NCLEX 10000 Respiratory

A physician orders metaproterenol/orciprenaline by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication? a) "I should use this inhaler whenever I get short of breath." b) "I need to call the physician right away if I feel my heart beating fast after using the drug." c) "I need to hold my breath as long as possible after I take a deep inhalation." d) "I can stop using this drug when I begin to feel better."

"I need to hold my breath as long as possible after I take a deep inhalation." Correct Explanation: The client demonstrates effective teaching if he states that he'll hold his breath for as long as possible after inhaling the drug. Holding the breath increases the absorption of the drug into the alveoli.

In preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment. Which statement by the mother indicates successful teaching? a) "I need to be sure to take my child's temperature every day." b) "I need to wash my hands more often." c) "Next time my child gets a cold I need to listen to the chest." d) "I hope I do not get a cold from my child."

"I need to wash my hands more often." Correct Explanation: Handwashing is the best way to prevent respiratory illnesses and the spread of disease. Bronchiolitis, a viral infection primarily affecting the bronchioles, causes swelling and mucus accumulation of the lumina and subsequent hyperinflation of the lung with air trapping. It is transmitted primarily by direct contact with respiratory secretions as a result of eye-to-hand or nose-to-hand contact or from contaminated fomites. Therefore, handwashing minimizes the risk for transmission.

A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions? a) "I should plan to do most of my exercises after I eat." b) "I should take my bronchodilator at bedtime to prevent insomnia." c) "I should try to eat several small meals during the day." d) "I should do my most difficult activities when I first get up in the morning."

"I should try to eat several small meals during the day." Explanation: The respiratory workload is increased in individuals with COPD. Because digestion also is energy consuming, clients with COPD may feel full after only a small meal. They may tolerate smaller, more frequent, high-calorie meals better than larger meals.

A client having an acute asthmatic attack is admitted to the emergency room. The health care provider writes an order for epinephrine 1:1,000 injection 0.3 ml subcutaneous stat. The nurse reads in the unit's drug reference that epinephrine 1:1,000 contains 1 mg/ml. Instructions direct the nurse to dilute each milligram of the 1:1,000 concentration with normal saline, resulting in a solution that contains 0.1 mg/1 ml. How many milligrams of epinephrine will be administered to the client after the nurse has added the diluent? Record your answer using two decimal places.

0.03 Explanation: Using the ratio-and-proportion method, calculate the correct dosage by using the following formula: (Dose on hand)/(Quantity on hand) = X/(Dose prescribed) 0.1 mg/1 ml = X/0.3 ml X = 0

The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse should determine if the client has:

Decreased chest movement on the affected side. Explanation: A pleural effusion is a collection of fluid between the pleural layers of the lung. The effusion decreases chest wall movement on the affected side.

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? a) "Before you do the exercise, I'll give you pain medication if you need it." b) "You need to start using the incentive spirometer 2 days after surgery." c) "Don't use the incentive spirometer more than 5 times every hour." d) "Breathe in and out quickly."

"Before you do the exercise, I'll give you pain medication if you need it." Correct Explanation: The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.

To help a client prevent atelectasis and pneumonia after surgery, what should the nurse do? a) Administer oxygen therapy as needed to maintain adequate oxygenation. b) Offer pain medication before having the client deep-breathe and use incentive spirometry. c) Encourage the client to drink 1,000 mL of fluids in 24 hours. d) Instruct the client to cough, deep-breathe, and turn in bed once every 8 hours.

Offer pain medication before having the client deep-breathe and use incentive spirometry. Correct Explanation: Deep-breathing exercises and use of incentive spirometry are more effective when pain is minimal. A client in severe pain tends to limit movement and to breathe shallowly to decrease the pain. Enough pain medication should be given to decrease pain without depressing respirations

To help a client prevent atelectasis and pneumonia after surgery, what should the nurse do? a) Encourage the client to drink 1,000 mL of fluids in 24 hours. b) Offer pain medication before having the client deep-breathe and use incentive spirometry. c) Administer oxygen therapy as needed to maintain adequate oxygenation. d) Instruct the client to cough, deep-breathe, and turn in bed once every 8 hours.

Offer pain medication before having the client deep-breathe and use incentive spirometry. Correct Explanation: Deep-breathing exercises and use of incentive spirometry are more effective when pain is minimal. A client in severe pain tends to limit movement and to breathe shallowly to decrease the pain. Enough pain medication should be given to decrease pain without depressing respirations.

A client with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse determines the following: a temperature of 103° F (39.4° C), body chills, and leukocytosis. The client begins to have difficulty breathing. In what order should the nurse perform the following actions?

Open the airway. Start an I.V. access site. Call the physician. Explain the situation to the family. Explanation: An open airway is essential to survival. The nurse should first ensure an open airway. Next, the nurse should start an I.V. and then notify the physician. Finally, the nurse should inform the family of the situation and, if appropriate, allow them to remain with the client.

A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a diagnosis of pneumothorax? a) Bradypnea and elevated blood pressure. b) Tracheal deviation toward the affected side. c) Presence of crackles and wheezes. d) Sudden, sharp pain on the affected side.

Sudden, sharp pain on the affected side. Explanation: Signs and symptoms of a pneumothorax include sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness.

Which statement indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan? a) The client will avoid direct contact with family and friends. b) The client will use oxygen via a nasal cannula at 5 L/min. c) The client states actions to reduce pain. d) The client agrees to call the health care provider (HCP) if dyspnea on exertion increases.

The client agrees to call the health care provider (HCP) if dyspnea on exertion increases. Correct Explanation: Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the client should notify the HCP.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. b) The client exhibits bronchial breath sounds over the affected area. c) The client exhibits restlessness and confusion. d) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Correct Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg.

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which conclusion would be accurate? a) `The client is severely hypoxic. b) The client's PaO2 level is within normal range. c) The oxygen level is low but poses no risk for the client. d) The client requires oxygen therapy with very low oxygen concentrations.

The client is severely hypoxic. Correct Explanation: Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention

The client lying in a lateral position, with the head of bed flat Explanation: A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration.

A client has been placed on isoniazid (INH) as prophylactic treatment against tuberculosis. Which of the following instructions should the nurse plan to include in the client's teaching plan about taking isoniazid? a) The client can double the dosage if a dose is missed. b) The client should limit tyramine-rich foods in the diet. c) The client should take the drug with antacids to decrease gastric distress. d) The client should increase fluid intake to 3,000 ml/day.

The client should limit tyramine-rich foods in the diet. Correct Explanation: When taking isoniazid, the client should limit tyramine-rich foods in his diet because these foods and the drug could interact to cause hypertension. Foods such as cheese, dairy products, alcohol (red wine and beer), bananas, raisins, caffeine, and chocolate should be limited.

A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse? a) The employee removes all personal protective equipment and washes his/her hands before leaving the client's room. b) The employee wears a gown, gloves, N95 respirator, and eye protection when entering the room. c) The employee does not remove the stethoscope, blood pressure cuff, and thermometer that are kept in the room. d) The employee enters the room wearing a gown, gloves, and a mask.

The employee enters the room wearing a gown, gloves, and a mask. Correct Explanation: The nurse should tell the employee to wear the proper personal protective equipment, including a gown, gloves, N95 respirator, and eye protection, when entering the client's room. Wearing a mask does not provide enough protection.

The nurse is teaching a client about the pathophysiology of asthma. Place in chronological order the sequence of an asthma attack. Use all of the options. 1 2 3 4 5 6 Trigger by stimulus Mucus production Acute asthma attack Breathlessness Airflow limitation Inflammation

Trigger by stimulus Inflammation Mucus production Airflow limitation Breathlessness Acute asthma attack Explanation: Asthma is triggered by a stimulus. The stimulus may be environmental, stress related, or medication related. Inflammation in the airways occurs as a response to the stimulus, followed by an increase in mucus production. The presence of inflammation and mucus narrow the bronchi, causing limited airflow. At this point, the client experiences breathlessness, chest tightness, and wheezing—all symptoms of an acute asthma attack

When suctioning a tracheostomy tube 3 days following insertion, what should the nurse do?

Use a sterile catheter each time the client is suctioned. Explanation: The recommended technique is to use a sterile catheter each time the client is suctioned. There is a danger of introducing organisms into the respiratory tract when strict aseptic technique is not used.

Which of the following demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion? a) Place the client in the semi-Fowler's position. b) Monitor the client's temperature after the procedure. c) Use sterile gloves during the procedure. d) Use povidone-iodine to clean the inner cannula when it is removed.

Use sterile gloves during the procedure. Correct Explanation: The tracheotomy site is a portal of entry for microorganisms. Sterile technique must be used within the first 24-48 hours because the site is a new source of infection.

A healthy client comes to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sound?

Vesicular Explanation: Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation

Which of the following symptoms is common in clients with active tuberculosis?

Weight loss. Explanation: Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats.

A client is admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to find during a nursing assessment? a) Barrel chest, tachycardia, and hypertension b) Dyspnea, cough, and bradycardia c) Wheezing, tachycardia, and restlessness d) Hypotension, confusion, and weight gainWheezing, tachycardia, and restlessness Explanation: Wheezing results when air is expired against resistance, such as from a collapsed airway. Tachycardia results from hypoxia, and restlessness is a result of cerebral hypoxia.

Wheezing, tachycardia, and restlessness Explanation: Wheezing results when air is expired against resistance, such as from a collapsed airway. Tachycardia results from hypoxia, and restlessness is a result of cerebral hypoxia.

A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations? a) Nonrebreather mask b) Simple mask c) Face tent d) Nasal cannula

a) Nonrebreather mask A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

A home health nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use? a) "I lubricate my lips and nose with a topical emollient." b) "I have a 'no smoking' sign posted at my front door to remind guests not to smoke." c) "I make sure my oxygen mask is on tightly so it won't fall off while I nap." d) "I clean my mask with water after every meal."

"I make sure my oxygen mask is on tightly so it won't fall off while I nap." Correct Explanation: The client requires additional teaching if he states that he fits his mask tightly. Applying the oxygen mask too tightly can cause skin breakdown, so the client should be cautioned against wearing it too tightly.

The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. a) The face has increased skin breakdown and edema. b) The family is coming in to visit. c) The client is tachycardic with drop in blood pressure. d) The client has increased secretions requiring frequent suctioning. e) The SpO2 and PO2 have decreased.

• The client is tachycardic with drop in blood pressure. • The face has increased skin breakdown and edema. • The SpO2 and PO2 have decreased. Correct Explanation: The prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern

A chronically ventilated client requests that care be withdrawn. The client is competent and understands the consequences of his/her decisions. The client is not depressed, but is certain that he/she does not want to live as he/she has been living. What should the nurse consider in this situation? Select all that apply.

• The physician must be notified of the request. • The client's chart must be checked for a healthcare power of attorney. • The client has the right to refuse medical treatment. Explanation: The client has the right to refuse any treatment. In addition, there might be a power of attorney in the chart, therefore the nurse should check the client's medical chart. The physician need to be informed of the client's request.

A teaching care plan to prevent transmission of respiratory syncytial virus (RSV) should include what information? Select all that apply. a) The virus can be spread by direct contact. b) Palivizumab is recommended to prevent RSV for all toddlers in daycare. c) Frequent handwashing helps reduce the spread of RSV. d) The virus is typically contagious for 3 weeks. e) The virus can be spread by indirect contact. f) Older children seldom spread RSV.

• The virus can be spread by direct contact. • The virus can be spread by indirect contact. • Frequent handwashing helps reduce the spread of RSV. Explanation: RSV can be spread through direct contact such as kissing the face of an infected person, and it can be spread through indirect contact by touching surfaces covered with infected secretions. Handwashing is one of the best ways to reduce the risk of disease transmission. Palivizumab can prevent severe RSV infections but is only recommended for the most at-risk infants and children. RSV is typically contagious for 3 to 8 days. RSV frequently manifests in older children as cold-like symptoms. Infected school-age children frequently spread the virus to other family members.

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? a) "This disease may come back later if I am under stress." b) "I'll stay in isolation for 6 weeks." c) "I'll always have a positive test for tuberculosis." d) "I'll have to take the medication for up to a year."

"I'll stay in isolation for 6 weeks." Correct Explanation: The client requires additional teaching if he states that he'll be in isolation for 6 weeks. The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He'll be positive when tested and if he's sick or under some stress he could have a relapse of the disease.

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when the client says: a) "My tuberculosis isn't contagious after I take the medication for 24 hours." b) "I'll stop being contagious when I have a negative acid-fast bacilli test." c) "I'm clear when my chest X-ray is negative after one month of medication." d) "I'm contagious as long as I have night sweats."

"I'll stop being contagious when I have a negative acid-fast bacilli test." Correct Explanation: A client with drug-resistant tuberculosis is not contagious when the client has had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when he/she shows clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce a negative acid-fast test results for several day

A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer? a) "My voice is hoarser than it used to be." b) "I've lost 10 pounds (4.5 kg) in the last month." c) "I've had a low-grade fever for 2 weeks." d) "My cough has changed from a dry cough to one with lots of sputum production."

"My cough has changed from a dry cough to one with lots of sputum production." Explanation: A cough that changes in character is one of the hallmark signs of lung cancer.

A 49-year-old male with a tracheostomy tube confides to the nurse during a clinic visit that he is beginning to avoid sexual activity because of the increased tracheostomy secretions. Which statement by the nurse will be most helpful to the client? a) "Use a scopolamine patch to decrease secretions." b) "Place a thin piece of gauze over the tracheostomy." c) "Wash the tracheostomy area with deodorizing antibacterial soap before sexual activity." d) "Avoid fluid intake 2 hours before sexual activity."

"Place a thin piece of gauze over the tracheostomy." Correct Explanation: Placing a thin piece of gauze over the tracheostomy during sexual activity will help to contain the secretions and yet allow ventilation

The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client? a) 25 seconds b) 10 seconds c) 20 seconds d) 30 seconds

10 seconds Correct Explanation: A client should be suctioned for no longer than 10 seconds at a time. Suctioning for longer than 10 seconds may reduce the client's oxygen level so much that he becomes hypoxic.

A client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range? a) 21 to 25 mcg/ml b) 5 to 10 mcg/ml c) 2 to 5 mcg/ml d) 10 to 20 mcg/ml

10 to 20 mcg/ml Correct Explanation: The therapeutic serum theophylline concentration ranges from 10 to 20 mcg/ml. Values below 10 mcg/ml aren't therapeutic. Concentrations above 20 mcg/ml are considered toxic.

Which client's care may a registered nurse (RN) safely delegate to the nursing assistant?

A client requiring assistance ambulating, who was admitted with a history of seizures. Explanation: The RN may safely delegate assistance ambulated the client with a history of seizures to a nursing assistant.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia.

A client with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first? a) Administer bronchodilators as prescribed. b) Encourage the client to relax and breathe slowly through the mouth. c) Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes. d) Draw blood for an arterial blood gas.

Administer bronchodilators as prescribed. Correct Explanation: In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, IV corticosteroids, and, possibly, IV theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? a) Auscultate breath sounds bilaterally every 4 hours. b) Instruct the client to breathe into a paper bag. c) Administer oxygen by nasal cannula as ordered. d) Encourage the client to deep-breathe and cough every 2 hours.

Administer oxygen by nasal cannula as ordered. Correct Explanation: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered

The nurse reviews blood gas results for several children with respiratory disorders. Based on the following results, which intervention by the nurse is most appropriate for each child? Use all options. Child 1: pH 7.261 PaCO2 56 HCO3 24 Child 2: pH 7.53 PaCO2 42 HCO3 51 Child 3: pH 7.41 PaCO2 39 HCO3 24 Child 4: pH 7.49 PaCO2 33 HCO3 24 Child 5: pH 7.28 PaCO2 38 HCO3 18 1 2 3 4 5 Continue current treatment. Infuse sodium bicarbonate. Administer potassium chloride. Administer oxygen. Apply a rebreather mask.

Administer oxygen. Administer potassium chloride. Continue current treatment. Apply a rebreather mask. Infuse sodium bicarbonate. Explanation: The first step in analyzing ABGs is to look at the pH. Normal blood pH is 7.4, plus or minus 0.05, forming the range 7.35 to 7.45. If blood pH falls below 7.35, it is acidic. If blood pH is above 7.45, it is alkalotic. If it falls into the normal range, label which side of 7.4 it falls on. Lower than 7.4 is normal/acidic, higher than 7.4 is normal/alkalotic. Label it. The second step is to examine the pCO2. Normal pCO2 levels are 35-45mmHg. Below 35 is alkalotic, above 45 is acidic. Label it. The third step is to look at the HCO3 level. A normal HCO3 level is 22-26 mEq/L. If the HCO3 is below 22, the patient is acidotic. If the HCO3 is above 26, the patient is alkalotic. Label it. Next, match either the pCO2 or the HCO3 with the pH to determine the acid-base disorder. For example, if the pH is acidotic, and the CO2 is acidotic, then the acid-base disturbance is being caused by the respiratory system. Therefore, we call it a respiratory acidosis. However, if the pH is alkalotic and the HCO3 is alkalotic, the acid-base disturbance is being caused by the metabolic (or renal) system. Therefore, it will be a metabolic alkalosis. Analysis of the ABGs finds the following: Child 1 is in respiratory acidosis, which requires the administration of oxygen. Child 2 is in metabolic alkalosis. This condition is often caused by excessive vomiting, resulting in a loss of chloride ions. It is often corrected with the administration of potassium chloride. Child 3 has normal blood gas values and the current treatment should be continued. Child 4 has respiratory alkalosis for which a rebreather mask should be used. Child 5 has metabolic acidosis, which is treated with IV infusion of sodium bicarbon

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

Airborne and contact precautions Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection

The client with a total laryngectomy receives tube feedings to meet fluid and nutrition needs. What is the primary rationale for tube feedings in this situation? a) Prevent pain from swallowing. b) Allow for adequate suture line healing c) Prevent fistula development. d) Ensure adequate intake.

Allow for adequate suture line healing Correct Explanation: A nasogastric (NG) tube is usually inserted during surgery to allow for enteral feedings postoperatively. The tube allows the suture line to heal adequately, minimizes contamination of the pharyngeal and esophageal suture lines, and prevents fluid from leaking through the wound into the trachea before healing occurs. Normal oral feedings are resumed as soon as the NG tube is removed, usually within 10 days after surgery.

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer? a) An inhaled corticosteroid b) An inhaled beta2-adrenergic agonist c) An oral corticosteroid d) An I.V. beta2-adrenergic agonist

An inhaled beta2-adrenergic agonist Correct Explanation: An inhaled beta2-adrenergic agonist helps promote bronchodilation, which improves oxygenation.

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer? a) An I.V. beta2-adrenergic agonist b) An oral corticosteroid c) An inhaled beta2-adrenergic agonist d) An inhaled corticosteroid

An inhaled beta2-adrenergic agonist Correct Explanation: An inhaled beta2-adrenergic agonist helps promote bronchodilation, which improves oxygenation. Although an I.V. beta2-adrenergic agonist can be used, the client needs be monitored because of the drug's greater systemic effects

A client with chronic obstructive pulmonary disease (COPD) is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory status, which finding should the nurse anticipate? a) A transverse chest diameter twice that of the anteroposterior diameter b) An inspiratory-expiratory (I:E) ratio of 2:1 c) An oxygen saturation of 94% d) A respiratory rate of 12 breaths/minute

An inspiratory-expiratory (I:E) ratio of 2:1 Correct Explanation: The normal I:E ratio is 1:2, meaning that expiration takes twice as long as inspiration. A ratio of 2:1 is seen in clients with COPD because inspiration is shorter than expiration.

A client with chronic obstructive pulmonary disease (COPD) is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory status, which finding should the nurse anticipate? a) A respiratory rate of 12 breaths/minute b) A transverse chest diameter twice that of the anteroposterior diameter c) An oxygen saturation of 94% d) An inspiratory-expiratory (I:E) ratio of 2:1

An inspiratory-expiratory (I:E) ratio of 2:1 Explanation: The normal I:E ratio is 1:2, meaning that expiration takes twice as long as inspiration. A ratio of 2:1 is seen in clients with COPD because inspiration is shorter than expiration. A client with COPD typically has a barrel chest in which the anteroposterior diameter is larger than the transverse chest diameter. A client with COPD usually has a respiratory rate greater than 12 breaths/minute and an oxygen saturation rate below 93%.

A 6-year-old boy is admitted to a pediatric unit for the treatment of osteomyelitis. Which essential medication classification would the nurse anticipate as documented on the medication report? a) Anti-inflammatory b) Analgesic c) Antibiotic d) Antipyretic

Antibiotic Correct Explanation: Staphylococcus. aureus is the most common causative pathogen of osteomyelitis; the usual source of the infection is an upper respiratory infection (URI) or skin lesion. The nurse anticipates an intravenous antibiotic as the essential medication.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. What should the nurse request in SBAR communication with the health care provider? a) Antibiotic therapy b) Arterial blood gasses c) Intubation and mechanical ventilationx d) Portable chest X-ray

Antibiotic therapy Explanation: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. With the symptoms of infection, antibiotic therapy would be recommended.

Which of the following activities should the nurse teach the client to implement after the removal of nasal packing on the second postoperative day? a) Keep a nasal drip pad in place to absorb secretions. b) Apply water-soluble jelly to lubricate the nares. c) Avoid cleaning the nares until swelling has subsided. d) Use a bulb syringe to gently irrigate nares.

Apply water-soluble jelly to lubricate the nares. Explanation: After removal of nasal packing, the client should be instructed to apply water-soluble jelly to the nares to lubricate the nares and promote comfort.

A nurse is feeding an average-size client when the client suddenly begins choking on his food. According to the American Heart Association (Heart and Stroke Foundation of Canada), the nurse should intervene using the actions listed below. List the actions in the sequence in which the nurse should perform them. 1 2 3 4 Activate the emergency response team. Ask the client if he can speak. Give abdominal thrusts until effective or until client is unresponsive. Perform cardiopulmonary resuscitation (CPR).

Ask the client if he can speak. Give abdominal thrusts until effective or until client is unresponsive. Activate the emergency response team. Perform cardiopulmonary resuscitation (CPR). Explanation: According to the American Heart Association (Heart and Stroke Foundation of Canada and Health Canada), the nurse should ask the client if he's choking and if he can speak. Next, the nurse should administer abdominal thrusts or chest thrusts (if the client is obese or pregnant). The nurse should continue thrusts until they are effective or until the client becomes unresponsive. When the latter occurs, the nurse should activate the emergency response team and then perform CPR.

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? a) Applying an oil-based lubricant to the client's mouth and nose b) Posting a "No smoking" sign over the client's bed c) Assessing the client's respiratory status, orientation, and skin color d) Changing the mask and tubing daily

Assessing the client's respiratory status, orientation, and skin color Correct Explanation: A nonrebreather mask can deliver high concentrations of oxygen to the client in acute respiratory distress. Assessment of a client's status is a priority for determining the effectiveness of therapy.

A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which of the following ways?

At a low flow rate. Explanation: The client with emphysema has a chronically elevated carbon dioxide level. As a result, the normal stimulus for breathing in the medulla becomes ineffective. Instead, peripheral pressoreceptors in the aortic arch and carotid arteries, which are sensitive to oxygen blood levels, stimulate respirations. This is in response to low oxygen levels that have developed over time. If the client receives high concentrations of oxygen, the blood level of oxygen will rise excessively, the stimulus for respiration will decrease, and respiratory failure may result.

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? a) At bedtime b) When secretions have mobilized c) Immediately before a meal d) When bronchospasms occur

At bedtime Explanation: The nurse should perform chest physiotherapy at bedtime to reduce secretions in the client's lungs during the night. Performing it immediately before a meal may tire the client and impair the ability to eat. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms.

The nurse is discussing a treatment plan for mononucleosis with an adolescent. The nurse emphasizes that the client must: a) Not return to school for 4 weeks. b) Complete the entire course of antibiotics. c) Remain on bed rest for 4 weeks. d) Avoid contact sports and vigorous exercise for 2 to 4 weeks.

Avoid contact sports and vigorous exercise for 2 to 4 weeks. Correct Explanation: Splenomegaly often accompanies mononucleosis and is present 2 to 4 weeks after contracting the infection. To prevent splenic rupture, contact sports and vigorous exercise should be avoided. Mononucleosis is caused by the Epstein-Barr virus; antibiotics are not useful unless an accompanying bacterial infection is present.

A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease? a) Amphotericin B b) Amantadine c) Rifampin d) Azithromycin

Azithromycin Correct Explanation: Azithromycin is the drug of choice for treating legionnaires' disease.

A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease?

Azithromycin Explanation: Azithromycin is the drug of choice for treating legionnaires' disease.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

Bleeding Explanation: The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively.

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding? a) Tactile fremitus b) Bronchophony c) Crepitation d) Egophony

Bronchophony Explanation: Bronchophony is an increased intensity and clarity of voice sounds heard over a bronchus surrounded by consolidated lung tissue. Over normal lung tissue, the words are unintelligible; however, over areas of tissue consolidation, such as with pneumonia, the words are clear because the tissue enhances the sounds.

A client's chest tube accidentally disconnects from the drainage tube. Which of the following actions should the nurse take first? a) Notify the physician. b) Reconnect the tube. c) Clamp the chest tube. d) Raise the level of the drainage system

Clamp the chest tube. Correct Explanation: When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity, which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified. First priority must be given to clamping the chest tube.

A client's chest tube accidentally disconnects from the drainage tube. Which of the following actions should the nurse take first?

Clamp the chest tube. Explanation: When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity, which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution.

Which performance improvement strategy helps prevent adverse reactions to blood products?

Confirming client identification with two qualified health professionals Explanation: The client must be correctly identified to prevent a life-threatening adverse blood reaction.

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? a) Wheezes b) Decreased breath sounds c) Crackles d) Rhonchi

Decreased breath sounds Correct Explanation: In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished.

The nurse has completed an assessment on a client with chronic obstructive pulmonary disease (COPD). One hour later, the client has become confused and is not aware of his/her surroundings. Respirations are 34 breaths/min and cyanosis is noted around the lips. Oxygen saturation levels have decreased from 94% to 84%. Place the following nursing interventions in order of priority. Use all options. 1 2 3 4 5 Call the rapid response team. Start oxygen at 2 L per nasal cannula. Elevate the head of the bed. Insert an intravenous line. Notify the family of the situation.

Elevate the head of the bed. Start oxygen at 2 L per nasal cannula. Call the rapid response team. Insert an intravenous line. Notify the family of the situation. Correct Explanation: The head of the bed would be elevated immediately to assist the client with lung expansion. Next, oxygen would be started. In this case, 2 L would be initiated because the client has COPD. The rapid response team would be notified because the client might need intubation if his/her breathing and oxygen saturations do not improve. An intravenous line would be necessary for any administration of emergency medications. Notifying the family would be the lowest priority at this time. Stabilizing the client is the priority

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Endotracheal suctioning b) Use of a cooling blanket c) Encouragement of coughing d) Incentive spirometry

Endotracheal suctioning Correct Explanation: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level

A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 ml/hour. How long will this transfusion take to infuse?

Explanation: One unit of packed red blood cells is about 250 mL. If the blood is delivered at a rate of 60 mL/h, it will take about 4 hours to infuse the entire unit. The transfusion of a single unit of packed red blood cells should not exceed 4 hours to prevent the growth of bacteria and minimize the risk of septicemia

A client who recently underwent a laryngectomy asks about learning esophageal speech. The nurse can explain that this communication technique involves: a) Holding an electronic instrument against the esophagus. b) Filling the esophagus with air. c) Replacing the larynx with scar tissue. d) Providing an access route from the trachea to the esophagus.

Filling the esophagus with air. Correct Explanation: Esophageal speech requires filling the esophagus with air and allowing it to vibrate out.

Which information in a change-of-shift report is most important to ensure continuity of client care? a) Head of bed is at a 30-degree angle to prevent aspiration pneumonia. b) Restraints are in place and have been checked every 2 hours. c) An antibiotic should be administered I.V. at 1200. d) Pain medication was given at bedtime; the client rested most of the night.

Head of bed is at a 30-degree angle to prevent aspiration pneumonia. Explanation: Because aspiration can cause respiratory complications, keeping the head of the bed at a 30-degree angle is the most important consideration. This concept is based on Maslow's hierarchy of needs, which prioritizes physical needs such as breathing.

Which information in a change-of-shift report is most important to ensure continuity of client care? a) Restraints are in place and have been checked every 2 hours. b) An antibiotic should be administered I.V. at 1200. c) Head of bed is at a 30-degree angle to prevent aspiration pneumonia. d) Pain medication was given at bedtime; the client rested most of the night.

Head of bed is at a 30-degree angle to prevent aspiration pneumonia. Explanation: Because aspiration can cause respiratory complications, keeping the head of the bed at a 30-degree angle is the most important consideration. This concept is based on Maslow's hierarchy of needs, which prioritizes physical needs such as breathing.

A female client diagnosed with lung cancer is to have a left lower lobectomy. What increases the client's risk of developing postoperative pulmonary complications? a) She ambulates and can climb one flight of stairs without dyspnea. b) The client tends to keep her real feelings to herself. c) Height is 5 feet, 7 inches (170.2 cm) and weight is 110 lb (49.9 kg). d) The client is 58 years of age.

Height is 5 feet, 7 inches (170.2 cm) and weight is 110 lb (49.9 kg). Explanation: Risk factors for postoperative pulmonary complications include malnourishment, which is indicated by this client's height and weight

A client diagnosed with tuberculosis is taking the prescribed chemotherapy of isoniazid, rifampin, and pyrazinamide. The nurse should assess the client for:

Hepatotoxicity. Explanation: The major side effect of these three drugs is hepatitis. While the client is undergoing chemotherapy for TB, the nurse should carefully monitor the client's liver function tests

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a) Hypoxia b) Semiconsciousness c) Hyperventilation d) Delirium

Hypoxia Correct Explanation: As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate

A client with asthma has been taking theophylline as ordered. Now, the client's blood theophylline level is 4.8 mcg/ml. Which dosage change will the physician order? a) Maintain the dose. b) Omit a dose. c) Decrease the dose. d) Increase the dose.

Increase the dose. Correct Explanation: When the client's serum theophylline concentration falls below the therapeutic level, the daily dosage of the ordered methylxanthine agent should be increased by up to 25%, and the serum theophylline concentration should be rechecked before further dosage changes are made.

Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)? a) Collapsed neck veins. b) Underdeveloped neck muscles. c) Increased anteroposterior chest diameter. d) Increased chest excursions with respiration.

Increased anteroposterior chest diameter. Correct Explanation: Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.

A client is scheduled for radical neck surgery and a total laryngectomy. During the preoperative teaching, the nurse should prepare the client for which of the following postoperative possibilities? a) Gastrostomy tube. b) Endotracheal intubation. c) Immediate speech therapy. d) Insertion of a laryngectomy tube.

Insertion of a laryngectomy tube. Explanation: The client may have a temporary laryngectomy tube, which remains in place until the wound is healed and a permanent stoma has formed, usually in 2 or 3 weeks

The nurse is caring for a child with history of strep throat. Upon current assessment, the child states abdominal pain and joint achiness. Which laboratory data would the nurse communicate with the physician immediately?

Leukocytosis Explanation: Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. This finding is expected in a client with rheumatic fever.

A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness? a) Petroleum jelly b) Antibiotic ointment c) Sterile water d) Lubricant jelly

Lubricant jelly Explanation: Lubricant jelly is a water-soluble agent that the nurse can apply safely during oxygen therapy to alleviate dryness of the nares.

A nurse is caring for a client who presents to the emergency department following a motor vehicle accident that caused chest trauma, as a result of hitting the steering wheel. Which assessment should most concern the nurse? a) Lung movement inward during expiration and outward during inspiration b) An increased anterior posterior diameter with hemoptysis c) Lung movement outward during expiration and inward during inspiration d) Barrel chest with pleurtic chest pain

Lung movement outward during expiration and inward during inspiration Correct Explanation: In paradoxical chest expansion, the lungs move outward during expiration and inward during inspiration. This is very common with a flail chest, commonly caused by hitting the steering wheel. The client may exhibit signs of ineffective gas exchange, such as tachypnea (an abnormally fast respiratory rate), secondary to a paradoxical breathing pattern.

A client reports difficulty breathing and a sharp pain in the right side of his chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal?

Maintaining effective respirations Explanation: As suggested by the ABCs of cardiopulmonary resuscitation — airway, breathing, and circulation — the most important goal is to maintain a patent airway and effective respirations, regardless of the client's diagnosis or clinical presentation.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation? a) Measles b) Cholera c) Impetigo d) Mumps

Measles Correct Explanation: Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately? a) Absent cough and gag reflexes b) Blood-tinged secretions c) Respiratory rate of 13 breaths/min d) Oxygen saturation of 90%

Oxygen saturation of 90% Correct Explanation: The nurse should respond immediately to an oxygen saturation (SaO2) of 90%. Normal SaO2 ranges from 95% to 100%. Therefore, an SaO2 of 90% indicates inadequate oxygenation, an adverse effect of moderate sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen.

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention?

Partial pressure of arterial oxygen (PaO2) of 69 mm Hg Explanation: In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

Which of the following home care activities would be appropriate for a client who underwent a laryngectomy? a) Stay inside in an air-conditioned environment in the summer. b) Participate in activities such as walking and golfing. c) Keep the stoma opening covered at all times. d) Avoid showering; take tub baths instead.

Participate in activities such as walking and golfing. Correct Explanation: The client should be encouraged to participate in activities such as walking, golfing, and other moderate recreational sports. It is not necessary to keep the stoma covered at all times, although a gauze bib can be used to protect the clothes from mucus and to keep irritants from entering the stoma.

A client is admitted after a motor vehicle crash and states that he is very anxious and the respiratory rate is 28 and arterial blood gases (ABG's) pH 7.51, CO2 30, HCO3 23. Which nursing action would be a priority? a) Assess pulse oximetry b) Administer lorazapam PO c) Place a nonrebreather mask d) Administer albuterol inhaler

Place a nonrebreather mask Correct Explanation: The client hyper-ventilating is exhibiting respiratory alkalosis. The priority action is to provide nonrebreather to increase CO2. Monitoring the pulse oximetry, treating the anxiety, and maintaining an open airway will be important after first treating the CO2 deficit.

A nurse is caring for a client with pulmonary edema whose respiratory status is declining. Chronologically arrange the nursing interventions to prioritize care. Use all the options. 1 2 3 4 5 6 Prepare suctioning equipment at the bedside. Position the client upright at a 45°angle. Administer furosemide (Lasix) 40 mg I.V. STAT. Administer oxygen via nasal cannula at 2 L/minute. Insert an indwelling urinary catheter. Call the physician.

Position the client upright at a 45°angle. Administer oxygen via nasal cannula at 2 L/minute. Prepare suctioning equipment at the bedside. Call the physician. Administer furosemide (Lasix) 40 mg I.V. STAT. Insert an indwelling urinary catheter. Explanation: The order of priority moves from the simple to the complex for bedside interventions when a client is in respiratory distress. The nurse should first attempt to maximize respiratory excursion as much as possible by sitting the client up, and then provide supplemental oxygen to minimize impending hypoxia. It is also important to have suction equipment readily available because the client may choke on oral secretions due to the pulmonary edema. After performing these interventions, the nurse should notify the physician and anticipate orders for administration of a diuretic (such as Lasix) and insertion of an indwelling urinary catheter to measure eventual output.

The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see figure). The nurse should

Proceed to suction the client's tracheostomy. Explanation: The nurse is wearing protective personnel equipment appropriately for suctioning the client: goggles, gown and respirator mask.

What instruction should the nurse give the client who underwent a laryngectomy and is now going home? a) Limit physical activity to shoulder and neck exercises. b) Provide adequate humidity in the home. c) Perform mouth care every morning and evening. d) Maintain a soft, bland diet.

Provide adequate humidity in the home. Correct Explanation: Adequate humidity should be provided in the home to help keep secretions moist. A bedside humidifier is recommended.

Which instruction should the nurse give the client who has undergone chest surgery to prevent shoulder ankylosis?

Raise the arm on the affected side over the head. Explanation: A client who has undergone chest surgery should be taught to raise the arm on the affected side over the head to help prevent shoulder ankylosis. This exercise helps restore normal shoulder movement, prevents stiffening of the shoulder joint, and improves muscle tone and power.

Which of the following should the nurse include in a postoperative teaching plan for a client with a laryngectomy? a) Telling the client to speak by covering the stoma with a sterile gauze pad. b) Reassuring the client that normal eating will be possible after healing has occurred. c) Instructing the client to control oral secretions by swabbing them with tissues or by expectorating into an emesis basin. d) Instructing the client to avoid coughing until the sutures are removed.

Reassuring the client that normal eating will be possible after healing has occurred. Correct Explanation: Normal eating is possible once the suture line has healed. Coughing is essential to keep the airway patent. Because the larynx has been removed, the ability to speak is lost. Swallowing is usually not affected nor is the ability to control oral secretions.

A client has been hospitalized with myxedema coma. What acid-base imbalance would be expected in this client? a) Metabolic acidosis b) Respiratory alkalosis c) Respiratory acidosis d) Respiratory alkalosis

Respiratory acidosis Correct Explanation: The client's respiratory drive is depressed, resulting in alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and coma. These symptoms, along with cardiovascular collapse and shock, require aggressive and intensive therapy if the client is to survive.

Which of the following alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago? a) Urine output of 180 ml during the past 3 hours. b) Sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours. c) Increased blood pressure and decreased pulse and respiratory rates. d) Restlessness and shortness of breath.

Restlessness and shortness of breath. Correct Explanation: Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding.

A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? a) Returning bicarbonate to the body's circulation b) Sequestering free hydrogen ions in the nephrons c) Returning acid to the body's circulation d) Excreting bicarbonate in the urine

Returning bicarbonate to the body's circulation Explanation: The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state.

With a diagnosis of right rib fracture and closed pneumothorax, the client should be placed in: a) Semi- to high-Fowler's position, tilted toward the right side. b) Modified Trendelenburg's position with the lower extremities elevated. c) Left side-lying position with the head elevated 15 to 30 degrees. d) Reverse Trendelenburg's position with the head down.

Semi- to high-Fowler's position, tilted toward the right side. Explanation: Pneumothorax will cause a client to feel extremely short of breath. Semi- or high- Fowler's position will facilitate ventilation by the unaffected lung. Positioning the client toward the affected side does not compromise the remaining, functional lung.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? a) Stroke b) Hyperglycemia c) Shock d) Seizures

Shock Correct Explanation: Complications of respiratory acidosis include shock and cardiac arrest.

A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute? a) enteric precautions b) reverse isolation c) hand-washing precautions d) airborne precautions

airborne precautions Correct Explanation: Transmission of SARS can be contained by airborne precautions that include an insolation room with negative pressure, use of N-95 respirator, and use of personal protective equipment. The disease is spread by the respiratory, not enteric, route.

A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute? a) reverse isolation b) hand-washing precautions c) enteric precautions d) airborne precautions

airborne precautions Correct Explanation: Transmission of SARS can be contained by airborne precautions that include an insolation room with negative pressure, use of N-95 respirator, and use of personal protective equipment. The disease is spread by the respiratory, not enteric, route.

Two days after placement of a pleural chest tube, the tube is accidentally pulled out of the chest wall. The nurse should first:

apply an occlusive dressing such as petroleum jelly gauze. Explanation: If the chest tube is accidentally pulled out (a rare occurrence), a petroleum jelly gauze and sterile 4×4 inch dressing should be applied over the chest wall insertion site immediately. The dressing should be covered with adhesive tape and be occlusive, and the surgeon should be notified.

The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. The nurse should instruct the client that:

aspirin-containing medications should not be taken for 2 weeks before surgery. Explanation: Aspirin-containing medications should be discontinued for 2 weeks before surgery to decrease the risk of bleeding.

The nurse has assisted the health care provider (HCP) at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should:

assess breath sounds Explanation: The nurse should first assess for bilateral breath sounds since a complication of central line insertion is a pneumothorax, which would cause an increase in respiratory rate and drop in oxygen, causing irritability.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis. Explanation: In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis.

A client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess:

chest movements. Explanation: The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, pulmonary embolus, or a rib or sternum fracture

A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed his wish to not be intubated with his girlfriend of 5 years, whom he's designated as his health care power of attorney. The client's children want their father to be intubated. A nurse caring for this client knows that: a) clients commonly confer health care power of attorney on someone who shares their personal values and beliefs. b) health care providers must honor the children's wishes to avoid a lawsuit. c) the children's biological relationship with their father supersedes his girlfriend's wishes. d) the client's girlfriend is responsible for national legislation regarding surrogate decision makers.

clients commonly confer health care power of attorney on someone who shares their personal values and beliefs. Correct Explanation: The health care power of attorney is someone who can make decisions when the client can't. Clients tend to select individuals who share their personal values and beliefs as their health care power of attorney. Family members and designated surrogates don't always agree; state laws regarding surrogate decision makers may differ. The legal rights of a health care power of attorney in regards to health care decisions supersede those of family members. The law designates the health care power of attorney as the person to make decision; violating this designation could result in a lawsuit

A nurse assessing a client for tracheal displacement should know that the trachea will deviate toward the: a) affected side in a simple pneumothorax. b) affected side in a hemothorax. c) affected side in a tension pneumothorax. d) contralateral side in a hemothorax.

contralateral side in a hemothorax. Correct Explanation: The trachea will shift according to the pressure gradients within the thoracic cavity.

The nurse is auscultating the lung sounds of a client with long-standing emphysema. The nurse is most likely to detect: a) stridor. b) diminished breath sounds. c) pleural friction rub. d) fine crackles.

diminished breath sounds. Explanation: In emphysema, the anteroposterior diameter of the chest wall is increased. As a result, the client's breath sounds may be diminished.

The nurse is caring for a client who has been diagnosed with atypical pneumonia. The nurse should assess this client carefully for: a) high fever. b) dry cough. c) severe chills. d) tachypnea.

dry cough. Correct Explanation: Atypical pneumonia is characterized by a gradual onset of symptoms, such as dry cough, headache, sore throat, fatigue, nausea, and vomiting.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

encourage coughing and deep breathing Explanation: When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia.

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the:

frontal and maxillary sinuses. Explanation: After detecting tenderness of the paranasal sinuses, the nurse should transilluminate both the frontal and maxillary sinuses; lack of illumination may indicate sinus congestion and pus accumulation.

The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis?

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic.

Which complication is associated with mechanical ventilation? a) immunosuppression b) gastrointestinal hemorrhage c) pulmonary emboli d) increased cardiac output

gastrointestinal hemorrhage Explanation: Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.

A client with chronic obstructive pulmonary disease tells a nurse that he feels short of breath. The client's respiratory rate is 36 breaths/minute and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer an ordered nebulizer treatment. The therapist says, "I have several more nebulizer treatments to do on the unit where I am now. As soon as I'm finished, I'll come and assess the client." The nurse's most appropriate action is to: a) stay with the client until the therapist arrives. b) notify the primary physician immediately. c) administer the treatment by metered-dose inhaler. d) give the nebulizer treatment herself.

give the nebulizer treatment herself. Correct Explanation: The client's needs are preeminent, so the nurse should administer the nebulizer treatment immediately.

A client is receiving streptomycin in the treatment regimen of tuberculosis. The nurse should assess for: a) IV infiltration. b) difficulty swallowing. c) hearing loss. d) decreased serum creatinine.

hearing loss. Correct Explanation: Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin does not cause difficulty in swallowing. Streptomycin is given via intramuscular injection.

A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for: a) increasing the ventilator rate. b) starting a high-protein diet. c) providing pain medication. d) initiating IV sedation.

initiating IV sedation. Explanation: The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures.

In which areas of the United States and Canada is the incidence of tuberculosis highest?

inner-city areas Explanation: Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease.

A nurse is assisting with the removal a of central venous access device (CVAD). The nurse should: a) turn the client to the left side. b) elevate the head of the bed. c) have the client exhale slowly and evenly. d) instruct the client to take a deep breath and hold it.

instruct the client to take a deep breath and hold it. Explanation: The client should be asked to perform the Valsalva maneuver (take a deep breath and hold it) during insertion and removal of a CVAD. This increases central venous pressure during the procedure and prevents air embolism. Trendelenburg is the preferred position for CVAD insertion and removal.

A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse bases her next action on the principle that: a) a quiet environment should be provided. b) it may be necessary to raise the head of this client's bed. c) encouraging the client to void before the medication takes effect will promote safety. d) this client may need intubation.

it may be necessary to raise the head of this client's bed. Correct Explanation: The nurse should consider positioning when caring for a client who has COPD and difficulty breathing. Elevating the head of the bed assists clients with COPD in breathing

The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, the nurse should assess the client for:

less difficulty breathing Explanation: Theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea.

A priority goal for the hospitalized client who 2 days earlier had a total laryngectomy with creation of a new tracheostomy is to:

maintain a patent airway. Explanation: The main goal for a client with a new tracheostomy is to maintain a patent airway.

Which action should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)?

mechanical ventilation Explanation: Endotracheal intubation and mechanical ventilation are required in ARDS to maintain adequate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway.

A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important?

monitoring intake and output. Explanation: Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage.

Clients who have had active tuberculosis are at risk for recurrence. Which condition increases that risk? a) physical and emotional stress b) cool and damp weather c) active exercise and exertion d) rest and inactivity

physical and emotional stress Correct Explanation: Tuberculosis can be controlled but never completely eradicated from the body. Periods of intense physical or emotional stress increase the likelihood of recurrence. Clients should be taught to recognize the signs and symptoms of a potential recurrence.

The nurse is reading the results of a tuberculin skin test (see figure). The nurse should interpret the results as: a) false. b) needing to be repeated. c) positive. d) negative.

positive. Explanation: The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purified protein derivative (PPD) by measuring the size of the firm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a firm, raised area, or an area that is less than 5 mm in diameter.

Which nursing intervention would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? a) monitoring clients for signs of hypercapnia b) maintaining adequate serum potassium levels c) teaching cigarette smoking cessation d) replacing fluids adequately during hypovolemic states

replacing fluids adequately during hypovolemic states Correct Explanation: One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients

A client has just been diagnosed as being in status asthmaticus. The nurse understands that this client will likely initially exhibit symptoms of: a) metabolic alkalosis b) metabolic acidosis c) respiratory acidosis d) respiratory alkalosis

respiratory alkalosis Correct Explanation: During status asthmaticus, there is a reduced PaCO2 and initial respiratory alkalosis, with a decreased PaCO2 and an increased pH. As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: a) acute CNS disturbances b) metabolic acidosis c) respiratory alkalosis d) increased PaCO2

respiratory alkalosis Correct Explanation: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation, which does not cause metabolic acidosis. Acute CNS disturbances result from multiple potential causes. Increased carbon dioxide levels are associated with acidosis, not alkalosis.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: a) respiratory alkalosis. b) metabolic acidosis. c) respiratory acidosis. d) metabolic alkalosis.

respiratory alkalosis. Correct Explanation: This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis

A nurse should interpret which finding as an early sign of a tension pneumothorax in a client with chest trauma? a) respiratory distress b) tracheal deviation c) diminished bilateral breath sounds d) muffled heart sounds

respiratory distress Explanation: Respiratory distress or arrest is a universal finding of a tension pneumothorax. Unilateral, diminished, or absent breath sounds is a common finding. Tracheal deviation is an inconsistent and late finding.

Which condition can place a client at risk for acute respiratory distress syndrome (ARDS)? a) asthma b) septic shock c) chronic obstructive pulmonary disease d) heart failure

septic shock Correct Explanation: The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflammation).

A client asks a nurse a question about the tuberculin skin test for tuberculosis. The nurse should base her response on the fact that the: a) area of redness is measured in 3 days and determines whether tuberculosis is present. b) skin test doesn't differentiate between active and dormant tuberculosis infection. c) test stimulates a reddened response in some clients and requires a second test in 3 months. d) presence of a wheal at the injection site in 2 days indicates active tuberculosis.

skin test doesn't differentiate between active and dormant tuberculosis infection. Correct Explanation: The tuberculin skin test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active.

A client with tuberculosis is taking Isoniazid (INH). To help prevent development of peripheral neuropathies, the nurse should instruct the client to:

supplement the diet with pyridoxine (vitamin B6). Explanation: INH competes for the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed.

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:

synchronized intermittent mandatory ventilation (SIMV). Explanation: In SIMV mode, the ventilator delivers a preset number of breaths at a preset tidal volume. The client can breathe on his own in between the breaths delivered by the ventilator

The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statements indicate that the client has understood the nurse's instructions? Select all that apply. a) "It is important that I isolate myself from family when possible." b) "I should use paper tissues to cough in and dispose of them promptly." c) "I will need to dispose of my old clothing when I return home." d) "I should always cover my mouth and nose when sneezing."

• "I should always cover my mouth and nose when sneezing." • "I should use paper tissues to cough in and dispose of them promptly." Explanation: When teaching the client how to avoid the transmission of tubercle bacilli, it is important for the client to understand that the organism is transmitted by droplet infection. Therefore, covering the mouth and nose when sneezing, using paper tissues to cough in with prompt disposal, indicate that the client has understood the nurse's instructions about preventing the spread of airborne droplets.

A client is being discharged with a home oxygen delivery device. Which comments indicate that the client understands safety regarding home oxygen? Select all that apply. a) "I can carry my oxygen in a bag for easy portability." b) "I need to keep my oxygen away from electrical sources." c) "I'll keep my oxygen out of the sun in all circumstances." d) "No one can smoke within 10 feet (3 meters) of the oxygen." e) "I should keep my oxygen away from direct heat."

• "I should keep my oxygen away from direct heat." • "No one can smoke within 10 feet (3 meters) of the oxygen." • "I need to keep my oxygen away from electrical sources." Correct Explanation: The client demonstrates understanding about the safe use of oxygen therapy at home when he states that no one should smoke within 10 feet of oxygen and that he should keep the oxygen away from electrical sources and direct heat and sunlight. It isn't safe to place oxygen in a bag; the tank should have adequate airflow around the concentrator. It's best not to place the oxygen tank in direct sunlight, but it isn't necessary to keep it out of the sun at all times

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of PE? Select all that apply. a) A client who has a large venous stasis ulcer on the right ankle area. b) A client who has a pleural effusion secondary to lung cancer. c) A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy. d) A client who is receiving supplemental oxygen following shoulder surgery. e) A client who has recently been admitted with a broken femur and is awaiting surgery. f) A client who is on complete bed rest following extensive spinal surgery.

• A client who is on complete bed rest following extensive spinal surgery. • A client who has a large venous stasis ulcer on the right ankle area. • A client who has recently been admitted with a broken femur and is awaiting surgery. • A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy. Explanation: Bed rest, poor venous circulation, fractures, and hormone replacement therapy can cause formation of a thromboembolus, placing these clients at risk for developing a PE. A deep vein thrombosis could break loose in the leg and travel to the lungs as a pulmonary embolus. The clot would then lodge in the pulmonary arteries or arterioles and impede blood flow. The client who is on complete bed rest is at risk for venous stasis, and the client who has a venous stasis ulcer is already demonstrating this condition. The client with a broken femur is at risk for a fat embolus, another form of PE. The client on estrogen replacement therapy is at increased risk for thromboembolic disorders.

The nurse is assessing a client with a right pneumothorax. Which assessment findings would be expected? a) Bilateral pleural friction rub. b) Chest pain on inspiration. c) Inspiratory wheezes in the right thorax. d) Absence of breath sounds in the right thorax. e) Tracheal shift to the right.

• Absence of breath sounds in the right thorax. • Chest pain on inspiration. Explanation: In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. The tracheal will shift to the unaffected side. Commonly chest pain occurs on inspiration.

A nurse preparing to administer medications to a client admitted to a respiratory unit is using the computerized medication-dispensing system and finds that the password is not working. The nurse should do which of the following? Select all that apply. a) Override the machine and deliver the medications. b) Use another nurse's password to finish dispensing the medication. c) Ask computer support to reset the password. d) Since the client is having respiratory problems, the medications should be given manually. e) Secure the medication until the problem can be corrected.

• Ask computer support to reset the password. • Secure the medication until the problem can be corrected.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find? Select all that apply.

• Clubbed fingers and toes • Barrel chest • Dyspnea on exertion Explanation: Typical findings in clients with COPD include dyspnea on exertion, a barrel chest, and clubbed fingers and toes. Clients with COPD are usually tachypneic with a prolonged expiratory phase.

A client's breathing stops after receiving the wrong medication. The nurse initiates the code protocol, and the client is emergently intubated. As soon as the client's condition stabilizes, the nurse completes an incident report. What should the nurse do next? Select all that apply. a) Place the incident report on the client's chart. b) Prepare for remediation on medication administration. c) Do not document in the nursing notes about an incident report being completed. d) Insure that the client and family receives a copy of the incident report. e) Notify the nursing supervisor and or medical director.

• Do not document in the nursing notes about an incident report being completed. • Notify the nursing supervisor and or medical director. • Prepare for remediation on medication administration. Explanation: The incident report, also known as an unusual occurrence report, is a confidential document. The physician, nursing supervisor, and hospital administration may need to be notified depending on the faculty policy.

The nurse is caring for a client with pneumonia. The nurse should expect to observe which signs and symptoms? Select all that apply. a) Use of accessory muscles during respiration b) Crackles or ronchi c) Pericardial friction rub d) Fever e) Dry cough f) Bradycardia

• Fever • Crackles or ronchi • Use of accessory muscles during respiration Correct Explanation: The client with pneumonia may have a fever, use accessory muscles for breathing, and exhibit crackles or rhonchi on auscultation

A client with a suspected pulmonary embolus is brought to the emergency department complaining of shortness of breath and chest pain. Which additional signs and symptoms are anticipated? Select all that apply. a) Thick green sputum b) Low-grade fever c) Frothy sputum d) Bradycardia e) Blood-tinged sputum f) Tachycardia

• Low-grade fever • Tachycardia • Blood-tinged sputum Explanation: A pulmonary embolism (PE) is a blockage to one or more arteries in the lungs. In addition to pleuritic chest pain and dyspnea, a client with a pulmonary embolus may present with a low-grade fever, tachycardia, and blood-tinged sputum.

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. What will the nurse report? Select all that apply. a) Administration of a corticosteroid inhaler for quick relief b) Lung sounds of stridor c) Nasal flaring with abdominal retractions d) Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 e) Increased respiratory effort f) A decreased respiratory rate

• Lung sounds of stridor • Nasal flaring with abdominal retractions • Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 • Increased respiratory effort Correct Explanation: The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor and an increased respiratory effort. Also arterial blood gases with an elevated CO2 and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratory compromise. Administration of a corticosteroid decreases inflammation over a period of time.

When caring for a client who has undergone a left lung lobectomy, what important postoperative measures related to care of chest tubes should be performed by the nurse? Select all that apply. a) Maintain wall suction at a low setting so there is intermittent bubbling. b) Measure drainage at the end of each shift. c) Ensure all connections are securely taped. d) Assess chest tube dressing for bleeding. e) Position the client in the prone or supine position to permit optimal drainage.

• Measure drainage at the end of each shift. • Assess chest tube dressing for bleeding. • Ensure all connections are securely taped. Explanation: It is important to ensure that chest tube connections are secure so there are no air leaks. In addition, postoperative considerations include checking the chest tube dressing. The drainage would also be measured at the end of each shift. These are primary considerations postoperatively after a lobectomy. Wall suction must be continuously bubbling to ensure there is active suction in the pleural space. The client needs to be in the Fowler's position to promote effective breathing. Prone or supine would not be appropriate.

A nurse is caring for a client with cystic fibrosis. With which members of the health care team is it most appropriate for her to collaborate? Select all that apply. a) Physical therapy b) Social services c) Nutritional services d) Respiratory therapy e) Occupational therapy

• Nutritional services • Physical therapy • Respiratory therapy Explanation: The major objectives of therapy for cystic fibrosis are promoting secretion clearance, controlling infection, and providing adequate nutrition. The respiratory therapist would help the client clear his secretions. Nutritional services are vital in promoting optimal nutrition. Exercise, a component of physical therapy, is important in clearing the airways.

A client with heart failure develops pink, frothy sputum and restlessness. Which of the following are the priority actions by the nurse? Select all that apply. a) Check the client's blood pressure. b) Auscultate bilateral lung sounds for crackles. c) Place the client in high Fowler's position. d) Calculate the client's fluid balance from the current nursing shift. e) Notify the physician of the client's change in status.

• Place the client in high Fowler's position. • Notify the physician of the client's change in status. • Auscultate bilateral lung sounds for crackles. Explanation: Proper positioning can help reduce venous return to the heart. Placing the patient in the high Fowler's position also decreases lung congestion. Auscultating lung sounds would be a priority to assess for the presence of crackles, which would indicate fluid.

To prevent oral complications when using a fluticasone metered-dose inhaler, a nurse should instruct the client to do which of the following? Select all that apply.

• Rinse out the mouth after using the inhaler. • Add a spacer to the metered dose inhaler. • Keep the mouth piece from becoming contaminated. Explanation: To prevent mouth sores, the nurse should teach the client to rinse the mouth after use. Yeast in the mouth/throat is a common side effect when using this medication.The use of a spacer will assist the client in getting more of the medication and keeping the mouth piece clean will decrease the chance of infections

To prevent oral complications when using a fluticasone metered-dose inhaler, a nurse should instruct the client to do which of the following? Select all that apply. a) Rinse out the mouth after using the inhaler. b) Only use the inhaler as needed. c) Keep the mouth piece from becoming contaminated. d) Add a spacer to the metered dose inhaler. e) Use the inhaler before meals.

• Rinse out the mouth after using the inhaler. • Add a spacer to the metered dose inhaler. • Keep the mouth piece from becoming contaminated. Explanation: To prevent mouth sores, the nurse should teach the client to rinse the mouth after use. Yeast in the mouth/throat is a common side effect when using this medication.The use of a spacer will assist the client in getting more of the medication and keeping the mouth piece clean will decrease the chance of infections. Fluticasone is for scheduled use and not for PRN use.

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

• Using the incentive spirometer • Administration of pain medications • Frequent repositioning Explanation: Activities that help to prevent the occurrence of postoperative pneumonia are coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer