring blood pressure in both arms D. Simultaneously palpating the bilateral carotids

D Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion. Prolonged capillary filling generally indicates poor circulation; this is an appropriate assessment. Many clients with vascular disease have poor blood flow, and pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is assessed in both arms.

The nurse is preparing to admit an adult client with pertussis. Which symptom does the nurse anticipate finding in this client? A. "Whooping" after a cough B. Hemoptysis C. Mild cold-like symptoms D. Post-cough emesis

D Clients with pertussis will have paroxysms of coughing often followed by changes in color and/or vomiting. Adults do not usually have the characteristic whooping sound associated with coughing that children with pertussis exhibit. 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.

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? A. "This is a noninvasive test performed to assess your heart rhythm." B. "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." C. "This is a painless test that is done to assess the structure of your heart using sound waves." D. "This test evaluates you for potentially fatal cardiac rhythms."

D EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities. A noninvasive test to assess the heart rhythm best describes the electrocardiogram. Injection of dobutamine (Dobutrex) followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography.

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? A. Homeless people B. Hospital staff C. Politicians D. Prison staff and inmates

D High-risk groups for respiratory infection include those who live in crowded areas such as long-term care facilities, prisons, and mental health facilities. Although homeless people are a high priority, they are not the group at greatest risk of those listed. Education could be provided in shelters or during outreach activities. Hospital staff are at risk owing to their contact with ill clients and family members; however, they are already aware of how to prevent respiratory infection. Politicians are not at higher risk for respiratory infection than any other group with public exposure.

A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? A. "Consume foods high in potassium." B. "Monitor for irregular pulse." C. "Monitor for muscle cramping." D. "Avoid grapefruit juice."

D Kidney disease is one of the most common causes of secondary hypertension. Psychiatric disturbance can exacerbate essential hypertension, but secondary hypertension is caused by a disease process or drugs. High sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? A. Psychiatric disturbance B. High sodium intake C. Physical inactivity D. Kidney disease

D Kidney disease is one of the most common causes of secondary hypertension. Psychiatric disturbance can exacerbate essential hypertension, but secondary hypertension is caused by a disease process or drugs. High sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.) A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg

D,E,F Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.

The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider? A. Saline infusion B. Morphine sulfate C. No treatment, continue monitoring D. Intravenous furosemide

D Normal right atrial pressure is 0 to 5 mm Hg; thus the health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure. Administering saline will increase the right atrial fluid balance and pressure. Morphine is indicated to reduce preload, measured by left ventricular end-diastolic pressure or left atrial pressure. Because this is an abnormal finding, the nurse should collaborate with the provider to decrease the right atrial pressure.

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? A. Auscultate the client's precordium for murmurs. B. Teach the client about the reason for the TEE. C. Reassure the client that the test is painless. D. Validate that the client has remained NPO.

D Owing to the risk for aspiration, the client must be NPO before the procedure. It is anticipated that the client with mitral stenosis may have an audible murmur; auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test because it is uncomfortable.

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? A. Determines the client's physical limitations B. Encourages alternate rest and activity periods C. Monitors and documents heart rate, rhythm, and pulses D. Positions the client to alleviate dyspnea

D Positioning the client to alleviate dyspnea will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action. Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A. A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness B. A 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) C. A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness D. A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

D The 70-year-old's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery. The 64-year-old is most stable and can be seen last. The 60-year-old and the 69-year-old should both be seen soon, but the 70-year-old client must be seen first.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? A. The client has diuresis of 400 mL in 24 hours. B. The client's blood pressure is 122/84 mm Hg. C. The client has an apical pulse of 82 beats/min. D. The client's weight decreases by 2.5 kg.

D The best indicator of fluid volume gain or loss is daily weight; because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid. Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.

All of these client assignments have been made by the charge nurse. Which assignment is questionable? A. The RN with 3 years of experience caring for a client with a pulmonary embolism (PE) who is receiving heparin therapy B. The LPN/LVN with 5 years of experience caring for a client with leg ulcers who is awaiting nursing home placement C. The RN with 8 years of experience caring for a client with peripheral arterial disease (PAD) and a total cholesterol of 390 mg/dL D. The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150 mm Hg

D The client with a headache and high blood pressure has unstable hypertension and is at risk for complications such as stroke, heart failure, or renal failure. The client should be assigned to an experienced RN, who can assess for end-organ damage and administer IV medications. (A better assignment would be to assign the client with a headache to an RN and the client with PAD to the LPN/LVN.) The RN with 3 years of experience has sufficient experience to provide care for a client with PE. The LPN/LVN can provide care for the client with leg ulcers, including dressing changes, if needed. The RN with 8 years of experience has sufficient knowledge to provide care for the client with PAD.

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

D The intranasal flu vaccine is approved for healthy clients ages 2 to 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 new 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.

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition? A. Small amount of blood at the IV insertion site B. Heavy menstrual bleeding C. +1 pitting edema of the affected extremity D. Client stating that the year is 1967

D The most serious complication from thrombolytic therapy is intracerebral bleeding, manifested by changes in the level of consciousness. Thrombolytics such as t-PA dissolve clots; even without this medication, a small amount of blood at the insertion site is not abnormal. Anticoagulants and thrombolytics may cause heavier-than-usual menstrual bleeding. Swelling is expected in the extremity with deep vein thrombosis.

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction? A. C-reactive protein of 1 mg/dL B. Homocysteine level of 13 mmol/L C. Creatine kinase (CK) of 125 mg/dL D. Troponin of 5.2 ng/mL

D The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL. A C-reactive protein level lower than 1 mg/dL is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mmol/dL is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage.

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? A. "I must stop taking my birth control pills." B. "I should drink lots of water so I don't get dehydrated." C. "I should exercise my legs when I have been sitting or standing for a long time." D. "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

D Wearing the graduated compression stockings is a prevention specific to the hospital setting; they are designed to prevent blood clots, unlike regular pantyhose. Discontinuation of birth control pills is a routine prevention for thromboembolism, but this prevention is not specific to the client's acute hospitalization. Drinking a lot of water, where the quantity is not specified, may not be indicated for this client. Exercise is a prevention that can be done outside the hospital.

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? A. Men do not tend to report chest pain. B. Men are more likely than women to die after MI. C. Men more than women tend to deny the importance of symptoms. D. Women may experience extreme fatigue and dizziness as sole symptoms.

D Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like. Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women.

The patient is a 68-year-old man who has had shortness of breath (SOB) for the past 2 to 3 days. His past medical history includes a 40-packyear smoking history, COPD, and heart failure. He reports that he became concerned when he woke from sleep because he could not breathe. Your physical assessment reveals crackles in the lower lobes bilaterally. His oxygen saturation (SpO2) is 84% without supplemental oxygen. 3. What are some factors that may affect gas exchange for this patient?

Decreased alveolar surface area (age related) is likely. Crackles may represent interstitial edema, which will further reduce gas exchange. The patient's decreased endurance will decrease gas exchange. Both his long-standing COPD and his existing heart failure negatively affect his gas exchange.

The patient is a 60-year-old man who has just been diagnosed with non-small cell lung cancer. He smoked cigarettes for about 25 years starting when he was 16 years old and quit when he was 41 years old. His lung cancer is at stage I in the left lower lobe. He is distraught, saying that he can't die now because he has one child in college and two in high school. He also fears chemotherapy and seems bitter that he quit smoking and got lung cancer anyway. His next statement is: "Why couldn't I get prostate cancer like most men? At least they survive. No one beats lung cancer." 1. For this cancer stage and type, what is/are the most likely therapy/therapies?

For stage I NSCLC, the treatment of choice is surgery with total removal of the tumor and probably of the left lower lobe. This surgery can now result in a cure of the disease. Additionally, because it is the left lung, which is smaller than the right and does not participate in gas exchange to the same degree, removal of the left lower lobe would not greatly change his physical endurance.

The patient is a 64-year-old man with COPD who lives with his wife of 35 years. He retired 2 years ago when his disease interfered with his with his job as a carpenter. He also quit smoking a year ago. Since then, his disease has remained stable; however, he now reports that he thinks his wife is preparing for widowhood by taking over all the home chores that he always performed (including driving and bill paying), limiting his interaction with friends, and making all decisions. He is angry and depressed. Routine assessment with pulmonary function testing show his FEV1 to be 40% of his predicted value, which is an improvement over the 32% value of FEV1 last year. 1. Should he continue to drive and pay bills? Why or why not?

If he is cognitively intact, without dizziness, and has sufficient endurance to steer the car correctly and stop appropriately, he should be allowed to continue to drive. He could be evaluated by the state highway patrol or the state driver's licensing bureau to ensure that his driving is safely performed. Bill paying is not a strenuous physical activity and could make him feel as though he were a contributing member of the family.

At a recent staff meeting, the medical-surgical nurse manager reports that the rate of repeated hospitalizations for patients with chronic heart failure has increased 50% in the past 3 months. As a staff nurse, you agree to be part of the unit quality improvement (QI) team to examine the cause(s) of the increase and make evidence-based recommendations for improving the outcomes for this patient population. Specific patient data and summaries are available for the team to review as needed. 1. Formulate a PICOT clinical question using the format described in Chapter 5.

PICOT questions may vary depending on whether intervention, etiology, diagnosis, prevention, meaning, or prognosis is being studied by the team. An example PICOT clinical question is: "Within a 90-day period following discharge (T), are patients with chronic heart failure (P) who comply with their most recent hospital discharge instructions (I) at decreased risk for repeat hospitalization (O) compared with patients with chronic heart failure (P) who are not compliant with their most recent hospital discharge instructions (C)?"

The patient is a 67-year-old man with moderate emphysema. He has just been admitted to the medical unit with a diagnosis of shortness of breath related to influenza. In the emergency department he received a chest x-ray and a nebulizer treatment with albuterol. He also had a saline lock placed and arterial blood gases were sent to the laboratory. Vital signs before transfer were: BP 158/92; HR 92; RR 32; T 101.4° F. The health care provider wrote the following orders: • Obtain admission vital signs • Schedule pulmonary function tests • Tylenol 650 mg orally as needed • Oxygen at 2 L per nasal cannula • Nebulizer treatment with albuterol every 6 hours • Intravenous antibiotic administration • Use of an incentive spirometer hourly • Drawing blood for a culture and sensitivity 1. The patient continues to have an elevated temperature (now 102.4° F). Which actions should you delegate to the LPN/LVN working with you and why?

The LPN/LVN can administer Tylenol, take vital signs, and encourage the use of the incentive spirometer. Administering oral medications, reminding patients about care, and monitoring temperature are all within the scope of practice for an LPN/LVN. IV antibiotic administration and drawing blood sample require additional training (depending on the state's nurse practice act).

The patient is a 67-year-old man with moderate emphysema. He has just been admitted to the medical unit with a diagnosis of shortness of breath related to influenza. In the emergency department he received a chest x-ray and a nebulizer treatment with albuterol. He also had a saline lock placed and arterial blood gases were sent to the laboratory. Vital signs before transfer were: BP 158/92; HR 92; RR 32; T 101.4° F. The health care provider wrote the following orders: • Obtain admission vital signs • Schedule pulmonary function tests • Tylenol 650 mg orally as needed • Oxygen at 2 L per nasal cannula • Nebulizer treatment with albuterol every 6 hours • Intravenous antibiotic administration • Use of an incentive spirometer hourly • Drawing blood for a culture and sensitivity 1. Which action should you delegate to the unlicensed assistive personnel (UAP) who is helping you to admit the patient? Provide a rationale for your choice.

The only action with the scope of practice for the UAP is to obtain this patient's admission vital signs. Administering medications, assessment of lungs, and patient teaching all require additional training and are appropriate to the scope of practice of licensed nurses.

The patient is a 67-year-old man with moderate emphysema. He has just been admitted to the medical unit with a diagnosis of shortness of breath related to influenza. In the emergency department he received a chest x-ray and a nebulizer treatment with albuterol. He also had a saline lock placed and arterial blood gases were sent to the laboratory. Vital signs before transfer were: BP 158/92; HR 92; RR 32; T 101.4° F. The health care provider wrote the following orders: • Obtain admission vital signs • Schedule pulmonary function tests • Tylenol 650 mg orally as needed • Oxygen at 2 L per nasal cannula • Nebulizer treatment with albuterol every 6 hours • Intravenous antibiotic administration • Use of an incentive spirometer hourly • Drawing blood for a culture and sensitivity 1. Which order takes priority at this time? Provide a rationale for your choice.

The oxygen should be started before anything else. The priority for this patient's care is the airway. He has emphysema and the flu, both of which can result in decreased gas exchange and reduced oxygenation.

A 67-year-old man recently lost his wife after being married for 42 years. He met his wife shortly after he returned from Vietnam as a combat soldier. He visits his physician and reports decreased appetite, moodiness, and extreme fatigue, even though he sleeps 10 to 12 hours a night. When giving his medical history, he admits that he drinks 4 or 5 beers and smokes marijuana almost every day. 1. What do you think caused this man's new symptoms and why?

The patient has encountered a new major stress event in his life with the loss of his wife of 42 years. He may have possible clinical depression and is trying to cope with his loss by drinking and using marijuana.

A 67-year-old man recently lost his wife after being married for 42 years. He met his wife shortly after he returned from Vietnam as a combat soldier. He visits his physician and reports decreased appetite, moodiness, and extreme fatigue, even though he sleeps 10 to 12 hours a night. When giving his medical history, he admits that he drinks 4 or 5 beers and smokes marijuana almost every day. 1. For what safety issues is this older adult at risk and why?

The patient is at risk for falling or having an accident while driving after consuming alcohol or drugs. These substances cause dizziness and drowsiness and impair judgment. He may also be at risk for suicide if he is diagnosed with severe clinical depression.

A nursing home administrator reports having severe headache and facial flushing for the past 3 weeks. He does not smoke but is overweight. Both of his parents have hypertension and cardiac disease. One of his nurses takes his blood pressure, which is 210/116. He states that he will see his primary care provider as soon as possible. At the physician's office, his heart rate is 88 beats/min, blood pressure is 190/110, and respiratory rate is 24 breaths/min. 1. What type of drug therapy may be prescribed for this patient? What are your nursing responsibilities when giving these drugs?

The patient may be prescribed a diuretic, which is the first type of drug indicated for managing hypertension. Diuretics are used to decrease blood volume and lower blood pressure. Teach the patient to take his diuretic in the morning rather than at night to prevent nocturia. If the patient is prescribed a calcium channel blocker, teach him to avoid grapefruit and grapefruit juice. If the patient is prescribed an angiotensin-converting enzyme inhibitor, teach him that a common side effect of this group of drugs is a nagging, dry cough and that he should report this to his health care provider.

A patient who had a supraglottic partial laryngectomy with a right-sided radical neck dissection 4 weeks ago is now receiving radiation therapy. He has lost 24 pounds since his surgery, which makes him 15 pounds less than his ideal weight. He tells you that he has no appetite and that what food he does eat "has no taste." In addition, although he expresses that he is glad to be alive, he does not want friends to visit because it takes so much energy to interact with them. He also says that he can no longer play the piano because of difficulty moving his right arm and shoulder. 1. Is the weight loss a concern? If so, what should you do about it?

Yes, his weight loss is very concerning and can interfere with his healing and recovery. The first action should be to involve a registered dietitian in his care. Ask him about food preferences. Work with whoever plans and cooks his meals to provide more protein and calories in the food he eats. Suggest using liquid supplements between meals.

The patient is a 64-year-old man with COPD who lives with his wife of 35 years. He retired 2 years ago when his disease interfered with his with his job as a carpenter. He also quit smoking a year ago. Since then, his disease has remained stable; however, he now reports that he thinks his wife is preparing for widowhood by taking over all the home chores that he always performed (including driving and bill paying), limiting his interaction with friends, and making all decisions. He is angry and depressed. Routine assessment with pulmonary function testing show his FEV1 to be 40% of his predicted value, which is an improvement over the 32% value of FEV1 last year. 1. Should you include the wife in any part of this discussion? Why or why not?

Yes, his wife should be included and should be encouraged to express her true feelings about the situation. Most likely, she is concerned that her husband's health will deteriorate faster if he exerts himself. Stress the concept that muscle strength and endurance can be maintained or even improved over time with some structured physical activity, although the basic disease will not improve. Also remind them that total inactivity will result in faster deconditioning.

A middle-aged man is admitted to the cardiac unit after reports of a severe headache and flushing of the face. He is diagnosed with severe hypertension. The patient is alert and oriented; BP = 192/104 and HR = 88. You are the RN assigned to his care. There is an unlicensed nursing technician working with you. 1. The cardiologist prescribes IV fluids, hourly blood pressure checks, blood pressure medication, and oxygen at 2 liters per nasal cannula. What part of the patient's care will you delegate to the unlicensed nursing technician? What information will you communicate upon delegation?

You can delegate hourly blood pressure checks to the unlicensed nursing technician, with the understanding that you must follow all Nurse Practice Acts related to appropriate delegation. You must communicate the task that is to be performed (blood pressure checks), the frequency of the task (hourly), and the method by which the task should be accomplished (manual vs. automated monitoring). You should also clarify that you need the unlicensed nursing technician to report his or her findings back to you hourly. It is important that you follow up with the unlicensed nursing technician hourly to obtain a report of the vital signs that were taken, so that you can make appropriate nursing decisions based on that data.

A middle-aged man is admitted to the cardiac unit after reports of a severe headache and flushing of the face. He is diagnosed with severe hypertension. The patient is alert and oriented; BP = 192/104 and HR = 88. You are the RN assigned to his care. There is an unlicensed nursing technician working with you. 1. What assessment data will you perform upon his arrival to the unit? Why?

You will assess all vital signs, specifically blood pressure, and conduct a head-to-toe physical assessment. Vital signs should be taken to continue observing the patient's condition (specifically hypertension) and trended to determine if treatment and interventions are working. During the physical assessment, you will specifically need to listen to the heart for the presence or absence of murmurs or other abnormal heart sounds and perform a basic neurologic assessment to determine the patient's orientation for baseline purposes.