Module 1: Gas exchange
When a client is seen in the emergency department with sudden onset severe dyspnea, coughing, and wheezes, which prescribed treatment would the nurse administer first? Inhaled corticosteroid Normal saline infusion Albuterol via nebulizer Intravenous methylprednisolone
Albuterol via nebulizer Rationale The client symptoms suggest acute asthma attack or anaphylaxis. Inhaled bronchodilators like albuterol act within a few minutes to relax bronchospasm, decrease bronchiolar inflammation, and dilate bronchioles. Inhaled corticosteroids are not rapidly acting and can be given after inhaled bronchodilators. Normal saline would be needed, but the nurse would not wait to give the bronchodilator while infusing saline. Intravenous corticosteroids like methylprednisolone take several hours to be effective and would not be the priority treatment.
Diagnosed with chronic obstructive pulmonary disease (COPD), a 50- year-old client's clinical data after treatment is: heart rate of 100 beats/min, blood pressure of 138/82 mm Hg, respiratory rate of 32 breaths/min, tympanic temperature 98.2°F (36.8°C), and an oxygen saturation of 80%. Which vital sign obtained by the nurse indicates a positive outcome? Select all that apply. One, some, or all responses may be correct. Radial pulse: 70 beats/min Temperature: 98.6°F (37°C) Respiratory rate: 14 breaths/min Blood pressure: 110/70 mm Hg Oxygen saturation: 92%
Respiratory rate: 14 breaths/min Blood pressure: 110/70 mm Hg Oxygen saturation: 92% Rationale The respiratory rate ranges in older adults from 12 to 20 breaths/min, and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high blood pressure. Thus a blood pressure of 110/70 mm Hg obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95% to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 98.2°F (36.8°C), is considered normal and not a sign of COPD.
The nurse performs a respiratory assessment and auscultates high- pitched, creaking, and accentuated breath sounds on expiration. Which term describes the findings? Rhonchi Wheezes Pleural friction rub Bronchovesicular
Wheezes Rationale Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.
Which assessment findings would indicate a possible asthma exacerbation? Select all that apply. Fever Stridor Wheezing Tachycardia Hypotension
Wheezing Tachycardia Rationale: Bronchial constriction with mucus production causes wheezing. With the decrease in arterial oxygenation associated with asthma, the heart rate will increase (tachycardia). An increased temperature is characteristic of infection, not asthma. Stridor is usually caused by foreign body obstruction and/or upper airway obstruction (such as croup), not asthma. Hypertension, not hypotension, may occur with asthma.
When the nurse is evaluating a client with an acute asthma attack who has just received a nebulized bronchodilator treatment, which finding requires the most rapid nursing action? Labored breathing and absent breath sounds Continued high-pitched expiratory wheezes Use of pursed-lip breathing during expiration Hyperresonance to percussion of posterior chest
Labored breathing and absent breath sounds Rationale Absent breath sounds and labored respirations indicate that the client has extremely limited airflow and is at risk for respiratory arrest. The nurse would notify the health care provider immediately and anticipate interventions such as intubation, systemic bronchodilators, and mechanical ventilation. Continued high-pitched respiratory wheezes indicate that further treatment is needed, but the client would not be at risk for respiratory arrest. Pursed-lip breathing is frequently used by clients with obstructive airway disease to help improve expiratory effort. Hyperresonance to percussion indicates air trapping in the lungs but is not an uncommon finding in clients with asthma.
The school nurse recommends suitable physical activity for a child with exercise-induced asthma. Which statement by a parent indicates the need for additional teaching? 'I'll sign him up for swimming lessons.' 'She'd really enjoy being on a bowling team.' 'I'll encourage him to join a youth running club.' 'I know she'd enjoy going to the gym and lifting weights.'
'I'll encourage him to join a youth running club.' Rationale Exercise-induced asthma is triggered by rapid mouth breathing of large volumes of dry, cool air, so running increases the risk for an attack. Recommended exercises for people with asthma include swimming, weight lifting, and similar activities that do not necessitate rapid breathing through the mouth.
Which insect or arthropod is a common trigger for children with asthma? Spider Centipede Carpenter ant Household cockroach
Household cockroach Rationale Research has identified that the presence of the common household cockroach can trigger an asthma exacerbation in children with asthma. Spiders, centipedes, and carpenter ants have not been identified as triggers in children who are prone to asthmatic attacks.
When caring for a client with chronic obstructive pulmonary disease (COPD) exacerbation and an oxygen saturation of 87% (0.87), which prescribed action by the health care provider would the nurse question? Infuse 5% dextrose in 0.45 saline at 50 mL/hour. Administer oxygen at no more than 3 L/minute. Assist the client to sit up at the bedside for meals. Give ibuprofen 400 mg every 6 hours prn pain or fever.
Administer oxygen at no more than 3 L/minute. Rationale Because the client is hypoxemic, oxygen would be given at the flow rate and method needed to increase the oxygen saturation to a level of at least 89% to 90%. Some (but not all) clients with COPD do have a decreased respiratory drive when oxygen saturations are in the high normal range, but this client needs a high FiO 2 to correct the current hypoxemia. The nurse would carefully monitor oxygen saturation and titrate oxygen flow rate down as the client's oxygen saturation improves. Intravenous fluids are likely needed to help liquefy respiratory secretions. Sitting up for meals will expand the thoracic cavity and improve respiratory effort as well as decreased risk for venous thrombosis. Ibuprofen is an appropriate treatment for pain or fever.
When a client is newly diagnosed with chronic obstructive pulmonary disease (COPD), which action by the nurse has the highest priority? Teach the client how to use the prescribed inhalers. Discuss the normal progression of the disease process. Ask whether the client is interested in quitting smoking. Explain the purpose of a pulmonary rehabilitation program.
Ask whether the client is interested in quitting smoking. Rationale Smoking cessation slows the progression of COPD and is the most important action that the client can take to help maintain lung function. Although many clients may not be ready to stop smoking, the nurse will assess the client's interest in smoking cessation at every encounter. Teaching correct inhaler use is important, but inhaled medications only treat the symptoms of COPD and do not slow disease progression. The client will be educated on the progression of COPD, but education alone does not change the progression of the disease. Pulmonary rehabilitation programs are helpful in improving ability to do activities of daily living and also will assist the client with tobacco cessation, but assessment of readiness to quit smoking is done before developing a plan to quit.
A client is admitted to the hospital with chronic asthma. Which complication would the nurse monitor in this client? Atelectasis Pneumothorax Pulmonary edema Respiratory alkalosis
Atelectasis Rationale: As a result of narrowed airways, adequate ventilation of lung tissue is compromised, and alveoli may collapse (atelectasis). Pneumothorax is not a common complication of asthma; a collapsed lung is referred to as a pneumothorax. Pulmonary edema is not a common complication of asthma; pulmonary edema is caused by left-sided heart failure. Respiratory alkalosis is not a common complication of asthma; with narrowed air passages, the client with asthma is at risk for hypoxia and respiratory acidosis.
Which instruction would the nurse give to the pregnant client with anemia? Take an iron and calcium supplement together daily. Drink orange juice with an iron supplement. Include fresh fruit at every meal. Include 4 servings of calcium-rich foods daily.
Drink orange juice with an iron supplement The vitamin C in orange juice aids in absorption of iron, which is used to treat anemia. Taking calcium at the same time as iron will reduce absorption of the iron. Fresh fruits are recommended in pregnancy but are not a primary source of iron. Including calcium-rich foods is also recommended, but this does not address anemia.
A client is hospitalized for an exacerbation of emphysema. The client is experiencing a fever, chills, and difficulty breathing on exertion. Which is an important nursing action? Checking for capillary refill Encouraging increased fluid intake Suctioning secretions from the airway Administering a high concentration of oxygen
Encouraging increased fluid intake Rationale Fluids will replace fluid loss from fever and decrease viscosity of secretions. Capillary refill relates to peripheral tissue perfusion. There are no data to suggest that secretions are blocking the airway; there is no support that suctioning is needed. High concentrations of oxygen generally are not administered to clients with chronic obstructive pulmonary disease (COPD); traditionally, the reason given for this was that clients with COPD become desensitized to carbon dioxide as a respiratory stimulus so that reduced oxygen levels act as the stimulus and high concentrations of oxygen levels may actually depress respirations. The newer theory suggests that the hypoxic drive is valid for a small number. The majority of cases involve the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia.
Which intervention would the nurse implement for a client admitted for an exacerbation of asthma? Determine the client's emotional state. Give prescribed medications to promote bronchiolar dilation. Provide education about the effect of a family history. Encourage the client to use an incentive spirometer routinely.
Give prescribed medications to promote bronchiolar dilation. Rationale Asthma involves spasms of the bronchi and bronchioles as well as increased production of mucus; this decreases the size of the lumina, interfering with inhalation and exhalation. Bronchiolar dilation will reduce airway resistance and improve the client's breathing. Although identifying and addressing a client's emotional state is important, maintaining airway and breathing are the priority. In addition, emotional stress is only one of many precipitating factors, such as allergens, temperature changes, odors, and chemicals. Although recent studies indicate a genetic correlation along with other factors that may predispose a person to the development of asthma, exploring this issue is not the priority. The use of an incentive spirometer is not helpful because of mucosal edema, bronchoconstriction, and secretions, all of which cause airway obstruction.
Which laboratory finding of a pregnant client would alert the nurse to the need for further assessment? Hemoglobin of 10 g/dL (100 mmol/L) Urine specific gravity of 1.020 Glucose level of 1+ in the urine White blood cell count of 9000/mm 3 (9 × 10 9/L)
Hemoglobin of 10 g/dL (100 mmol/L) Rationale This hemoglobin reading suggests a true anemia. The lowest hemoglobin resulting from physiological anemia of pregnancy is 12 g/dL (120 mmol/L). This type of anemia occurs because the plasma volume increases to a greater extent than the red blood cells during pregnancy. A urine specific gravity of 1.020 is within the expected range of 1.010 to 1.030. A 1+ urine glucose level is not unusual during pregnancy because of the lowered renal threshold for glucose during pregnancy; if it increases to 2+, further investigation for diabetes should be undertaken. A white blood cell count of 9000/mm 3 (9 × 10 9/L) is within the expected range of 5000 to 10,000/mm 3 (5 to 10 × 10 9 mmol/L). It may increase to 15,000/mm 3 during the second half of pregnancy.
The nurse is assessing a pregnant 16-year-old client. Which factors associated with adolescent pregnancy would the nurse consider when developing a plan of care for this client? Select all that apply. One, some, or all responses may be correct. Higher rate of postpartum depression Inappropriate dietary choices Higher rate of anemia Incomplete bone mass Undeveloped secondary sex characteristics
Higher rate of postpartum depression Inappropriate dietary choices Higher rate of anemia Incomplete bone mass Rationale Adolescents have higher rates of postpartum depression than older women. An important aspect of nursing care for pregnant adolescents is to engage with them during the pregnancy and provide a supportive, welcoming environment and to develop a network of community resources supportive of pregnant and parenting teens to address their psychosocial issues. Adolescents may have inadequate diets and eat more fast foods. The diet is generally high in fats and carbohydrates and deficient in protein, calcium, fruits, and vegetables. Anemia is more common in teens and intensive nutrition evaluation and counseling is indicated. Peak bone mass is reached in the late teens or early 20s. When a teen is pregnant, higher levels of calcium are required to both provide support for the pregnancy and to support the teen's own bone health. Secondary sex characteristics appear early and are complete by the end of puberty; if the adolescent is pregnant, she has completed puberty.
Which client statement demonstrates an understanding of cyanocobalamin (vitamin B 12) prescribed for pernicious anemia? "I should have a vitamin B 12 injection every month." "I'll take vitamin B 12 supplements every morning with my breakfast." "I'll eat a diet high in green vegetables." "I will increase my intake of processed foods fortified with vitamin B 12."
I should have a vitamin B 12 injection every month." Rationale Vitamin B 12 is administered via injection on a weekly or monthly basis. For the client with pernicious anemia, there is inadequate intrinsic factor for adequate absorption of vitamin B 12. Green vegetables are not an important source of vitamin B 12. Vitamin B 12 is found primarily in meat, fish, poultry, and eggs. Although there is an abundance of foods fortified with vitamin B 12, for the client with pernicious anemia, the vitamin will not be absorbed in adequate amounts secondary to lack of intrinsic factor.
Which cause of anemia would the nurse recognize as the most common cause of anemia in 1-year-olds? Thalassemia Lead poisoning Iron deficiency Sickle shape of blood cells
Iron deficiency Rationale Breast milk and unfortified infant formulas increase the risk for iron-deficiency anemia in infants. Cow's milk, which is introduced at 1 year of age, is also low in iron and may cause iron-deficiency anemia unless iron supplements or iron-rich solid foods are added to the diet. Thalassemia is a genetic disease that affects specific populations and is not a common disorder. Lead poisoning usually occurs in children older than 1 year, and its prevalence is less than that of iron-deficiency anemia. Sickle cell anemia is a genetic disease that affects specific populations and is not as common as iron-deficiency anemia.
The nurse is teaching pursed-lip breathing to a client with chronic obstructive pulmonary disease (COPD). The client asks about the benefit of the exercises. Which explanation would the nurse give? Prevents complications that are associated with COPD Relieves shortness of breath by increasing the breath rate Increases the amount of air that the client can inhale with each breath Keeps the airway open longer to decrease the work that goes into breathing
Keeps the airway open longer to decrease the work that goes into breathing Rationale Pursed-lip breathing keeps the airway open longer to decrease the work that goes into breathing. Clients with COPD are taught to breathe out through pursed lips to help keep the air passages open until exhalation is complete. Pursed-lip breathing does not prevent COPD complications. Pursed-lip breathing may relieve shortness of breath by decreasing the breath rate. Pursed-lip breathing does not increase the amount of air taken in during inspiration.
Which laboratory result of a client with chronic bronchitis would be most important for the nurse to communicate to the health care provider? PaO 2 75 mm Hg PaCO 2 48 mm Hg Hematocrit 52% (0.52) Leukocytes 16,000 mm 3 (16 x 10 9/L)
Leukocytes 16,000 mm 3 (16 x 10 9/L) Rationale An elevated leukocyte (white blood cell) count indicates likely infection and will require collaborative actions, such as diagnostic testing and antibiotic treatment. The PaO 2 is mildly decreased, but chronically low PaO 2 is common in clients with chronic bronchitis. The PaCO 2 is slightly elevated, but carbon dioxide retention is a common finding in clients with chronic bronchitis. The hematocrit is mildly elevated, but polycythemia is common in clients with chronic bronchitis as a compensatory mechanism for low oxygen saturation. The complete blood count, differential white blood count, and arterial blood gases results are mentioned. You need to recollect the ranges to determine which finding is associated with chronic obstructive pulmonary disease (COPD).
When preparing a child with asthma for discharge, which instructions would the nurse emphasize to the family? Select all that apply. One, some, or all responses may be correct. Limit allergens in the home. Maintain a dry home environment. Avoid placing limits on the child's behavior expectations. Continue the medications even if the child is asymptomatic. Prevent exposure to infection by having the child tutored at home.
Limit allergens in the home. Continue the medications even if the child is asymptomatic. Rationale: Parents should be taught to limit allergens in the home that can precipitate asthma attacks (e.g., no carpets, no down pillows, no scented products; wet-mopping floors, vacuuming when the child is not in the home). Medications to control inflammation, including inhaled corticosteroids and long-acting β 2-agonists, must be continued to suppress exacerbations of asthma. Environmental moisture is necessary for these children; in addition, cold environments should be avoided. Consistent limits should be placed on the child's behavior, regardless of the illness; a chronic illness does not eliminate the need for limit setting. The child should return to school and continue to interact with schoolmates and friends.
Which finding in a client with asthma exacerbation requires the most rapid action by the nurse? Report of chest tightness Heart rate of 112 beats per minute Expiratory wheezes in both lungs Markedly decreased breath sounds
Markedly decreased breath sounds Rationale: Markedly decreased breath sounds may indicate very limited airflow and lifethreatening asthma exacerbation. The nurse would immediately check oxygen saturation and anticipate possible need for mechanical ventilation. Clients with asthma exacerbation frequently report chest tightness, but this finding does not indicate possible impending respiratory arrest. Tachycardia is common with asthma exacerbation because of stress and increased work of breathing, but a heart rate of 112 beats per minute is not life-threatening. Expiratory wheezes are heard early in asthma exacerbation; inspiratory wheezes are a more ominous finding and indicate further progression of airway obstruction.
Which finding would be of most concern when the nurse assesses a client with emphysema? Barrel chest Oral cyanosis Pursed-lip expiration Respirations 26 breaths per minute
Oral cyanosis Rationale Central cyanosis indicates hypoxemia and requires further assessment and actions such as checking oxygen saturation and administration of oxygen. Clients with chronic obstructive pulmonary disease (COPD) often develop a barrel chest over time because of air being trapped, thus resulting in enlarged lungs and thoracic cavity. Pursed-lip expiration is commonly used by clients with COPD to improve expiratory effort and volumes. An elevated respiratory rate is common in COPD as a compensatory mechanism to improve gas exchange.
A child recovering from a severe asthma attack is given oral prednisone 15 mg twice daily. Which intervention would be a priority for the nurse? Having the child rest as much as possible Checking the child's eosinophil count daily Preventing exposure of the child to infection Offering sips of water when administering the medication
Preventing exposure of the child to infection Rationale Prednisone reduces the child's resistance to certain infectious processes and, as an anti-inflammatory medication, masks infection. The child will self-limit activity depending on respiratory status. The eosinophil count is often consistently increased in children with asthma. The child will need adequate hydration to help loosen and expel mucus.
Which diagnostic test would be most useful in evaluating the effectiveness of treatment for asthma? Chest x-ray Pulmonary function tests Serum eosinophil counts Immunoglobulin E levels
Pulmonary function tests Rationale: The most useful test when evaluating the effectiveness of asthma treatment is pulmonary function testing, which measures airflow. A chest x-ray might be used to check for complications of asthma such as respiratory infection, but is not used to evaluate the effectiveness of asthma treatment. Serum eosinophil counts might be used to determine whether a client's asthma was caused by allergies, but eosinophil counts will not be commonly used to check for effectiveness of treatment. Immunoglobulin E levels might be checked to determine if a client had allergic asthma, but would not be used to check for whether treatment was effective.
The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is priority when the client becomes short of breath during the care? Obtain a pulse oximeter to determine the client's oxygen saturation level. Put the client in a high Fowler position. Darken the lights and provide a rest period of at least 15 minutes. Continue the hygiene activities while reassuring the client.
Put the client in a high Fowler position. Rationale Putting the client in the high Fowler position will help expand the lungs and decrease the severity of shortness of breath. Leaving the client to obtain a pulse oximeter while the client is experiencing shortness of breath places the client in danger. Providing a rest period of at least 15 minutes may be appropriate but is not the priority. The nurse needs to acknowledge the change in the client's condition, such as shortness of breath, and take care of this immediate client need before continuing the hygiene activities.
A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. Assist the client in assuming a position of comfort and perform postural drainage.
Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. Rationale Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically. Five liters of oxygen may cause respiratory depression and carbon dioxide narcosis in a client with COPD. Chest physiotherapy (postural drainage) may be done later after the client's condition improves. Delaying intervention is likely to worsen the respiratory distress.
Which statement by the student nurse demonstrates correct understanding of anemia related to chronic disease? "Red blood cells (RBCs) are normal in size and color; however, the number of cells produced is decreased." "RBC indices are usually low, indicating a need for oral iron supplementation." "Administration of vitamins B 12 and folate will help treat this type of long- term anemia." "This is the mildest form of anemia and is easily corrected through administration of blood products."
Red blood cells (RBCs) are normal in size and color; however, the number of cells produced is decreased." Rationale Anemia of chronic disease results in a decrease in the production of RBCs in response to chronic inflammation; the RBCs are normal size, shape, and color. RBC indices such as mean corpuscular volume and mean hemoglobin concentration are usually normal. Administration of folate or B 12 will not correct the anemia, because these levels are generally within normal limits. This form of anemia can be very severe, and treatment is directed at the identification and management of the underlying cause.
Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation? Metabolic alkalosis caused by excessive production of acid metabolites Respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid Metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation
Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid Rationale: The restricted ventilation accompanying an asthma attack limits the body's ability to blow off carbon dioxide. As carbon dioxide accumulates in the body fluids, it reacts with water to produce carbonic acid; the result is respiratory acidosis. The problem basic to asthma is respiratory, not metabolic. Respiratory alkalosis is caused by the exhalation of large amounts of carbon dioxide; asthma attacks cause carbon dioxide retention. Asthma is a respiratory problem, not a metabolic one; metabolic acidosis can result from an increase of nonvolatile acids or from a loss of base bicarbonate.
Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? Respiratory acidosis Respiratory alkalosis Respiratory compensation Respiratory decompensation
Respiratory alkalosis Rationale Hyperventilation causes excess amounts of carbon dioxide (CO 2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess CO 2 retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD). Respiratory compensation and decompensation are terms not associated with this situation.
When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears moist rumbling sounds that improve after the client coughs. Which term would the nurse use to document the lung sounds? Rhonchi Wheezes Fine crackles Vesicular sounds
Rhonchi Rationale Rhonchi are coarse and moist sounds caused by obstruction of the airway with thick mucus, and they usually clear or change with coughing as the mucus moves or is expectorated. Wheezes are high-pitched, continuous sounds. Fine crackles are high- pitched popping noises. Vesicular sounds are the normal breath sounds.
In which order would the nurse take these prescribed actions when caring for a client with chronic obstructive pulmonary disease (COPD) who is admitted with fever, increased dyspnea, and oxygen saturation of 86%?
Start oxygen per nonrebreather mask. Obtain blood and sputum cultures. Infuse ceftriaxone 1 g intravenously. Administer acetaminophen for fever. Rationale This client's low oxygen saturation needs immediate improvement to prevent complications such as metabolic (lactic) acidosis, and the nurse would immediately start high-flow oxygen. Antibiotics should be rapidly started, but cultures would be needed before initiation of antibiotic therapy. Once cultures are obtained, infusion of antibiotics to treat the likely pulmonary infection is needed. Administration of acetaminophen to treat fever would be done last, after therapies to treat the priority problems of hypoxemia and infection are implemented.
A client with an acute emphysema episode is dyspneic and anxious. To decrease the dyspnea, which action would the nurse take? Increase the client's oxygen intake. Have the client breathe into a paper bag. Teach the client to do pursed-lip breathing. Check the client's vital signs.
Teach the client to do pursed-lip breathing. Rationale The purpose of pursed-lip breathing (PLB) is to prolong exhalation and thereby prevent bronchiolar collapse and air trapping. PLB is simple and easy to teach and learn, and it gives the client more control over breathing, especially during exercise and periods of dyspnea. Increasing the client's oxygen intake is contraindicated. It is believed that the client should receive low amounts of oxygen to prevent CO 2 intoxication (CO 2 narcosis). However, the results of one recent study of clients with stable chronic obstructive pulmonary disease (COPD) indicate that the hypercarbic drive is preserved. More research is needed before this theory is applied clinically. Having the client breathe into a paper bag is contraindicated because it increases carbon dioxide retention. Checking the client's vital signs, including the blood pressure, should be part of assessment, but assessment does not decrease dyspnea.
A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse expect to be prescribed for the client? Oral hydroxyurea Vitamin B 12 injections Oral iron supplements Erythropoietin injections
Vitamin B 12 injections Rationale A shiny tongue, paresthesias of the limbs, ataxia, and cobalamin of 125 pg/mL (normal: 200-835 pg/mL) are the manifestations of pernicious anemia. The client has pernicious anemia because of a vitamin B 12 deficiency and should be given vitamin B 12 injections. Vitamin B 12 cannot be given orally to a client with pernicious anemia because the client does not produce the intrinsic factors needed to absorb vitamin B 12. Hydroxyurea is administered orally to clients with hemochromatosis. Oral iron supplements are given to clients with iron-deficiency anemia. Erythropoietin injections are given to clients who have low red blood cells, hemoglobin, and hematocrit.
Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct. Mold Cold air Pet dander Air pollution Cigarette smoke
All. Mold Cold air Pet dander Air pollution Cigarette smoke Rationale Clients with asthma should be instructed to avoid asthma attack triggers such as mold, cold air, pet dander, air pollution, and cigarette smoke.
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? Red blood cell count Sputum culture Arterial blood gas Hemoglobin
Arterial blood gas Rationale Red blood cell count, sputum culture, and hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.
After assessing four clients who have respiratory disorders, which client would the nurse suspect as having metabolic acidosis? Client 1: Tachypnea Client 2: Pursed-lip breathing Client 3: Kussmaul respirations Client 4: Abdominal paradox
Client 3: Kussmaul respirations Rationale Kussmaul respirations are the regular, rapid, and deep respirations observed in clients who have metabolic acidosis. Client 3 may have metabolic acidosis. Respiratory rate 20 breaths per minute indicates tachypnea (client 1), which is a sign of fever, hypoxemia, and restrictive lung disease. Pursed-lip breathing (client 2) is exhalation through the mouth with lips pursed together to slow exhalation and is a sign of chronic obstructive pulmonary disease (COPD) or asthma. The abdominal paradox (client 4) is the inward movement of the abdomen during inspiration. It is a nonspecific indicator of severe respiratory distress.
Which client would the nurse suspect as having type I-mediated asthma when reviewing the laboratory reports of four clients? Client A Client B Client C Client D
Client A Rationale Asthma is a type I or IgE-mediated hypersensitivity reaction. Client A, with IgE antibodies in the blood, has type 1-mediated asthma. Client B, with no antibodies, may not have humoral allergy or may have a humoral deficiency. Client C and client D may have either type II or type III hypersensitivity reactions.
Which client in the pulmonary clinic will the nurse plan to teach about pulmonary function testing? Client who has Chronic Obstructive Lung Disease (COPD) Client who is being evaluated for lung histoplasmosis Client who is recovering after pulmonary embolism Client who has had positive tuberculosis skin testing
Client who has Chronic Obstructive Lung Disease (COPD) Rationale Pulmonary function testing is used to diagnose and determine progression of disease in clients with COPD. Pulmonary function testing is not used to evaluate for clients for histoplasmosis or pulmonary embolism, because pulmonary embolism affects blood vessels rather than airflow and respiratory effort and evaluation of histoplasmosis requires laboratory testing. A client with a positive tuberculosis skin test would be taught about chest x-ray and sputum testing.
Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? Prevents bronchial spasm Decreases air trapping in lung Improves alveolar surface area Strengthens diaphragmatic contraction
Decreases air trapping in lung Rationale Pursed-lip breathing provides positive pressure in the airways during expiration, prolonging expiration and decreasing the air trapping, which is characteristic of emphysema. Pursed-lip breathing will not decrease bronchospasm, which is characteristic of asthma. Alveolar surface area is not changed by pursed-lip breathing. Diaphragmatic contraction is not strengthened by pursed-lip breathing.
Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator? Is able to obtain pulse oximeter readings Demonstrates use of a metered-dose inhaler Knows the health care provider's office hours Can identify triggers that may cause wheezing
Demonstrates use of a metered-dose inhaler Rationale: Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack; this is an important skill to have. Home management typically includes self-monitoring of the peak expiratory flow rate rather than pulse oximetry. Although knowing the health care provider's office hours is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance. Although it is important to be able to identify triggers that may cause wheezing, knowing these cannot prevent all wheezing; therefore, being able to abort wheezing with a bronchodilator is the greater priority.
The nurse teaches a client with chronic obstructive pulmonary disease (COPD) and cor pulmonale about nutrition. Which instruction would the nurse include? Eat small meals six times a day to limit oxygen needs. Drink large amounts of fluid to help liquefy secretions. Lie down after eating to conserve energy needed for digestion. Increase the intake of protein to decrease intravascular hydrostatic pressure.
Eat small meals six times a day to limit oxygen needs. Rationale Eating small meals will decrease the amount of oxygen necessary for ingestion and digestion at any one time; a small volume of food in the stomach will not impede the downward movement of the diaphragm during inhalation. Although fluids can help liquefy secretions, they should not be encouraged for a client with heart failure. Lying down increases intra-abdominal pressure, pushing a full stomach against the diaphragm and limiting respiratory excursion. Protein maintains or increases hydrostatic pressure; it does not decrease it.
Which laboratory test result would the nurse expect to be decreased in a client with iron-deficiency anemia? Ferritin level Platelet count White blood cell count Total iron-binding capacity
Ferritin level Rationale Ferritin, a form of stored iron, is reduced with iron-deficiency anemia. Platelets will be within the expected range or increased with iron-deficiency anemia. Red, not white, blood cells are decreased with iron-deficiency anemia. Total iron-binding capacity will be increased with iron-deficiency anemia.
A child with status asthmaticus is admitted to the pediatric intensive care unit. Which would the nurse include in the plan of care as the child starts to recover from the episode? Maintain the high-Fowler position. Restrict fluids to two thirds of the usual intake. Keep droplet precautions in place for 24 hours. Administer the prescribed prophylactic antibiotic.
Maintain the high-Fowler position. Rationale The high-Fowler position decreases pressure on the diaphragm and promotes lung expansion. Fluids should not be restricted. Adequate fluid intake should be maintained to promote hydration. Droplet precautions are not required. Asthma is not an infectious disease, and there are no data to indicate an accompanying infection. If the practitioner prescribes an antibiotic, it is to treat a concurrent infection; prophylactic antibiotic therapy is not required for children with status asthmaticus.
Which medication would cause the nurse to monitor a client closely for hemolytic anemia? Tacrolimus Methyldopa Azathioprine Procainamide
Methyldopa
Which medication would cause the nurse to monitor a client closely for hemolytic anemia? Tacrolimus Methyldopa Azathioprine Procainamide
Rationale Hemolytic anemia is an autoimmune disorder in which destruction of red blood cells occurs before the end of their normal lifespan. This disorder may result after administration of methyldopa. Tacrolimus may cause adverse effects such as nephrotoxicity, lymphoma, and leukopenia. Azathioprine, administered as an immunosuppressant, may cause bone marrow suppression. Procainamide can induce the formation of antinuclear antibodies and cause a lupus-like syndrome.
A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue? Provide small, frequent meals. Encourage pursed-lip breathing. Schedule nursing activities to allow for rest. Encourage bed rest until energy level improves.
Schedule nursing activities to allow for rest. Rationale Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small, frequent meals may decrease pressure on the diaphragm and facilitate breathing, this precaution does not address the client's fatigue. Although pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.
A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon awakening in the morning. To address the concern, the nurse would make which suggestion? Use a clean and disinfected humidifier in the bedroom. Sleep with two or more pillows. Cough regularly even if the cough does not produce sputum. Cough and deep-breathe each night before going to sleep.
Use a clean and disinfected humidifier in the bedroom. Rationale A humidifier will help liquefy secretions and promote their expectoration. Sleeping on pillows facilitates breathing; it does not relieve chest congestion. Nonproductive coughing should be avoided because it is irritating and exhausting. Deep breathing and coughing at night will not help relieve early-morning congestion.
The nurse is caring for a school-aged child with cystic fibrosis. Which pathophysiologic factor has the greatest effect on the child's health status? Extremely thick mucus causing obstructed airways Acute inflammation of the lung parenchyma Endocrine glands secreting increased levels of hormones Increased irritability of the airways resulting in obstruction
Extremely thick mucus causing obstructed airways Rationale Dysfunction of the exocrine glands leads to an excessive accumulation of thick mucus, a slower flow rate of mucus, and incomplete expectoration of mucus, all of which contribute to airway obstruction. Acute inflammation of the lung parenchyma is associated with pneumonia, not cystic fibrosis. The endocrine glands are not affected in cystic fibrosis. Increased irritability of the airways that causes obstruction is associated with asthma, not cystic fibrosis.
Which laboratory value will the nurse review when caring for a client with a megaloblastic anemia? Serum iron Folate level Transferrin level Platelet count
Folate level Rationale Because folate and vitamin B 12 deficiencies cause megaloblastic anemias, the nurse will review levels of those nutrients. Iron and transferrin levels will be used to evaluate microcytic anemia. Platelet count is not related to megaloblastic anemia.
Which action would the nurse take to prevent postoperative respiratory complications after abdominal surgery? Implement postural drainage. Encourage pursed-lip breathing. Assist with incentive spirometry. Teach sustained exhalation.
Assist with incentive spirometry. Rationale Incentive spirometry expands collapsed alveoli and enhances surfactant activity, thereby preventing atelectasis. Postural drainage helps clear accumulated secretions from the pulmonary tree and would typically be used for clients with pneumonia who have secretions at distal areas of the lungs. Pursed-lip breathing is used for clients with chronic obstructive pulmonary disease (COPD) to help with more complete expiration; it would not directly promote alveolar expansion. Sustained exhalation would occur with pursed-lip breathing and would not directly assist with alveolar expansion.
