Med Surg I Exam 2

The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicate an understanding of this prescription? 1. "These pills will make me feel better fast and I can return back to work." 2. "The antibiotics will help prevent me from developing a bacterial pneumonia." 3. "If I had gotten this prescription sooner, I could have prevented this illness." 4. "I need to take these pills until I feel better; then I can stop taking the rest."

2 Rationale: Secondary bacterial infections often accompany influenza, and antibiotics are often prescribed to help prevent the development of a bacterial infection resulting from a weakened client immune system.

A nurse at a provider's office is reviewing information with a client scheduled for a pulmonary function tests (PFTs). Which of the following information should the nurse include? 1. "Do not use inhaler medications for 6 hr following the test." 2. "Do not smoke tobacco for 6 to 8 hr prior to the test." 3. "You will be asked to bear down and hold your breath during the test." 4. "The arterial blood flow to your hand will be elevated as part of the test."

2 Rationale: To ensure accurate results, the client should not smoke tobacco for 6 to 8 hr prior to the test.

The client is admitted to emergency department complaining of shortness of breath and fever. The vitals signs are T 100.4, P 94, R 26, and BP 134/86. Which concept should the nurse identify as a concern for the client. Select all that apply. 1. Clotting 2. Oxygenation 3. Infection 4. Perfusion 5. Coping

2 & 3 Rationale: Shortness of breath and a low-grade fever indicate pneumonia; the oxygenation and infection concept applies to the client.

The client diagnosed with community-acquired pneumonia is admitted to the medical unit. Which health-care provider order should the nurse implement first? 1. Start IV with 1,000 mL 0.9% saline 2. Ceftriaxone 1 g IVPB every 12 hours 3. Obtain sputum and blood cultures 4. CBC and basic metabolic panel

3 Rationale: Culture specimens should be obtained prior to the initiation of antibiotic medication to prevent skewing of results.

The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)? 1. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain. 2. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who till not swallow medication. 3. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad. 4. The 45-year-old client diagnosed with a peritonsillar abscess who requires VPB antibiotic therapy four (4) times a day.

3 Rationale: The postoperative client with purulent drainage could be developing an infection. The experienced nurse would be needed to assess and monitor the client's condition.

Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply. 1. Assessing temperature every 4 hours 2. Checking ventilator settings every 4 hours 3. Getting the patient out of bed as soon as prescribed 4. Keeping the head of the bed elevated to 30 degrees or above 5. Maintaining the client in the prone position 6. Providing adequate humidification 7. Providing meticulous mouth care every 12 hours 8. Suggesting that the pneumonia vaccine be prescribed

3, 4, 7

The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication? 1. Muscle weakness 2. Purulent sputum 3. Nuchal rigidity 4. Intermittent loss of muscle control

3. Nuchal rigidity Rationale: Nuchal rigidity is a sign/symptom of meningitis, which is a life-threatening potential complication of sinusitis resulting from the close proximity of the sinus cavities to the meninges.

An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse's priority action? 1. Placing a nasotracheal tube 2. Assessing for bilateral breath sounds 3. Assessing for oxygen saturation by pulse oximetry 4. Applying oxygen with a bag-valve-mask device

4

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? 1. Blood-tinged sputum 2. Dry, nonproductive cough 3. Sore throat 4. Bronchospasms

4 Rationale: Bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse should notify the provider immediately.

The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss? 1. Instruct the children to always keep a tissue or handkerchief with them. 2. Explain that the children current with immunizations will not get a cold. 3. Tell the children they should go to the doctor if they get a cold. 4. Demonstrate to the students how to properly wash hands correctly

4 Rationale: Hand washing is the single most useful treatment for prevention of disease.

The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy? 1. Vitamin C 2,000 mg daily 2. Strict bedrest 3. Humidification of air 4. Decongestant therapy

1 Rationale: Alternative therapies are not accepted as standard medical practice. These may be encouraged as long as they do not interfere with the medical regimen. Vitamin C in large doses is thought to improve the immune system's function.

A nurse is caring for a client scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? 1. Position the client in an upright position, leaning over the bedside table 2. Explain the procedure 3. Obtain ABGs 4. Administer benzocaine spray

1 Rationale: Positioning the client in an upright position and bent over the bedside table widens the intercostal space for the provider to access the pleural fluid.

Which information should the nurse teach the client diagnosed with acute sinusitis? 1. Instruct the client to complete all the ordered antibiotics. 2. Teach the client how to irrigate the nasal passages. 3. Have the client demonstrate how to blow the nose. 4. Give the client samples of a narcotic analgesic for the headache.

1 Rationale: The client should always be taught to take all of the antibiotics as ordered. Discontinuing antibiotics prior to the full dose results in the development of antibiotic-resistant bacteria. Sinus infections are difficult to treat and may become chronic and will then require several weeks of therapy or possibly surgery to control.

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? Select all that apply. 1. Client who has dysphagia 2. Client who has AIDS 3. Client who was vaccinated for pneumococcus and influenza 6 months ago 4. Client who is postoperative and has received local anesthesia 5. Client who has a closed head injury and is receiving mechanical ventilation 6. Client who has myasthenia gravis

1, 2, 5, 6 Rationale: The client who has difficulty swallowing is at increased risk for pneumonia due to aspiration. The client who has AIDS is immunocompromised, which increases the risk of opportunistic infections, such as pneumonia. Mechanical ventilation is invasive and places the client at risk for ventilator-associated pneumonia. A client who has myasthenia gravis has generalized weakness and can have difficulty clearing airway secretions, which increases the risk of pneumonia.

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risk for complications? Select all that apply. 1. Dyspnea 2. Localized bloody drainage on the dressing 3. Fever 4. Hypotension 5. Report of pain at the puncture site

1, 3, 4 Rationale: Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. Fever can indicate infection. Hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation b. administer prescribed albuterol nebulizer therapy c. Place the client in high-fowlers position d. Ask the client to perform deep-breathing exercises.

A Rationale: Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor ad hypoxia, manifested by anxiety and restlessness, should be immediately intubates to ensure airway patency.

The charge nurse receives morning laboratory and respiratory data on the clients. Which data requires immediate intervention? 1. ABG results of pH 7.35, PaCO2 56, HCO3 29, PaO2 78 for a client diagnosed with COPD. 2. Pulse oximetry reading of 89% on a two-day postsurgical total knee replacement. 3. Hgb of 9 g/dL and Hct of 28% on a client who is receiving the second unit of blood. 4. B-type natriuretic peptide (BNP) of 100 on a client diagnosed with stage 4 congestive heart failure

2 Rationale: This pulse oximetry reading indicates an arterial blood oxygen of less than 60. The client should be seen immediately to prevent respiratory failure.

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients

A Rationale: Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inpatient admission or within 6 hours of presentation to the ED.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? Select all that apply. a. Create a communication system b. Don't go out in public alone c. Find hobbies to enjoy at home d. Try loose-fitting shirts with collars e. Wear fashionable scarves

A, D, E Rationale: The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? Select all that apply. a. I held the clients morning bronchodilator medication b. The client is ready to go down to radiology for this examination c. Physical therapy states the client can run on a treadmill d. I advised the client not to smoke for 6 hours prior to the test e. The client is alert and can follow your commands

A, D, E Rationale: To ensure PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers.

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. Bronchodilator Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators b. Cholinergic antagonist Causes bronchodilation by inhibiting the parasympathetic nervous system c. Corticosteroid Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors d. Cromone Disrupts the production of pathways of inflammatory mediators

B Rationale: Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that actives beta2 receptors.

A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. Albumin 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm3 d. White blood cell (WBC) count: 12,500/mm3

B Rationale: INH can cause liver damage, especially if the client drinks alcohol. The ALT is extremely high ad needs to be reported immediately.

The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine? 1. Elderly and chronically ill clients 2. Child-care workers and children less than four (4) years of age 3. Hospital chaplains and health-care workers 4. Schoolteachers and students living in a dormitory

1 Rationale: The elderly and chronically ill are at great risk for developing serious complications if they contract the influenza virus.

The client diagnosed with respiratory distress has arterial blood gases of pH 7.45; PaCO2 54; HCO3 25; PaO2 52. Which should the nurse implement? Select all that apply. 1. Apply oxygen via nonrebreather mask 2. Call the rapid response team (RRT) 3. Elevate the head of the bed 4. Stay with the client 5. Notify the health-care provider (HCP)

1, 2, 3, 4, 5 Rationale: The PaO2 is very low; this client should be placed on a ventilator. The nurse should provide as much oxygen as possible until this can be done. The RRT is called when an individual identifies a situation that requires immediate intervention to prevent the client from going into an arrest situation. Elevating the HOB allows for better lung expansion. The nurse should not leave the client but should direct care from the bedside. The HCP should be notified of the client's status.

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning. c. Suctioning for a total of three times if needed. d. Suctioning for only 10 to 15 seconds each time.

A Rationale: Suction should only be applied while withdrawing the catheter.

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first? a. Ask the client to gargle with mouthwash containing lidocaine b. Administer prescribed intravenous pain medications c. Explain that soreness is normal and will improve in a couple days d. Assess the clients neck for redness and swelling

A Rationale: Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can provide relief from a sore throat after radiation therapy.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucous glands producing large amounts of thick mucous d. Left ventricular hypertrophy creating a decrease in cardiac output

A Rationale: Smoking increase pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema.

Which teaching point is most important for the client with bacterial pharyngitis? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.

B Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria.

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

A Rationale: The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mmHg on the cardiac monitor. What action by the nurse takes priority? a. Assess the clients lung sounds b. Notify the rapid response team c. Provide reassurance to the client d. Take a full set of vital signs

B Rationale: This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment.

A nurse assesses a client with a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply) a. Production of pink sputum b. Tracheal deviation c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage of 75 mL/hr

B & C Rationale: Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation.

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and akin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3

B, C Rationale: Rifampin can cause liver damage, evidenced by the clients high INR and prothrombin time.

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the clients activity tolerance? (Select all that apply) a. What color is your sputum? b. Do you have any difficulty sleeping? c. How long does it take to perform your morning routine? d. Do you walk upstairs every day? e. Have you lost weight lately?

B, C, E Rationale: Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat.

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurses immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site

B, D, E, F Rationale: Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

A Rationale: The treatment regimen for TB ranges from 6 to 12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy.

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in the clients plan of care? Select all that apply a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client 3x a day d. Provide a diet high in protein and vitamins e. Administer acetaminophen (Tylenol) twice daily.

A, C, D Rationale: Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection.

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? Select all that apply. 1. Oxygen equipment 2. Incentive spirometer 3. Pulse oximeter 4. Sterile dressing 5. Suture removal kit

1, 3, 4 Rationale: Oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure. Pulse oximetry is necessary to monitor oxygen saturation level during the procedure. A sterile dressing is necessary to apply to the puncture site following the procedure.

A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply. 1. Decreased SpO2 2. Elevated temperature 3. Crackles auscultated over the trachea 4. Crackles auscultated in the lung periphery 5. High-pressure ventilator alarm sounds 6. Presence of fluid within the endotracheal tube 7. Presence of fluid within the ventilator tubing

1, 3, 4, 6

A nurse assess a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next? a. Collect the nasal drainage on a piece of paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination d. Palpate the nose, face, and neck

A Rationale: the client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of the cerebrospinal fluid (CSF),=. CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper.

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Initiate standard precautions b. apply direct pressure c. Sit the client upright d. Loosely pack the nares with gauze

A Rationale: the nurse should implement standard precautions and don gloves prior to completing the other actions.

A nurse assess a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 liters of oxygen d. The trachea is deviated toward the opposite side of the neck

D Rationale: A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What response by the nurse is best? a. Breathing so quickly can be dehydrating. b. Everyone with pneumonia is dehydrated. c. This is really just to administer your antibiotics. d. Why do you think you are so dehydrated?

A Rationale: Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to degree of dehydration.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation b. Notify the Rapid Response Team c. Oxygenate the client with a bag-valve-mask d. Palpate the skin of the upper chest

A Rationale: The client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should fist assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for air.

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency

D Rationale: A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. a. Applying water-soluble lip balm to the clients lips b. Ensuring the humidification provided is adequate. c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions though the tracheostomy

A & D Rationale: The UAP can perform hygiene measures such as applying lip and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises.

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply) a. Assisting with the chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours

A, B, C, D Rationale: The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse should perform frequent respiratory system assessments. Antipyretic medications are also used.

A nurse pans care for a client who has COPD and thick, tenacious secretions. Which interventions should the nurse include in this clients plan of care? (Select all that apply). a. Ask the client to drink 2 liters of fluid daily b. Add humidity to the prescribed oxygen c. Suction the client every 2 to 3 hours d. Use a vibrating positive expiratory pressure device e. Encourage diaphragmatic breathing

A, B, D Rationale: Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions.

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

A, B, D Rationale: Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions.

A nurse is planning discharge teaching on tracheostomy care for an older adult client. What factors does the nurse need to access before teaching this particular client? (Select all that apply) a. Cognition b. Dexterity c. Hydration d. range of motion e. Vision

A, B, D, E Rationale: The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and should be assessed.

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? Select all that apply a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

A, C, D, E Rationale: Clients over 65 years of age and any client (no matter the age) with a chronic health condition would be considered a priority for a pneumonia vaccination.

A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? a. Review the clients pulmonary function test results b. Ask about medications the client is currently taking c. Assess how frequently the client uses a bronchodilator d. Consult the provider and request arterial blood gases

B Rationale: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the clients history.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Evaluate the head of the clients bed b. Measure and compare cuff pressures c. Place the client on NPO status d. Request that the client have a swallow study

B Rationale: Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next? a. Administer an albuterol treatment. b. Notify the rapid response team. c. Assess the client peripheral pulses d. Obtain blood and sputum cultures

B Rationale: Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care.

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. Chest x-rays are always ordered when we suspect pneumonia. b. Older people often have vague symptoms, so an x-ray is essential. c. The x-ray can be done and read before laboratory work is reported. d. We are testing for any possible source of infection in the client.

B Rationale: It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive manifestations are present to obtain the x-ray leads to a costly delay in treatment.

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond? a. I will consult the speech therapist to ensure you are swallowing properly. b. This is normal after surgery. What types of food do you like to eat? c. I will ask the dietician to change the consistency of the food in your diet. d. Replacement of protein, calories, and water is very important after surgery.

B Rationale: Many clients experience changes in taste after surgery. The nurse should identify foods that the client wants to eat to ensure client maintains necessary nutrition.

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the clients oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

B Rationale: Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has approved switching to a nasal cannula during meals.

The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the clients on Contact Precautions. b. Cohort the clients in the same area of the unit. c. Do not allow pregnant caregivers to care for these clients. d. Place the clients on enhanced Droplet Precautions.

B Rationale: Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Clients can be cohorted together in the same set of rooms on one part of the unit to use distancing to help prevent the spread of the disease.

A client is scheduled to have a tracheostomy placed in one hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously d. Start the preoperative antibiotic infusion

B Rationale: Since this is an operative procedure, the client must sign an informed consent, which must be on the chart.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions

B Rationale: The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30 pack-year history of smoking b. A 52-year old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions

B Rationale: The client who is in tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure.

A nurse observes that a clients anterior-posterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding? a. Are you taking ant medications or herbal supplements? b. Do yo have any chronic breathing problems? c. How often do you perform aerobic exercise? d. What is your occupation and what are your hobbies?

B Rationale: The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or sever chronic asthma.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60 pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client he needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.

C

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best? a. Breathing so rapidly interferes with oxygenation b. Maybe the client has respiratory distress syndrome c. The blood clot interferes with perfusion in the lungs d. The client needs immediate intubation and mechanical ventilation

C Rationale: A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated.

A nurse assess a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client states he is dizzy. Nurse applies oxygen and pulse oximetry. b. Client heart rate is 55 beats/min. Nurse withholds pain medication. c. Client has reduced breath sounds. Nurse calls physician immediately. d. Client respiratory rate is 18 breaths/min. Nurse decreases oxygen flow rate.

C Rationale: A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately.

A nurse working in a geriatric clinic sees clients with cold symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor- Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

C Rationale: Fexofenadine is a second-generation antihistamine. First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine.

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a. I need to take extra vitamin C while on INH b. I should take this medicine with milk or juice c. I will take this medication on an empty stomach d. My contact lenses will be permanently stained

C Rationale: INH needs to be taken on an empty stomach, either 1 hour before and 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin (Rifadin).

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching? a. I will carry this medication with me at all items in case I need it b. I will take this medication when I start to experience an asthma attack c. I will take this medication every morning to help prevent a acute attack d. I will be weaned off this medication when I no longer need it

C Rationale: Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. There are a variety of support groups for people who have COPD. b. I will ask your provider to prescribe you with an antianxiety agent. c. Share any thoughts and feelings that cause you to limit social activities. d. Friends can be a good support system for clients with chronic disorders.

C Rationale: Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected.

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, "How will this medication help me?" How should the nurse respond? a. This medication will treat your sleep apnea b. This sedative will help you to sleep at night c. This medication will promote daytime wakefulness d. This analgesic will increase comfort while you sleep.

C Rationale: Modafinil is helpful for clients who have narcolepsy (uncontrollable daytime sleep) related to sleep apnea. This medication promotes daytime wakefulness.

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

C Rationale: Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to a UAP.

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will be certain to shake the inhaler well before I use it. b. It may take a while before I notice a change in my asthma. c. I will use the drug when I have an asthma attack. d. I will use the drug when I have an asthma attack.

C Rationale: Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it should not be used as a rescue drug.

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole wheat bread d. Pasta salad, custard, orange juice

C Rationale: Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus

C Rationale: The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. Ice packs may help with the facial pain. b. Limit fluids to dry out your sinuses. c. Try warm, moist heat packs on your face. d. We will schedule you for a computed tomography scan this week.

C Rationale: The client has rhinosinusitis. Comfort measures for this condition include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation b. Administer prescribed intravenous pain medication c. Assist the client to choose a communication method d. Ambulate the client in the hallway to assess gait

C Rationale: The client will not be able to speak after the surgery. The nurse should assist the client to choose a communication method that he or she would like to use after the surgery.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? a. Call the physician and request a prescription for food or water. b. Provide the client with ice chips instead of a drink of water. c. Assess the clients gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

C Rationale: The topical anesthetic used during the procedure will have affected the clients gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

C Rationale: To prevent ulcers and for client safety, when ties are uses that must be knotted, the knot should be placed at the side of the clients neck, not the back.

A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention? a. Hollow sounds are heard all over the trachea. The nurse increases the oxygen flow rate. b. Crackles are heard in bases. The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.

C Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no interventions.

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

C, E Rationale: Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client

D Rationale: A thoracentesis is an invasive procedure with many potential serious complications.

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. When the insertion site becomes red and warm to the touch b. When the tube drainage decreases and becomes sanguineous c. When the client experiences pain at the insertion site d. When the tube becomes disconnected from the drainage system

D Rationale: Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax.

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the clients anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

D Rationale: A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3 = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 92%.

D Rationale: Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the clients hypoxia, which is the priority.

A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction at the level prescribed by the provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

D Rationale: Padded clamps should be kept at the bedside for use if the drainage system becomes dislodged or is interrupted.

A client is in the family practice clinic reporting a severe cold that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

D Rationale: Sneezing and coughing into ones sleeve helps prevent the spread of upper respiratory infections. The client does have manifestations of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset.

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who has a longer expiratory phase than inspiratory phase d. A 27-year-old client with a heart rate of 120 beats/min

D Rationale: Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding.

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year old client with an oxygen saturation level of 92% at rest c. A 35-year-old who has a longer expiratory phase than inspiratory phase d. A 27-year-old client with a heart rate of 120 beats/min

D Rationale: Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask d. Stay with the client and have someone else call the provider immediately.

D Rationale: This client may have a tracheainnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.

A nurse caring for an older client who has a pulmonary infection. Which action should the nurse take first? a. Encourage the client to increase fluid intake. b. Assess the client's level of consciousness c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.

b Rationale: Assessing the clients level of consciousness will be the most important because it will show how the client is responding to the presence of the infection.