Med surge Quiz 2 part 2 (TB CH 25-27)

During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply) A. a vigorous reflex cough B. increased chest expansion C. increased residual volume D. decreased lung sounds at the base of the lungs E. increased anteroposterior (AP) chest diameter

. Correct answers: c, d, e Rationale: The anterior-posterior diameter of the thoracic cage and the residual volume increase in older adults. An older adult has a less forceful cough. The costal cartilages calcify with aging and interfere with chest expansion. Decreased breath sounds at the base of lungs is also a common finding in older adults

The nurse is performing a respiratory assessment. Which finding best supports the presence of impaired airway clearance? A. Basilar crackles B. Oxygen saturation of 85% C. Presence of greenish sputum D. Respiratory rate of 28 breaths/min

A. Basilar crackles Rationale: The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with impaired airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with other lower respiratory problems.

A school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus? (Select all that apply.) A. Cover the nose when coughing. B. Obtain an influenza vaccination. C. Stay at home when symptomatic. D. Drink noncaffeinated fluids daily. E. Obtain antibiotic therapy promptly.

A, B, C Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic. Rationale: Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.

During admission of a patient diagnosed with non-small cell lung cancer, the nurse questions the patient related to a history of which risk factors for this type of cancer? (Select all that apply.) A. Asbestos exposure B. Exposure to uranium C. Chronic interstitial fibrosis D. History of cigarette smoking E. Geographic area in which they were born

A, B, D Asbestos exposure Exposure to uranium History of cigarette smoking Rationale: Non-small cell cancer is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk but not necessarily where the patient was born.

19. A patient arrives in the emergency department with a possible nasal fracture after being hit by a baseball. Which finding by the nurse is most important to report to the health care provider? a. Clear nasal drainage b. Report of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose

ANS: A Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate complications.

The nurse is caring for a postoperative patient with impaired airway clearance. What nursing actions would promote airway clearance? (Select all that apply.) A. Maintain adequate fluid intake. B. Maintain a 15-degree elevation. C. Splint the chest when coughing. D. Have the patient use incentive spirometry. E. Teach the patient to cough at end of exhalation.

A, C, E Maintain adequate fluid intake. Splint the chest when coughing. Teach the patient to cough at end of exhalation. Rationale: Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should teach the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. Incentive spirometry promotes lung expansion. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

The nurse is admitting a patient with a diagnosis of pulmonary embolism. Which risk factors are a priority for the nurse to assess? (Select all that apply.) A. Cancer B. Obesity C. Pneumonia D. Cigarette smoking E. Prolonged air travel

A,B, D,E Cancer Obesity Cigarette smoking Prolonged air travel Rationale: An increased risk of pulmonary embolism is associated with obesity, cancer, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

The nurse is caring for a patient with a fever due to pneumonia. What assessment data does the nurse obtain that correlates with the patient having a fever? (Select all that apply.) A. A temperature of 101.4° F B. Heart rate of 120 beats/min C. Respiratory rate of 20 breaths/min D. A productive cough with yellow sputum E. Reports of unable to have a bowel movement for 2 days

A,B,D A temperature of 101.4° F Heart rate of 120 beats/min A productive cough with yellow sputum Rationale: A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.

A patient with a persistent cough is diagnosed with pertussis. What medication does the nurse anticipate administering to this patient? A. Antibiotic B. Corticosteroid C. Bronchodilator D. Cough suppressant

A. Antibiotic Rationale: Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordetella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.

1. While listening to the posterior chest of a patient who is experiencing acute shortness of breath, the nurse hears these sounds. How should the nurse document the lung sounds? Click here to listen to the audio clip a. Pleural friction rub b. Low-pitched crackles c. High-pitched wheezes d. Bronchial breath sounds

ANS: C Wheezes are continuous high-pitched or musical sounds heard initially with expiration. The other responses are typical of other adventitious breath sounds.

A patient with a gunshot wound to the right side of the chest arrives in the emergency department with severe shortness of breath and decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? A. Cover the chest wound with a nonporous dressing taped on three sides. B. Pack the chest wound with sterile saline soaked gauze and tape securely. C. Stabilize the chest wall with tape and initiate positive pressure ventilation. D. Apply a pressure dressing over the wound to prevent excessive loss of blood.

A. Cover the chest wound with a nonporous dressing taped on three sides. Rationale: The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.

A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? A. IV antibiotic therapy will be started as soon as possible. B. Lobectomy surgery is usually needed to drain the abscess. C. Oral antibiotics will be used until there is evidence of improvement. D. Culture and sensitivity tests are needed for 1 year after resolving the abscess.

A. IV antibiotic therapy will be started as soon as possible. Rationale: IV antibiotics are used until the patient and radiographs show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.

During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? A. Pneumococcal B. Staphylococcus aureus C. Haemophilus influenzae D. Bacille-Calmette-Guérin (BCG)

A. Pneumococcal Rationale: The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, or living in a long-term care facility. A S. aureus vaccine has been researched but not yet been effective. The H. influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis is prevalent.

An older adult patient living alone is admitted to the hospital with pneumococcal pneumonia. Which clinical manifestation is consistent with the patient being hypoxic? A. Sudden onset of confusion B. Oral temperature of 102.3° F C. Coarse crackles in lung bases D. Clutching chest on inspiration

A. Sudden onset of confusion Rationale: Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.

The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurse's priority action? A. Test the drainage for the presence of glucose. B. Suction the nose to maintain airway clearance. C. Document the findings and continue monitoring. D. Apply a drip pad and reassure the patient this is normal.

A. Test the drainage for the presence of glucose. Rationale: Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.

4. On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third bilaterally. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes

ANS: A Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

15. Which patient in the ear, nose, and throat clinic should the nurse assess first? a. A patient who reports having a sore throat and has a muffled voice. b. A patient with a history of a total laryngectomy whose stoma is red. c. A patient who has a "scratchy throat" and a positive rapid strep antigen test. d. A patient who is receiving radiation for throat cancer and has severe fatigue

ANS: A A muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. A tracheal stoma is normally red. Strep throat and fatigue do not indicate life-threatening problems

14. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? a. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. O2 saturation of 90%

ANS: A Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure

6. The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated? a. Use a hand-held manometer to measure cuff pressure. b. Review the health record for the prescribed cuff pressure. c. Suction the patient through a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before removing the nonfenestrated inner cannula.

ANS: A Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings

18. The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient reports level 8 (0 to 10 scale) pain. d. The patient's temperature is 100.1° F (37.8° C).

ANS: A Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data indicate a need for nursing action but not as immediately as the low O2 saturation

8. A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient reports hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask? a. "How much alcohol do you drink in an average week?" b. "Do you have a family history of head or neck cancer?" c. "Have you had frequent streptococcal throat infections?" d. "Do you use antihistamines for upper airway congestion?"

ANS: A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Patients with streptococcal throat infections will also have pain and a fever

20. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted after increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider? a. Respirations are 36 breaths/min. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present

ANS: A The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of O2 or medications. The other findings are common chronic changes occurring in patients with COPD.

7. Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx? a. "I will need to buy a water bottle to carry with me." b. "I should not use any lotions on my neck and throat." c. "Until the radiation is complete, I may have diarrhea." d. "Alcohol-based mouthwashes will help clean my mouth."

ANS: A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy

2. The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination? (Select all that apply.) a. A 76-yr-old nursing home resident b. A 36-yr-old female patient who is pregnant c. A 42-yr-old patient who has a 15 pack-year smoking history d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-yr-old patient who has allergies to penicillin and cephalosporins

ANS: A, B, D Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old patient increases the risk for infection. Current guidelines suggest that healthy individuals between 6 months and age 49 years receive intranasal immunization with live, attenuated influenza vaccine

1. The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.

ANS: A, B, D, C The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.

1. A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which assessment findings should the nurse report to the health care provider before the patient goes for the CT (Select all that apply.)? a. Allergy to shellfish b. Patient reports claustrophobia c. Elevated serum creatinine level d. Recent bronchodilator inhaler use e. Inability to remove a wedding band

ANS: A, C Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging or pulmonary spirometry

1. The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session? (Select all that apply.) a. Decongestants can be used to relieve swelling. b. Avoid blowing the nose to decrease the nosebleed risk. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position

ANS: A, C, D, E The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions

11. The nurse provides discharge instructions for a patient after a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. "I can participate in fitness activities except swimming." b. "I must keep the stoma covered with an occlusive dressing." c. "I need to have smoke and carbon monoxide detectors installed." d. "I will wear a Medic-Alert bracelet to identify me as a neck breather."

ANS: B An occlusive dressing will completely block the patient's airway. The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective.

3. A patient with diabetes has arterial blood gas (ABG) results pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 ?2- 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure

ANS: B Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Acidosis does not cause intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure.

22. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patient's lung sounds for wheezes or crackles. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patient's intradermal skin test.

ANS: B Labeling of specimens at the bedside during a procedure is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel

10. The nurse observes a student who is listening to a patient's lungs. Which action by the student indicates a need to review respiratory assessment skills? a. The student compares breath sounds from side to side at each level. b. The student listens during the inspiratory phase, then moves the stethoscope. c. The student starts at the apices of the lungs, moving down toward the lung bases. d. The student instructs the patient to breathe slowly and deeply through the mouth.

ANS: B Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily

12. A patient admitted to the emergency department with a sudden onset of shortness of breath is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Ensure that the patient has been NPO. b. Start an IV so contrast media may be given. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to expect to inspire deeply and exhale forcefully.

ANS: B Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli and contrast media may be given IV. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography scans are most useful in determining the presence of cancer and a radioactive glucose preparation is used. For spirometry, the patient is asked to inhale deeply and exhale as long, hard, and fast as possible

17. Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/VN) caring for a patient with a permanent tracheostomy? a. Assess the patient's risk for aspiration. b. Suction the tracheostomy when directed. c. Teach the patient to provide tracheostomy self-care. d. Determine the need for tracheostomy tube replacement.

ANS: B Suctioning of a stable patient can be delegated to LPNs/VNs. The RN should perform patient assessment and patient teaching.

16. Which information will be most important for the nurse to communicate to the health care provider about an older patient who has influenza? a. Fever of 100.4° F (38° C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

ANS: B The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter pain relievers and increased fluid intake.

8. The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to 88% while ambulating. What is the priority action of the nurse? a. Notify the health care provider. b. Administer PRN supplemental O2. c. Document the response to exercise. d. Encourage the patient to pace activity.

ANS: B The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental O2 when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.

12. Which action should the nurse take first when a patient develops epistaxis? a. Pack the affected nare tightly with an epistaxis balloon. b. Apply squeezing pressure to the nostrils for 10 minutes. c. Obtain silver nitrate that may be needed for cauterization. d. Instill a vasoconstrictor medication into the affected nare.

ANS: B The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area but will not be sufficient to stop bleeding. Cauterization, nasal packing, and vasoconstrictors are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed

2. The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a. Using oral antihistamines for 2 weeks before the allergy season may prevent reactions. b. Identifying and avoiding environmental triggers are the best way to prevent symptoms. c. Frequent hand washing is the primary way to prevent spreading the condition to others. d. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use

ANS: B The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinopharyngitis (common cold) can be prevented by washing hands, but allergic rhinitis cannot

3. The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. "I will drink lots of juices and other fluids to stay well hydrated." b. "I can use nasal decongestant spray until the congestion is gone." c. "I can take acetaminophen (Tylenol) to treat my sinus discomfort." d. "I will watch for changes in nasal secretions or the sputum that I cough up."

ANS: B The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective

22. When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a rapid strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: B The patient's clinical manifestations are consistent with streptococcal pharyngitis, and the nurse will anticipate the need for a rapid strep antigen test or cultures (or both). Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing out the mouth after inhaler use may prevent fungal oral infections, but the patient's assessment data are not consistent with a fungal infection. NSAIDs are often prescribed for pain and fever relief with pharyngitis.

17. A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse expect to take next? a. Complete a head-to-toe assessment. b. Administer an inhaled bronchodilator. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).

ANS: C Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of O2 delivered to tissues, so high oxygen concentrations should be given. A head-to-toe assessment and repeat ABGs may be implemented later. Bronchodilators are not needed for metabolic alkalosis and there is no indication that the patient is having difficulty with airflow.

18. After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base. b. A patient with chronic bronchitis who has a low forced vital capacity. c. A patient with possible lung cancer who has just returned after bronchoscopy. d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing

ANS: C Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.

5. A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube

ANS: C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.

7. The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. Which sounds would the nurse most likely hear on auscultation? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous high-pitched sounds of short duration during inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

ANS: C Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration

9. The nurse teaches a patient about pulmonary spirometry testing. Which statement by the patient indicates teaching was effective? a. "I should use my inhaler right before the test." b. "I won't eat or drink anything 8 hours before the test." c. "I will inhale deeply and blow out hard during the test." d. "My blood pressure and pulse will be checked every 15 minutes."

ANS: C For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure.

11. A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Have the patient repeat the instructions immediately after teaching. b. Accomplish the patient teaching just before the scheduled discharge. c. Arrange for the patient's caregiver to be present during the teaching. d. Start giving the patient discharge teaching during the admission process

ANS: C Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

10. A patient who had a total laryngectomy has previously expressed hopelessness about the loss of control over personal care. Which information obtained by the nurse indicates that this identified problem is resolving? a. The patient allows the nurse to suction the tracheostomy. b. The patient's spouse provides the daily tracheostomy care. c. The patient asks to learn how to clean the tracheostomy stoma. d. The patient uses a communication board to request "No Visitors."

ANS: C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

6. A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse implement directly after the procedure? a. Encourage the patient to drink clear liquids. b. Place the patient on bed rest for at least 4 hours. c. Keep the patient NPO until the gag reflex returns. d. Maintain the head of the bed elevated 90 degrees

ANS: C Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag and cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler's position

14. After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Arrange for arterial blood gases to be drawn immediately. b. Cover stoma with sterile gauze and ventilate through stoma. c. Attempt to reinsert the tracheostomy tube with the obturator in place. d. Assess the patient's oxygen saturation and notify the health care provider

ANS: C The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Assessing the patient's oxygenation is an important action, but it is not as appropriate until there is an established airway.

13. A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a. Monitor the incision for bleeding. b. Maintain adequate IV fluid intake. c. Keep the patient in semi-Fowler's position. d. Teach the patient to suction the tracheostomy.

ANS: C The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube. The patient may be taught to suction after the tracheostomy is stable, if needed, but not during the immediate postoperative period

21. Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? a. Hyperresonance b. Tripod positioning c. Reduced excursion d. Accessory muscle use

ANS: C The technique for palpation for chest excursion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection

4. The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.

ANS: C This patient needs suctioning to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary; 30 seconds is recommended. Incentive spirometer use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

9. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the most accurate response by the nurse? a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c. "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration." d. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally."

ANS: C Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible

1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down for complete a full physical assessment. b. Complete the health history and check for allergies before treatment. c. Briefly ask specific questions about this episode of respiratory distress. d. Delay the physical assessment to first complete pulmonary function tests.

ANS: C When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered

19. The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

ANS: D ABGs with a decreased pH and increased PaCO2 indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal, close to normal, or compensated.

15. The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding requires immediate action? a. The bicarbonate level (HCO3 ?2-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg.

ANS: D All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.

20. A patient arrives in the ear, nose, and throat clinic with foul-smelling nasal drainage from the right nare, reporting a piece of tissue being "stuck up my nose." Which action should the nurse take first? a. Notify the clinic health care provider. b. Obtain aerobic culture specimens of the drainage. c. Ask the patient about how the cotton got into the nose. d. Have the patient occlude the left nare and blow the nose

ANS: D Because the highest priority action is to remove the foreign object from the nare, the nurse's first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose.

16. Which assessment finding for an older patient indicates that the nurse should take immediate action? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral basilar crackles

ANS: D Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as O2 saturation, and notify the health care provider. A barrel-shaped chest, and a weak cough effort are associated with aging and immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier

1. The nurse provides discharge instructions after a rhinoplasty. Which statement by the patient indicates that the teaching was successful? a. "My nose will look normal after 24 to 48 hours." b. "I can take 800 mg ibuprofen every 6 hours for pain." c. "I will remove and reapply the nasal packing every day." d. "I will elevate my head for 48 hours to minimize swelling."

ANS: D Maintaining the head in an elevated position will decrease the amount of nasal swelling. Nonsteroidal antiinflammatory drugs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery

21. The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? a. Assess patient for allergies to penicillin antibiotics. b. Teach the patient to sleep in a warm, dry environment. c. Avoid giving the patient warm food or warm liquids to drink. d. Teach patient to "swish and swallow" prescribed oral nystatin.

ANS: D Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the "swish and swallow" technique is to expose all the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin allergy because C. albicans infection is treated with antifungals

13. The nurse admits a patient who has a diagnosis of acute asthma. Which statement indicates that the patient may need teaching regarding medication use? a. "I have not had any acute asthma attacks during the past year." b. "I became short of breath an hour before coming to the hospital." c. "I've been taking acetaminophen every 6 hours for chest wall pain." d. "I've been using my albuterol inhaler frequently over the last 4 days."

ANS: D The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.

2. The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. High-Fowler's position with the left arm extended b. Supine with the head of the bed elevated 30 degrees c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

ANS: D The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.

5. The nurse palpates the posterior chest and notes absent fremitus while the patient says "99". Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

ANS: D To assess for tactile fremitus, the nurse uses the palms of the hands to palpate for vibration while the patient repeats a word or phrase such as "99." After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing are appropriate interventions for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.

The nurse is caring for a group of patients. Which patient is at risk of aspiration? A. A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery B. A 26-yr-old patient with continuous enteral feedings through a nasogastric tube C. A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia D. A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

B. A 26-yr-old patient with continuous enteral feedings through a nasogastric tube Rationale: Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without enteral nutrition. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.

The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to an employee. Which question should the nurse ask before administration of this vaccine? A. "Are you allergic to chicken?" B. "Could you be pregnant now?" C. "Did you ever have influenza?" D. "Have you ever had hepatitis B?"

B. "Could you be pregnant now?" Rationale: The live attenuated influenza vaccine (LAIV) is given by nasal spray and approved for healthy people age 2 to 49 years. The LAIV is given only to nonpregnant, healthy people. The inactivated vaccine is given by injection and is approved for use in people 6 months or older. The inactivated vaccine can be used in pregnancy, in people with chronic conditions, or in people who are immunosuppressed. Influenza vaccination is contraindicated if the person has a history of Guillain-Barré syndrome or a hypersensitivity to eggs.

The nurse teaches a patient with a pulmonary embolism how to administer enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? A. "I need to take this medicine with meals." B. "The medicine will be prescribed for 10 days." C. "I will inject this medicine into my upper arm." D. "The medicine will dissolve the clot in my lung."

B. "The medicine will be prescribed for 10 days." Rationale: Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.

When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? A. Patient comfort B. Airway patency C. Incisional drainage D. Blood pressure and heart rate

B. Airway patency Rationale: Remember the ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. Comfort, drainage, and vital signs follow the ABCs in priority.

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? A. Suction the tracheostomy opening. B. Maintain the airway with a sterile hemostat. C. Use an Ambu bag and mask to ventilate the patient. D. Insert the tracheostomy tube obturator into the stoma.

B. Maintain the airway with a sterile hemostat. Rationale: As long as the patient is not in acute respiratory distress after dislodging the tracheostomy tube, the nurse should use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. The tracheostomy is an open surgical wound that has not had time to mature into a stoma. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily.

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. What should the nurse assess this patient for? A. Cough reflex B. Mucociliary clearance C. Reflex bronchoconstriction D. Ability to filter particles from the air

B. Mucociliary clearance Rationale: Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? A. Level of consciousness B. Quality of breath sounds C. Presence of the gag reflex D. Tracheostomy cuff pressure

B. Quality of breath sounds Rationale: Before performing tracheostomy care, the nurse will auscultate lung sounds to determine the presence of secretions. To prevent aspiration, secretions must be cleared either by coughing or by suctioning before performing tracheostomy cannula care.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which provider orders must the nurse verify have been completed before administering a dose of cefuroxime? A. Orthostatic blood pressures B. Sputum culture and sensitivity C. Pulmonary function evaluation D. Serum laboratory studies ordered for AM

B. Sputum culture and sensitivity Rationale: The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? A. Assessing the need for suctioning B. Suctioning the patient's oropharynx C. Assessing the patient's swallowing ability D. Maintaining appropriate cuff inflation pressure

B. Suctioning the patient's oropharynx Rationale: Providing the person has been trained in correct technique, the UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse. An RN should perform a swallowing assessment and maintain cuff inflation pressure.

After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? A. Bronchospasm B. Pneumothorax C. Pulmonary edema D. Respiratory acidosis

Correct Answer: B Pneumothorax Rationale: Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.

A patient is being discharged from the emergency department after being treated for epistaxis. In teaching first aid measures in the event the epistaxis would recur, what measures should the nurse suggest? (Select all that apply.) A. Tilt patient's head backwards. B. Apply ice compresses to the nose. C. Tilt head forward while sitting upright. D. Pinch the entire soft lower portion of the nose. E. Lying down until 15 minutes after the bleeding ceases

C, D. Tilt head forward while sitting upright. Pinch the entire soft lower portion of the nose. Rationale: Use simple first aid measures to control nosebleeds. These include: (1) placing the patient in a sitting position, leaning slightly forward with head tilted forward and (2) applying direct pressure by squeezing the entire soft lower portion of the nose (nostrils) together for 5 to 15 minutes. Tilting the head back does not stop the bleeding but allows the blood to enter the nasopharynx, which could result in aspiration or nausea or vomiting from swallowing blood. Lying down also will not decrease the bleeding.

The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of a fungal lung infection with Candida albicans. What patient statement indicates to the nurse that further teaching is required? A. "I will be given amphotericin B to treat the fungus." B. "I got this fungus because I am immunocompromised." C. "I need to be isolated from my family and friends so they won't get it." D. "The effectiveness of my therapy can be monitored with fungal serology titers."

C. "I need to be isolated from my family and friends so they won't get it." Rationale: The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? A. Water-seal chamber has 5 cm of water B. No new drainage in collection chamber C. Chest tube with a loose-fitting dressing D. Small pneumothorax at CT insertion site

C. Chest tube with a loose-fitting dressing Rationale: If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water. Having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? A. Bilateral erythema of especially large tonsils B. Temperature 102.2° F, diaphoresis, and chills C. Contraction of neck muscles during inspiration D. β-Hemolytic streptococcus in the throat culture

C. Contraction of neck muscles during inspiration Rationale: Contraction of neck muscles during inspiration indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress. The reddened and enlarged tonsils indicate pharyngitis. The increased temperature, diaphoresis, and chills indicate an infection, which could be β-hemolytic streptococcus or fungal infection, but not an emergency situation for the patient.

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect to teach the patient about? A. Nasal packing B. Epistaxis balloon C. Gastrostomy tube D. Peripheral skin care

C. Gastrostomy tube Rationale: Because 50% of patients with head and neck cancer are malnourished before treatment begins, many patients need enteral nutrition via a gastrostomy tube because the effects of treatment make it difficult to take in enough nutrients orally, whether surgery, chemotherapy, or radiation is used. Nasal packing could be used with epistaxis or with nasal or sinus problems. Peripheral skin care would not be expected because it is not related to head and neck cancer.

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation would the nurse expect to find? A. Hyperresonance on percussion B. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpation D. Fine crackles in all lobes on auscultation

C. Increased vocal fremitus on palpation Rationale: A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.

While ambulating a patient with metastatic lung cancer, the nurse observes a decrease in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? A. Continue with ambulation. B. Obtain a provider's order for arterial blood gas. C. Obtain a provider's order for supplemental oxygen. D. Move the oximetry probe from the finger to the earlobe.

C. Obtain a provider's order for supplemental oxygen. Rationale: An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.

The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? A. Teach the patient to cough and deep breathe. B. Take the temperature, pulse, and respiratory rate. C. Obtain a sputum specimen for culture and Gram stain. D. Check the patient's oxygen saturation by pulse oximetry.

C. Obtain a sputum specimen for culture and Gram stain. Rationale: A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.

The nurse is caring for a patient with unilateral lung cancer. What is the priority nursing action to enhance oxygenation in this patient? A. Positioning patient on right side B. Maintaining adequate fluid intake C. Positioning patient with "good lung" down D. Performing postural drainage every 4 hours

C. Positioning patient with "good lung" down Rationale: Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? A. Electrolyte levels and daily weights B. Assessment of speech and swallowing C. Respiratory rate and oxygen saturation D. Pain assessment and assessment of mobility

C. Respiratory rate and oxygen saturation Rationale: The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.

The nurse is performing a focused respiratory assessment of a patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? A. Auscultation of bilateral breath sounds B. Percussion of anterior and posterior chest wall C. Palpation of the chest bilaterally for tactile fremitus D. Inspection for anterior and posterior chest expansion

Correct Answer: A Auscultation of bilateral breath sounds Rationale: Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment.

A frail older adult patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? A. Bases of the posterior chest area B. Apices of the posterior lung fields C. Anterior chest area above the breasts D. Midaxillary on the left side of the chest

Correct Answer: A Bases of the posterior chest area Rationale: Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case, the nurse should start at the bases.

What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? A. Fingernails B. Chest excursion C. Spinal curvatures D. Respiratory pattern

Correct Answer: A Fingernails Rationale: Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately after the procedure? A. Monitor the patient for laryngeal edema. B. Assess the patient's level of consciousness. C. Monitor and manage the patient's level of pain. D. Assess the patient's heart rate and blood pressure.

Correct Answer: A Monitor the patient for laryngeal edema. Rationale: Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these

The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What other manifestations should the nurse expect to observe in this patient? A. Restlessness, tachypnea, tachycardia, and diaphoresis B. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis C. Combativeness, retractions with breathing, cyanosis, and decreased output D. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

Correct Answer: A Restlessness, tachypnea, tachycardia, and diaphoresis Rationale: With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue are later manifestations of inadequate oxygenation.

When assessing the patient in acute respiratory distress, what should the nurse expect to observe? (Select all that apply.) A. Cyanosis B. Tripod position C. Kussmaul respirations D. Accessory muscle use E. Increased AP diameter

Correct Answer: A D Cyanosis Accessory muscle use Rationale: Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore, it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from chronic obstructive pulmonary disease, cystic fibrosis, or with advanced age.

When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient? (Select all that apply.) A. Is it hard for you to fall asleep? B. Do you awaken abruptly during the night? C. Do you sleep more than 8 hours per night? D. Do you need to sleep with the head elevated? E. Do you often need to urinate during the night?

Correct Answer: A,B,D Is it hard for you to fall asleep? Do you awaken abruptly during the night? Do you need to sleep with the head elevated? Rationale: A patient with obstructive sleep apnea may have insomnia, abrupt awakenings, or both. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.

The patient with Parkinson's disease has a pulse oximetry reading of 72% but has no other signs of decreased oxygenation. What is the most likely explanation for the low SpO2 level? A. Anemia B. Artifact C. Dark skin color D. Thick acrylic nails

Correct Answer: B Artifact Rationale: Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.

The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? A. Frequency, family history, hematemesis B. Cough sound, sputum production, pattern C. Weight loss, activity tolerance, orthopnea D. Smoking status, medications, residence location

Correct Answer: B Cough sound, sputum production, pattern Rationale: The sound of the cough, sputum production and description, and the pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for chronic obstructive pulmonary disease, and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems but are not as important when dealing with a cough.

The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient's lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of: A. pain. B. atelectasis. C. pneumonia. D. pleural effusion.

Correct Answer: B atelectasis. Rationale: After surgery, there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.

A patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? A. "Bibasilar wheezes present on inspiration." B. "Diminished breath sounds in the bases of both lungs." C. "Fine crackles posterior right and left lower lung fields." D. "Expiratory wheezing scattered throughout the lung fields."

Correct Answer: C "Fine crackles posterior right and left lower lung fields." Rationale: Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration.

The nurse is interpreting a tuberculin skin test (TST) for a patient with end-stage renal disease due to diabetes. Which finding would indicate a positive reaction? A. Acid-fast bacilli cultured at the injection site B. 15-mm area of redness at the TST injection site C. 11-mm area of induration at the TST injection site D. Wheal formed immediately after intradermal injection

Correct Answer: C 11-mm area of induration at the TST injection site Rationale: An area of induration 10 mm or larger would be a positive reaction in a person with end-stage renal disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis.

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes

Correct Answer: C 5 minutes Rationale: After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.

Which patient has early clinical manifestations of hypoxemia? A. A 48-yr-old patient who is intoxicated and acutely disoriented to time and place. B. A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair. C. A 72-yr-old patient who has four new premature ventricular contractions per minute. D. A 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output.

Correct Answer: C A 72-yr-old patient who has four new premature ventricular contractions per minute. Rationale: Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output.

A patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas exchange in the lung and tissue oxygenation? A. Thoracentesis B. Bronchoscopy C. Arterial blood gases D. Pulmonary function tests

Correct Answer: C Arterial blood gases Rationale: Arterial blood gases are used to assess the efficiency of gas exchange in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.

When auscultating the patient's lower lungs, the nurse hears low-pitched sounds similar to blowing through a straw under water on inspiration. How should the nurse document these sounds? A. Stridor B. Vesicular C. Coarse crackles D. Bronchovesicular

Correct Answer: C Coarse crackles Rationale: Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. They are heard over all lung areas except the major bronchi. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.

The nurse is palpating the patient's chest during a focused respiratory assessment in the emergency department. Which finding is a medical emergency? A. Increased tactile fremitus B. Diminished chest movement C. Tracheal deviation to the left D. Decreased anteroposterior (AP) diameter

Correct Answer: C Tracheal deviation to the left Rationale: Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.

After swallowing, a 73-yr-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormal finding? A. Decreased response to hypercapnia B. Decreased number of functional alveoli C. Increased calcification of costal cartilage D. Decreased respiratory defense mechanisms

Correct Answer: D Decreased respiratory defense mechanisms Rationale: Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration.

A patient has metabolic acidosis secondary to type 1 diabetes. What physiologic response should the nurse expect to assess in the patient? A. Vomiting B. Increased urination C. Decreased heart rate D. Increased respiratory rate

Correct Answer: D Increased respiratory rate Rationale: When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? A. Thoracentesis B. Pulmonary angiogram C. CT scan of the patient's chest D. Positron emission tomography (PET)

Correct Answer: D Positron emission tomography (PET) Rationale: PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose

The key anatomic landmark that separates the upper respiratory tract from the lower respiratory tract is the A. carina B. larynx C. trachea D. epiglottis

Correct answer: a Rationale: The carina is the anatomic landmark that separates the upper respiratory tract from the lower respiratory tract. The larynx, epiglottis, and trachea are all above the carina (part of the upper respiratory tract).

The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? A. thoracentesis B. bronchoscopy C. pulmonary angiography D. sputum culture and sensitivity

Correct answer: a Rationale: Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication. A paracentesis is removal of fluid from the abdomen.

When caring for a patient with acute bronchitis, the nurse will prioritize interventions by A. auscultating lung sounds B. encouraging fluid restriction C. administering antibiotic therapy D. teaching the patient to avoid cough suppressants

Correct answer: a Rationale: Assessing lung sounds is a priority nursing intervention for patients with bronchitis. Evidence of consolidation would indicate progression of bronchitis to pneumonia. This would require a change in treatment. Fluid intake and use of cough suppressants should be encouraged. Antibiotic treatment is generally not indicated.

A priority nursing intervention for a patient who had just undergone a chemical pleurodesis for recurrent pleural effusion is A. giving ordered analgesia B. monitoring chest tube drainage C. sending pleural fluid for laboratory analysis D. monitoring the patient's level of consciousness

Correct answer: a Rationale: Chemical pleurodesis involves instillation of a chemical slurry after the pleural effusion is drained. The chest tubes are clamped while the patient is turned in different positions. Pain is common, and thus analgesic agents should be given.

You are caring for patients exposed to a chlorine leak from a local factory. The nurse would closely monitor these patients for A. pulmonary edema B. anaphylactic shock C. respiratory alkalosis D. acute tubular necrosis

Correct answer: a Rationale: Chemical pneumonitis results from exposure to toxic chemical fumes. In the acute scenario, lung injury is diffuse and characterized as pulmonary edema

A patient has been receiving high-dose corticosteroids and broad-spectrum antibiotics for treatment of an infection after a traumatic injury. The nurse plans care for the patient knowing that the patient is most susceptible to A. candidiasis B. cryptococcosis C. histoplasmosis D. coccidioidomycosis

Correct answer: a Rationale: Pulmonary fungal infections occur most often in seriously ill patients being treated with corticosteroids, chemotherapy, and immunosuppressive drugs or with multiple antibiotics and in patients with human immunodeficiency virus (HIV) infection and cystic fibrosis. Candida albicans is the leading cause of fungal infections.

The best method for determining the risk for aspiration in a patient with a tracheostomy is to A. consult a speech therapist for swallowing assessment B. have the patient drink plain water and assess for coughing C. ask the patient to rate the perceived degree of swallowing difficulty D. assess for sputum changes 48 hours after the patient drinks small amount of blue dye

Correct answer: a Rationale: The ability to swallow secretions without aspiration has traditionally been evaluated with the use of blue dye; however, this method is no longer recommended. Instead, clinical assessment by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations of swallow are recommended. Patients should begin swallowing with thickened liquids, not plain water. Ability to swallow should be assessed with the cuff deflated, because cuff inflation may interfere with swallowing ability.

The nurse notes tidaling of the water level in the water-seal chamber in a patient with closed chest tube draingage. The nurse should A. Continue to monitor the patient B. check all connections for a leak in the system C. lower the drainage collector further from the chest D. clamp the tubing at a distal point away from the patient

Correct answer: a Rationale: Tidaling is a normal fluctuation of the water in the water-seal chamber of a chest tube. Tidaling reflects the intrapleural pressure during inspiration and expiration.

To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for A. dyspnea and hypotension B. apprehension and restlessness C. cyanosis and cool, clammy skin D. increased urine output and diaphoresis

Correct answer: b Rationale: Early symptoms of inadequate oxygenation include unexplained restlessness, apprehension, and irritability. Dyspnea, hypotension, bradycardia, cyanosis, cool and clammy skin are late signs.

When auscultating the chest of an older patient in mild respiratory distress, it is best to A. begin listening at the apices B. begin listening at the lung bases C. begin listening on the anterior chest D. ask the patient to breathe through the nose with the mouth closed

Correct answer: b Rationale: Normally, auscultation should proceed from the lung apices to the bases so that opposite areas of the chest are compared. For the patient in mild respiratory distress, start at the bases. The patient may not be able to breathe through the nose with the mouth closed, and, there is no sign that the patient needs immediate intubation.

When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes A. maintaining the patient on bed rest B. using intermittent pneumatic compression socks C. encouraging the patient to cough and deep breathe D. teaching the patient how to use the incentive spirometer

Correct answer: b Rationale: Deep vein thrombosis (DVT) is the main cause of pulmonary embolism. Preventing VTE with the use of intermittent pneumatic compression devices, early ambulation, and prophylactic anticoagulant agents would be priority nursing interventions

When caring for a patient with a lung abscess, what is the nurse's priority interventions? A. postural drainage B. antibiotic administration C. obtaining a sputum sample D. patient teaching about home care

Correct answer: b Rationale: IV antibiotic therapy should be started as soon as possible. Postural drainage is not recommended because it may spread infection into other bronchi. Findings in a sputum specimen are not diagnostic for a lung abscess. Teaching about home care is important but not the priority.

The nurse receives an order for a patient with lung cancer to receive influenza vaccine and pneumococcal vaccines. The nurse will A. call the health care provider to question the order B. give both vaccines at the same time in different arms C. give the pneumococcal vaccine and obtain a nasal influenza vaccine D. give the flu shot and tell the patient to come back in 1 week to have the pneumococcal vaccine

Correct answer: b Rationale: Patients at risk for pneumonia (e.g., patients with lung cancer) should have influenza and pneumococcal vaccines. The vaccines may be given at the same time in different arms.

While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. which nursing interventions would apply? (select all that apply) A. notify the health care provider at once B. place the patient in semi-Fowler's position C. use a bag-valve-mask(BVM) and begin rescue breathing for the patient D. instill 10 mL of normal saline into the tracheostomy tube to loosen secretions E. continue patient assessment, including O2 saturation, respiratory rate and breath sounds

Correct answer: b, e Rationale: Secretions are initially blood-tinged and then decrease in amount and become less bloody over time. Placing the patient in semi-Fowler's position will facilitate drainage. Normal saline through the tracheostomy tube is not recommended to help with removal of thickened secretions because it causes hypoxia and may contribute to the development of ventilatorassociated pneumonia (VAP). There is no sign that the patient has respiratory distress, so use of the bag-valve-mask is not appropriate

The nurse can best determine adequate arterial oxygenation of the blood by assessing A. heartrate B. hemoglobin level C. arterial oxygen partial pressure D. arterial carbon dioxide partial pressure

Correct answer: c Rationale: The ability of the lungs to oxygenate arterial blood adequately is determined by examination of the partial pressure of oxygen in arterial blood (PaO2) and arterial oxygen saturation (SaO2). The heartrate, hemoglobin level, and mean arterial pressure do not help evaluate oxygenation. PaCO2 evaluates the ventilation portion.

The nurse identifies a flail chest in a trauma patient when A. multiple rib fractures are determined by x-ray B. a tracheal deviation to the unaffected side is present C. paradoxical chest movement occurs during respiration D. there is a decreased movement of the involved chest wall

Correct answer: c Rationale: Flail chest causes paradoxical respiration. On inspiration, the flail section sinks in, with a mediastinal shift to the uninjured side. On expiration, the flail section bulges outward, with a mediastinal shift to the injured side.

After a pneumonectomy, an appropriate nursing intervention is A. monitoring chest tube drainage and functioning B. positioning the patient on the unaffected side or back C. doing range-of-motion exercises on the affected side D. auscultating frequently for lung sounds on the affected side

Correct answer: c Rationale: Teach a patient who has had a pneumonectomy (removal of 1 whole lung) to perform range-of-motion exercises on the surgical side that are similar to those for patients who have undergone mastectomy. The patient will not always have chest tube drainage. Position the patient on the operative side to promote lung expansion. There will not be lung sounds on the operative side because the entire lung has been removed.

A patient is seen in the clinic for a nosebleed, which is controlled by placement of anterior nasal packing. During discharge teaching, the nurse teaches the patient to A. use aspirin for pain relief B. remove the packing later that day C. avoid vigorous nose blowing and strenuous activity D. insert more packing into the nose if rebleeding occurs

Correct answer: c Rationale: The nurse should teach the patient about home care before discharge: to avoid vigorous nose blowing, strenuous activity, lifting, and straining for 4 to 6 weeks; to sneeze with the mouth open; and to avoid the use of aspirin-containing products. You would not teach the patient to insert more packing into a nose with packing already in-situ.

Which respiratory assessment finding does the nurse interpret as abnormal? A. inspiratory chest expansion of 1 inch B. symmetric chest expansion and contraction C. resonance (to percussion) over the lung bases D. bronchial breath sounds in the lower lung fields

Correct answer: d Rationale: Bronchial or bronchovesicular sounds heard in the peripheral lung fields would be abnormal. All the other assessment findings are considered normal.

A patient asks, "how does the air get into my lungs?" The nurse bases her answer on knowledge that air moves into the lungs because of A. positive intrathoracic pressure B. contraction of the accessory abdominal muscles C. Stimulation of the respiratory muscles by the chemoreceptors D. a decrease in intrathoracic pressure from an increase in thoracic cavity size

Correct answer: d Rationale: During inspiration, the diaphragm contracts, moves downward, and increases intrathoracic volume. At the same time, the external intercostal muscles and scalene muscles contract, increasing the lateral and anteroposterior dimension of the chest. This causes the size of the thoracic cavity to increase and intrathoracic pressure to decrease. As a result, air is pulled into the lungs.

When assessing subjective data related to the respiratory health of a patient with emphysema, the nurse asks about (select all that apply) A. date of last chest x-ray B. dyspnea during rest of exercise C. pulmonary function test results D. ability to sleep through the entire night E. prescription and over-the-counter medication

Correct answers: b, d, e Rationale: Important parts of the subjective respiratory assessment include dyspnea during exercise or at rest, what medications they are currently taking, and their ability to sleep at night. The date of the last chest x-ray and pulmonary function test (PFT) results are all objective measures of assessment.

An appropriate nursing intervention to assist a patient with pneumonia manage thick secretions and fatigue would be to A. perform postural drainage every how B. provide analgesics as ordered to promote patient comfort C. administer O2 as prescribed to maintain optimal O2 levels D. teach the patient how to cough effectively and expectorate secretions

Correct answer: d Rationale: A forced expiratory technique (i.e., huff coughing) clears secretions with less change in pleural pressure and less risk of bronchial collapse. Before the patient attempts coughing, the nurse should ensure the patient is breathing deeply from the diaphragm. The nurse should place hands on the patient's lower lateral chest wall and then ask the patient to breathe deeply through the nose. The nurse's hands should move outward, which represents a breath from the diaphragm

Which nursing action would be of highest priority when suctioning a patient with a tracheostomy? A. auscultating lung sounds after suctioning is complete B. Giving antianxiety medications 30 minutes before suctioning C. instilling 5 mL of normal saline into the tracheostomy tube before suctioning D. assessing the patient's oxygen saturation before, during and after suctioning

Correct answer: d Rationale: A patient with a tracheostomy is at risk for hypoxemia during and after suctioning. Pre-oxygenate patients with 100% FIO2 prior to suctioning. Monitor the patient's O2 status before, during, and after suctioning. Routine instillation of normal saline via ET tube or tracheostomy is no longer recommended.

A patient with allergic rhinitis reports severe nasal congestion; sneezing; and watery, itchy eyes and nose at various times of the year. When teaching the patient about how to control these symptoms, the nurse teaches the patient to A. avoid all intranasal sprays and oral antihistamines B. limit the usage of nasal decongestant spray to 10 days C. use oral decongestants at bedtime to prevent symptoms during the night. D. keep a diary of when the allergic reaction occurs and what precipitates it.

Correct answer: d Rationale: An important intervention involves identifying and avoiding triggers of allergic reactions. The nurse should have the patient keep a diary of times when the allergic reaction occurs and of the activities that precipitate the reaction.

A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) A. acid-base balance B. oxygenation status C. acidity of the blood D. bicarbonate (HCO3-) E. compliance and resistance

Correct answers: a, b, c, d Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status, ventilation status, and acid-base balance. ABG analysis includes measurement of the partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), bicarbonate (HCO3 - ), and arterial oxygen saturation (SaO2) in arterial blood. Compliance and resistance cannot be determined with ABGs.

Defense mechanisms that help protect the lung from inhaled particles and microorganisms include the (select all that apply) A. cough reflex B. mucociliary escalator C. alveolar macrophages D. reflex bronchoconstriction E. alveolar capillary membrane

Correct answers: a, b, c, d Rationale: Respiratory defense mechanisms are efficient in protecting the lungs from inhaled particles, microorganisms, and toxic gases. These include the cough reflex, mucociliary escalator, reflex bronchoconstriction, and alveolar macrophages. The alveolar capillary membrane is not part of the respiratory defense mechanism.

When planning health care teaching, to prevent or detect early head and neck cancer, which people would be the priority to target (select all that apply)? A. 65-year-old man who has used chewing tobacco most of his life B. 45-year-old rancher who uses snuff to stay awake while driving his hers of cattle C. 21-year-old college student who drinks beer on the weekends with his fraternity brothers D. 78-year-old woman who has been drinking liquor since her husband died 15 years ago E. 22- year-old woman who has been diagnosed with human papiloma virus of the cervix

Correct answers: a, b, d, e Rationale: Tobacco use causes 85% of head and neck cancers. Excess alcohol consumption and sun exposure are other risk factors. Head and neck cancers in those younger than 50 years of age have been associated with human papillomavirus (HPV) infection

Which patients have the greatest risk for aspiration pneumonia?(select all that apply) A. patient with seizures B. patient with head injury C. patient who had thoracic surgery D. patient who had a myocardial infarction E. patient who is receiving nasogastric tube feeding

Correct answers: a, b, e Rationale: Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., due to seizures, anesthesia, head injury, stroke, or alcohol intake), difficulty swallowing, and nasogastric tubes with or without tube feeding.

Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy for cancer would include (select all that apply) A. encouraging regular exercise such as swimming B. washing around the stoma daily with a moist washcloth C. encouraging participation in post laryngectomy support group D. providing pictures and "hands-on" instruction for tracheostomy care E. teaching how to hold breath and trying to gag to promote swallowing reflex

Correct answers: b, c, d . Rationale: Although regular exercise is important, shoulder and arm exercises are contraindicated. The nurse would teach the patient not to swim, as water entering the laryngeal stoma would risk choking and aspiration. All the other activities identified (including cleaning around the stoma daily with a damp, moist washcloth, providing pictures and "hands-on" time to practice for tracheostomy care, and encouraging the patient to join a support group with other laryngectomees) are appropriate

Which statement(s) describe(s) the management of a patient following lung transplantation( select all that apply)? A. high doses of O2 are administered around the clock B. using a home spirometer will help to monitor lung function C. immunosuppressant therapy usually involves a 3-drug regimen D. most patients have an acute rejection episode within the first 2 days E. A lung biopsy is done using a transtracheal method if rejection is suspected

Correct answers: b, c, e Rationale: Acute rejection after lung transplantation is common. It can happen as soon as 5 to 10 days after surgery. Accurate diagnosis is achieved by transtracheal biopsy. Home spirometry has been useful in monitoring trends in lung function. Teach patients to keep medication logs, documentation of laboratory results, and spirometry records. Immunosuppressive therapy usually includes a 3 drug regimen of tacrolimus, mycophenolate mofetil (CellCept), and prednisone.

A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the interprofessional management will include (select all that apply) A. antiviral agents to treat influenza B. treatment with antibiotics starting ASAP C. a throat culture or rapid strep antigen test D. supportive care, including cool, bland liquids E. comprehensive history to determine possible cause

Correct answers: c, d, e Rationale: The goals of nursing management are infection control, symptom relief, and prevention of secondary complications. Drugs are not prescribed until the cause is known. Unnecessary antibiotic use leads to the development of antibiotic-resistant organisms. A thorough history and a throat culture help identify the cause. Encourage the patient with pharyngitis to increase fluid intake. Cool, bland liquids and gelatin do not irritate the pharynx; citrus juices are often irritating.

A patient with TB has been admitted to the hospital and is placed on airborne precautions and in an isolation room. What should the nurse teach the patient? (select all that apply) A. expect routine TB testing to evaluate the infection B. No visitors will be allowed while in airborne isolation C. adherence to precautions includes coughing into paper tissues D. take all medications for full length of time to prevent multidrug-resistant TB E. wear a standard isolation mask if leaving the airborne infection isolation room

Correct answers: c, d, e Rationale: To reduce antibiotic-resistant tuberculosis, patients must take multiple drugs for a minimum of 3 months. If patients need to be out of the negative-pressure room, they must wear a standard isolation mask to prevent exposure to others. Teach patients to cover the nose and mouth with paper tissue every time they cough, sneeze, or produce sputum. If a person has a positive reaction to the tuberculin skin test, he or she does not need to be tested again because the sensitivity to tuberculin persists throughout life. Nurses and visitors must wear high-efficiency particulate air (HEPA) masks when entering the patient's room.

The nurse determines that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? A. "I will seek immediate medical treatment for any upper respiratory infections." B. "I should continue to do deep breathing and coughing exercises for at least 12 weeks." C. "I will increase my food intake to 2400 calories a day to keep my immune system well." D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." Rationale: The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? A. "My liver function will be checked with blood tests every 2 to 3 months." B. "The medication will decrease the congestion within 3 to 5 minutes after use." C. "I may develop a serious infection because the medication reduces my immunity." D. "I will use the medication every day of the season whether I have symptoms or not."

D. "I will use the medication every day of the season whether I have symptoms or not." Rationale: Budesonide should be started 2 weeks before pollen season starts and used on a regular basis, not as needed. The spray acts to decrease inflammation and the effect is not immediate as with decongestant sprays. At recommended doses, budesonide has only local effects and will not result in immunosuppression or a systemic infection. Zafirlukast (Accolate) is a leukotriene receptor antagonist and may alter liver function tests (LFTs). LFTs must be monitored periodically in the patient taking zafirlukast.

The nurse teaches a patient with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? A. "I should avoid using ibuprofen for pain and discomfort." B. "It is important for me to take my blood pressure medication every day." C. "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." D. "If I get a nosebleed, I will lie down flat and raise my feet above my heart."

D. "If I get a nosebleed, I will lie down flat and raise my feet above my heart." Rationale: A simple measure to control epistaxis (or a nosebleed) is for the patient to remain quiet in a sitting position. Another measure is to apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. Aspirin and nonsteroidal antiinflammatory drugs such as ibuprofen increase the bleeding time and should be avoided. Elevated blood pressure makes epistaxis more difficult to control. The patient should continue with antihypertensive medications as prescribed.

A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and now has exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? A. Pulmonary infarction B. Pulmonary hypertension C. Cytomegalovirus (CMV) D. Bronchiolitis obliterans (BOS)

D. Bronchiolitis obliterans (BOS) Rationale: BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.

The nurse is reviewing the health history of a patient with laryngeal cancer. Which finding would the nurse expect? A. Family history of lung cancer B. Recent inhalation of noxious fumes C. Frequent straining of the vocal cords D. Chronic use of alcohol and tobacco products

D. Chronic use of alcohol and tobacco products Rationale: Tobacco use causes 85% of head and neck cancers. Excess alcohol use is another major risk factor. Other risk factors include exposure to the sun, asbestos, industrial carcinogens, marijuana use, radiation therapy to the head and neck, and poor oral hygiene.

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? A. Age older than 80 years B. History of upper respiratory infections C. Chronic obstructive pulmonary disease (COPD) D. History of a severe allergic reaction to the vaccine

D. History of a severe allergic reaction to the vaccine Rationale: Contraindications to vaccination include a history of severe allergic reactions to previous flu vaccine. Patients with anaphylactic hypersensitivity to eggs should discuss the vaccine with their HCP, as alternatives for vaccinating patients with egg allergies are now available. Advanced age and a history of respiratory illness are not contraindications for influenza vaccination.

The nurse is caring for a patient with impaired airway clearance. What is the priority nursing action to assist this patient to expectorate thick lung secretions? A. Humidify the oxygen as able. B. Administer a cough suppressant q4hr. C. Teach patient to splint the affected area. D. Increase fluid intake to 3 L/day if tolerated.

D. Increase fluid intake to 3 L/day if tolerated. Rationale: Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? A. Apply an external splint to the nose. B. Insert plastic nasal implant surgically. C. Humidify the air for mouth breathing. D. Maintain surgical packing in the nose.

D. Maintain surgical packing in the nose. Rationale: A goal that is common to nursing and medical management of a patient after rhinoplasty is to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma. Therefore, the nurse helps to keep the nasal packing in the nose. The packing applies direct pressure to oozing blood vessels to stop postoperative bleeding. A medical goal includes realigning the fracture with an external or internal splint. The nurse helps maintain the airway by humidifying inspired air because the nose is unable to do so following surgery because it is swollen and packed with gauze.

The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? A. Coughing B. Fever, chills C. Dust allergy D. Maxillary pain

D. Maxillary pain Rationale: The nurse should assess the patient for sinus pain or pressure as a clinical indicator of acute sinusitis. Coughing and fever are nonspecific clinical indicators of a URI. A history of an allergy that is likely to affect the upper respiratory tract is supportive of the sinusitis diagnosis but is not specific for sinusitis.

An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? A. Perform a comprehensive health history with the patient to review prior respiratory problems. B. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. C. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. Rationale: Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed.

A patient is admitted for joint replacement surgery and has a permanent tracheostomy. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Suction the tracheostomy. B. Check stoma site for skin breakdown. C. Complete tracheostomy care using sterile technique. D. Provide oral care with a toothbrush and tonsil suction tube.

D. Provide oral care with a toothbrush and tonsil suction tube. Rationale: Oral care (for a stable patient with a tracheostomy) can be delegated to UAP. A registered nurse would be responsible for assessments (e.g., checking the stoma for skin breakdown) and tracheostomy suctioning and care.

The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? A. Electromyography B. Intraoral electrolarynx C. Neck type electrolarynx D. Transesophageal puncture

D. Transesophageal puncture Rationale: The transesophageal puncture provides a fistula between the esophagus and trachea with a one-way valved prosthesis to prevent aspiration from the esophagus to the trachea. Air moves from the lungs and vibrates against the esophagus, and words are formed with the tongue and lips as the air moves out the mouth. The electromyography and both electrolarynx methods produce low-pitched mechanical sounds.

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse understand is the reason for using this type of surgery? A. The patient has lung cancer. B. The incision will be medial sternal or lateral. C. Chest tubes will not be needed postoperatively. D. Less discomfort and faster return to normal activity.

D.Less discomfort and faster return to normal activity. Rationale: The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? A. Notify the health care provider. B. Administer a nitroglycerin tablet sublingually. C. Conduct a thorough assessment of the chest pain. D. Sit the patient up in bed as tolerated and apply oxygen.

D.Sit the patient up in bed as tolerated and apply oxygen. Rationale: The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the health care provider. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.