Respiratory
The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider? A. Fever of 100.4° F (38° C) B. Diffuse crackles in the lungs C. Sore throat and frequent cough D. Myalgia and persistent headache
B. Diffuse crackles in the lungs
Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? A. Pain at injection site B. Flushing and dizziness C. Peak flow reading 75% of normal D. Respiratory rate 22 breaths/minute
B. Flushing and dizziness
The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? A. Albuterol (Ventolin) 2.5 mg per nebulizer B. Methylprednisolone (Solu-Medrol) 60 mg IV C. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) D. Triamcinolone (Azmacort) 2 puffs per metered-dose inhaler (MDI)
A. Albuterol (Ventolin) 2.5 mg per nebulizer
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? A. Allergy to shellfish B. Apical pulse of 104 C. Respiratory rate of 30 D. Oxygen saturation of 90%
A. Allergy to shellfish
After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider? A. Clear nasal drainage B. Complaint of nasal pain C. Bilateral nose swelling and bruising D. Inability to breathe through the nose
A. Clear nasal drainage
A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? A. Auscultate breath sounds. B. Administer the PRN morphine. C. Have the patient cough forcefully. D. Notify the patient's health care provider.
A. Auscultate breath sounds.
Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? A. Cough productive of bloody, purulent mucus B. Scattered rhonchi and wheezes heard bilaterally C. Respiratory rate 28 breaths/minute while ambulating in hallway D. Complaint of sharp chest pain with deep breathing
A. Cough productive of bloody, purulent mucus
A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance? A. Assist the patient to splint the chest when coughing. B. Teach the patient about the need for fluid restrictions. C. Encourage the patient to wear the nasal oxygen cannula. D. Instruct the patient on the pursed lip breathing technique.
A. Assist the patient to splint the chest when coughing.
A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask? A. "How much alcohol do you drink in an average week?" B. "Do you have a family history of head or neck cancer?" C. "Have you had frequent streptococcal throat infections?" D. "Do you use antihistamines for upper airway congestion?"
A. "How much alcohol do you drink in an average week?"
The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? A. "I must keep the stoma covered with an occlusive dressing at all times." B. "I can participate in most of my prior fitness activities except swimming." C. "I should wear a Medic-Alert bracelet that identifies me as a neck breather." D. "I need to be sure that I have smoke and carbon monoxide detectors installed."
A. "I must keep the stoma covered with an occlusive dressing at all times."
Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx? A. "I will need to buy a water bottle to carry with me." B. "I should not use any lotions on my neck and throat." C. "Until the radiation is complete, I may have diarrhea." D. "Alcohol-based mouthwashes will help clean oral ulcers."
A. "I will need to buy a water bottle to carry with me."
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? A. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg B. 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg C. 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg D. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
A. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? A. A 23-year-old who is complaining of a sore throat and has a muffled voice B. A 34-year-old who has a "scratchy throat" and a positive rapid strep antigen test C. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue D. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed
A. A 23-year-old who is complaining of a sore throat and has a muffled voice
The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? A. A 76-year-old nursing home resident B. A 36-year-old female patient who is pregnant C. A 42-year-old patient who has a 15 pack-year smoking history D. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis E. A 24-year-old patient who has allergies to penicillin and cephalosporins
A. A 76-year-old nursing home resident B. A 36-year-old female patient who is pregnant D. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis
Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? A. Age Correct B. Blood pressure Correct C. Respiratory rate Correct D. Oxygen saturation E. Presence of confusion Correct F. Blood urea nitrogen (BUN) level Correct
A. Age B. Blood pressure C. Respiratory rate E. Presence of confusion F. Blood urea nitrogen (BUN) level
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Document the amount of drainage every eight hours. B. Obtain samples of drainage for culture from the system. C. Assess patient pain level associated with the chest tube. D. Check the water-seal chamber for the correct fluid level.
A. Document the amount of drainage every eight hours.
A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate? A. Have the patient add dietary salt to meals. B. Teach the patient about the signs of hypoglycemia. C. Suggest decreasing intake of dietary fat and calories. D. Instruct the patient about pancreatic enzyme replacements.
A. Have the patient add dietary salt to meals.
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? A. Inspiratory crackles at the bases B. Expiratory wheezes in both lungs C. Abnormal lung sounds in the apices of both lungs D. Pleural friction rub in the right and left lower lobes
A. Inspiratory crackles at the bases
A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? A. Listen to the patient's breath sounds. B. Ask about inhaled corticosteroid use. C. Determine when the dyspnea started. D. Obtain the forced expiratory volume (FEV) flow rate.
A. Listen to the patient's breath sounds.
A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? A. Notify the health care provider. B. Document changes in respiratory status. C. Encourage the patient to cough and deep breathe. D. Administer IV methylprednisolone (Solu-Medrol).
A. Notify the health care provider.
The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies? A. Observe for distended neck veins. B. Auscultate for crackles in the lungs. C. Palpate for heaves or thrills over the heart. D. Review hemoglobin and hematocrit values.
A. Observe for distended neck veins.
Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)? A. Obtain oxygen saturation using pulse oximetry. B. Monitor for increased oxygen need with exercise. C. Teach the patient about safe use of oxygen at home. D. Adjust oxygen to keep saturation in prescribed parameters.
A. Obtain oxygen saturation using pulse oximetry.
The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include? A. Options for smoking cessation B. Reasons for annual sputum cytology testing C. Erlotinib (Tarceva) therapy to prevent tumor risk D. Computed tomography (CT) screening for lung cancer
A. Options for smoking cessation
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? A. Oxygen saturation is 88%. B. Blood pressure is 145/90 mm Hg. C. Respiratory rate is 22 breaths/minute when lying flat. D. Pain level is 5 (on 0 to 10 scale) with a deep breath.
A. Oxygen saturation is 88%.
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? A. Paradoxic chest movement B. Complaint of chest wall pain C. Heart rate of 110 beats/minute D. Large bruised area on the chest
A. Paradoxic chest movement
The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding? A. Peripheral edema B. Elevated temperature C. Clubbing of the fingers D. Complaints of chest pain
A. Peripheral edema
Which action should the nurse take first when a patient develops a nosebleed? A. Pinch the lower portion of the nose for 10 minutes. B. Pack the affected nare tightly with an epistaxis balloon. C. Obtain silver nitrate that will be needed for cauterization. D. Apply ice compresses over the patient's nose and cheeks.
A. Pinch the lower portion of the nose for 10 minutes.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider? A. Respirations are 36 breaths/minute. B. Anterior-posterior chest ratio is 1:1. C. Lung expansion is decreased bilaterally. D. Hyperresonance to percussion is present.
A. Respirations are 36 breaths/minute.
A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? A. Start an IV so contrast media may be given, B. Ensure that the patient has been NPO for at least 6 hours. C. Inform radiology that radioactive glucose preparation is needed. D. Instruct the patient to undress to the waist and remove any metal objects.
A. Start an IV so contrast media may be given.
The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse? A. The oxygen saturation is 89%. B. The nose appears red and swollen. C. The patient's temperature is 100.1° F (37.8° C). D. The patient complains of level 8 (0 to 10 scale) pain.
A. The oxygen saturation is 89%.
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? A. Use a manometer to ensure cuff pressure is at an appropriate level. B. Check the amount of cuff pressure ordered by the health care provider. C. Suction the patient first with a fenestrated inner cannula to clear secretions. D. Insert the decannulation plug before the nonfenestrated inner cannula is removed.
A. Use a manometer to ensure cuff pressure is at an appropriate level.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? A. Weak, nonproductive cough effort B. Large amounts of greenish sputum C. Respiratory rate of 28 breaths/minute D. Resting pulse oximetry (SpO2) of 85%
A. Weak, nonproductive cough effort
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? A. Yellow-tinged skin B. Orange-colored sputum C. Thickening of the fingernails D. Difficulty hearing high-pitched voices
A. Yellow-tinged skin
A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). It is most appropriate for the nurse to teach the patient about A. α1-antitrypsin testing. B. use of the nicotine patch. C. continuous pulse oximetry. D. effects of leukotriene modifiers.
A. α1-antitrypsin testing.
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving? A. Blood pressure (BP) is less than 140/90 mm Hg. B. Patient reports decreased exertional dyspnea. C. Heart rate is between 60 and 100 beats/minute. D. Patient's chest x-ray indicates clear lung fields.
B. Patient reports decreased exertional dyspnea.
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care? A. Positioning on the right side B. Bed rest for the first 24 hours C. Frequent use of an incentive spirometer D. Chest tube placement with continuous drainage
C. Frequent use of an incentive spirometer
A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which response by the nurse is best? A. "Would you like to talk to the hospital chaplain about your feelings?" B. "Can you tell me what it is that makes you think you will die so soon? " C. "Are you afraid that the treatment for your cancer will not be effective?" D. "Do you think that taking an antidepressant medication would be helpful?"
B. "Can you tell me what it is that makes you think you will die so soon? "
A young adult female patient with cystic fibrosis (CF) tells the nurse that she is not sure about getting married and having children some day. Which initial response by the nurse is best? A. "Are you aware of the normal lifespan for patients with CF?" B. "Do you need any information to help you with that decision?" C. "Many women with CF do not have difficulty conceiving children." D. "You will need to have genetic counseling before making a decision."
B. "Do you need any information to help you with that decision?"
The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? A. "I will drink lots of fluids with my meals." B. "I can have ice cream as a snack every day." C. "I will exercise for 15 minutes before meals." D. "I will decrease my intake of meat and poultry."
B. "I can have ice cream as a snack every day."
The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? A. "I will call the doctor if I still feel tired after a week." B. "I will continue to do the deep breathing and coughing exercises at home." C. "I will schedule two appointments for the pneumonia and influenza vaccines." D. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks."
B. "I will continue to do the deep breathing and coughing exercises at home."
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? A. "I will avoid being outdoors whenever possible." B. "My husband will be sleeping in the guest bedroom." C. "I will take the bus instead of driving to visit my friends." D. "I will keep the windows closed at home to contain the germs."
B. "My husband will be sleeping in the guest bedroom."
Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? A. "Stop exercising if you start to feel short of breath." B. "Use the bronchodilator before you start to exercise." C. "Breathe in and out through the mouth while you exercise." D. "Upper body exercise should be avoided to prevent dyspnea."
B. "Use the bronchodilator before you start to exercise."
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? A. A large air leak in the water-seal chamber B. 400 mL of blood in the collection chamber C. Complaint of pain with each deep inspiration D. Subcutaneous emphysema at the insertion site
B. 400 mL of blood in the collection chamber
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? A. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled B. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath C. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)
B. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? A. A patient with loud expiratory wheezes B. A patient with a respiratory rate of 38/minute C. A patient who has a cough productive of thick, green mucus D. A patient with jugular venous distention and peripheral edema
B. A patient with a respiratory rate of 38/minute
After the nurse has received change-of-shift report, which patient should the nurse assess first? A. A patient with pneumonia who has crackles in the right lung base B. A patient with possible lung cancer who has just returned after bronchoscopy C. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing D. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
B. A patient with possible lung cancer who has just returned after bronchoscopy
When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse? A. The patient is offered a tissue from the box at the bedside. B. A surgical face mask is applied before visiting the patient. C. A snack is brought to the patient from the unit refrigerator. D. Hand washing is performed before entering the patient's room.
B. A surgical face mask is applied before visiting the patient.
After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? A. Teach about treatment for drug-resistant TB treatment. B. Ask the patient whether medications have been taken as directed. C. Schedule the patient for directly observed therapy three times weekly. D. Discuss with the health care provider the need for the patient to use an injectable antibiotic.
B. Ask the patient whether medications have been taken as directed.
Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? A. Cover stoma with sterile gauze and ventilate through stoma. B. Attempt to reinsert the tracheostomy tube with the obturator in place. C. Assess the patient's oxygen saturation and notify the health care provider. D. Ventilate the patient with a manual bag and face mask until the health care provider arrives.
B. Attempt to reinsert the tracheostomy tube with the obturator in place.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? A. Chest x-ray via stretcher B. Blood cultures from two sites C. Ciprofloxacin (Cipro) 400 mg IV D. Acetaminophen (Tylenol) rectal suppository
B. Blood cultures from two sites
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? A. Delay the physical assessment to first complete pulmonary function tests. B. Briefly ask specific questions about this episode of respiratory distress. C.Complete the admission database to check for allergies before treatment. D. Delay the physical assessment to first complete pulmonary function tests.
B. Briefly ask specific questions about this episode of respiratory distress.
The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/minute and the current peak flow is 420 L/minute. Which action should the nurse take first? A. Tell the patient to go to the hospital emergency department. B. Instruct the patient to use the prescribed albuterol (Proventil). C. Ask about recent exposure to any new allergens or asthma triggers. D. Question the patient about use of the prescribed inhaled corticosteroids.
B. Instruct the patient to use the prescribed albuterol (Proventil).
A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, which action by the nurse is most important? A. Teach the patient to keep mask on at all times. B. Keep the air entrainment ports clean and unobstructed. C. Give a high enough flow rate to keep the bag from collapsing. D. Drain moisture condensation from the oxygen tubing every hour.
B. Keep the air entrainment ports clean and unobstructed.
A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? A. Elevate the head of the bed to 80 to 90 degrees. B. Keep the patient NPO until the gag reflex returns. C. Place on bed rest for at least 4 hours after bronchoscopy. D. Notify the health care provider about blood-tinged mucus.
B. Keep the patient NPO until the gag reflex returns.
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding? A. Intercostal retractions B. Kussmaul respirations Correct C. Low oxygen saturation (SpO2) D. Decreased venous O2 pressure
B. Kussmaul respirations Correct
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Listen to a patient's lung sounds for wheezes or rhonchi. B. Label specimens obtained during percutaneous lung biopsy. C. Instruct a patient about how to use home spirometry testing. D. Measure induration at the site of a patient's intradermal skin test.
B. Label specimens obtained during percutaneous lung biopsy.
The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD).What is the best way for the nurse to determine the appropriate oxygen flow rate? A. Minimize oxygen use to avoid oxygen dependency. B. Maintain the pulse oximetry level at 90% or greater. C. Administer oxygen according to the patient's level of dyspnea. D. Avoid administration of oxygen at a rate of more than 2 L/minute.
B. Maintain the pulse oximetry level at 90% or greater.
The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? A. No wheezes are audible. B. Oxygen saturation is >90%. C. Accessory muscle use has decreased. D. Respiratory rate is 16 breaths/minute.
B. Oxygen saturation is >90%.
A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)? A. Patient is claustrophobic. B. Patient is allergic to shellfish. C. Patient recently used a bronchodilator inhaler. D. Patient is not able to remove a wedding band. E. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.
B. Patient is allergic to shellfish. E. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.
The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? A. Turn and reposition immobile patients at least every 2 hours. B. Place patients with altered consciousness in side-lying positions. C. Monitor for respiratory symptoms in patients who are immunosuppressed. D. Insert nasogastric tube for feedings for patients with swallowing problems.
B. Place patients with altered consciousness in side-lying positions.
An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? A. Listening to the patient's lung sounds several times during the shift B. Placing the patient on droplet precautions and in a private hospital room. C. Increasing the oxygen flow rate to keep the oxygen saturation above 90% D. Monitoring patient serology results to identify the specific infecting organism
B. Placing the patient on droplet precautions and in a private hospital room.
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? A. Start a peripheral IV line to administer the necessary sedative drugs. B. Position the patient sitting upright on the edge of the bed and leaning forward. C. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. D. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
B. Position the patient sitting upright on the edge of the bed and leaning forward.
Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? A. Even, unlabored respirations B. Pulse oximetry reading of 92% C. Respiratory rate of 18 breaths/minute D. Absence of wheezes, rhonchi, or crackles
B. Pulse oximetry reading of 92%
Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? A. Assess the patient's risk for aspiration. B. Suction the tracheostomy when needed. C. Teach the patient about self-care of the tracheostomy. D. Determine the need for replacement of the tracheostomy tube.
B. Suction the tracheostomy when needed.
A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? A. Position the patient so that the left chest is dependent. B. Tape a nonporous dressing on three sides over the chest wound C. Cover the sucking chest wound firmly with an occlusive dressing. D. Keep the head of the patient's bed at no more than 30 degrees elevation.
B. Tape a nonporous dressing on three sides over the chest wound
A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement? A. Discuss the role of diet in blood glucose control. B. Teach the patient about administration of insulin. C. Give oral hypoglycemic medications before meals. D. Evaluate the patient's home use of pancreatic enzymes.
B. Teach the patient about administration of insulin.
A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? A. Change the oxygen flow rate to the highest prescribed rate. B. Teach the patient to use the Flutter airway clearance device. C. Reinforce the ongoing use of pursed lip breathing techniques. D. Teach the patient about consistent use of inhaled corticosteroids.
B. Teach the patient to use the Flutter airway clearance device.
The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? A. The patient inhales slowly through the nose. B. The patient puffs up the cheeks while exhaling. C. The patient practices by blowing through a straw. D. The patient's ratio of inhalation to exhalation is 1:3.
B. The patient puffs up the cheeks while exhaling.
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? A. Teach the patient about the use of expectorants. B. Use a swab to obtain a sample for a rapid strep antigen test. C. Discuss the need to rinse the mouth out after using any inhalers. D. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).
B. Use a swab to obtain a sample for a rapid strep antigen test.
The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? A. "I can take acetaminophen (Tylenol) to treat my discomfort." B. "I will drink lots of juices and other fluids to stay well hydrated." C. "I can use my nasal decongestant spray until the congestion is all gone." D. "I will watch for changes in nasal secretions or the sputum that I cough up."
C. "I can use my nasal decongestant spray until the congestion is all gone."
The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective? A. "I will use my inhaler right before the test." B. "I won't eat or drink anything 8 hours before the test." C. "I should inhale deeply and blow out as hard as I can during the test." D. "My blood pressure and pulse will be checked every 15 minutes after the test."
C. "I should inhale deeply and blow out as hard as I can during the test."
A patient seen in the asthma clinic has recorded daily peak flows that are 75% of the baseline. Which action will the nurse plan to take next? A. Increase the dose of the leukotriene inhibitor. B. Teach the patient about the use of oral corticosteroids. C. Administer a bronchodilator and recheck the peak flow. D. Instruct the patient to keep the next scheduled follow-up appointment.
C. Administer a bronchodilator and recheck the peak flow.
While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse? A. Notify the health care provider. B. Document the response to exercise. C. Administer the PRN supplemental O2. D. Encourage the patient to pace activity.
C. Administer the PRN supplemental O2.
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? A. Purpose of antibiotic therapy B. Ways to limit oral fluid intake C. Appropriate use of cough suppressants. D. Safety concerns with home oxygen therapy
C. Appropriate use of cough suppressants.
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? A. Leave the tracheostomy inner cannula inserted at all times. B. Place the decannulation cap in the tube before cuff deflation. C. Assess the ability to swallow before using the fenestrated tube. D. Inflate the tracheostomy cuff during use of the fenestrated tube.
C. Assess the ability to swallow before using the fenestrated tube.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear? A. Continuous rumbling, snoring, or rattling sounds mainly on expiration B. Continuous high-pitched musical sounds on inspiration and expiration C. Discontinuous, high-pitched sounds of short duration heard on inspiration Correct D. A series of long-duration, discontinuous, low-pitched sounds during inspiration
C. Discontinuous, high-pitched sounds of short duration heard on inspiration
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate? A. Have the patient rest in bed with the head elevated to 15 to 20 degrees. B. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed. C. Encourage the patient to sit up at the bedside in a chair and lean slightly forward. D. Place the patient in the Trendelenburg position with several pillows behind the head.
C. Encourage the patient to sit up at the bedside in a chair and lean slightly forward.
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse? A. Ask if the patient is experiencing shortness of breath, hives, or itching. B. Ask the patient about any visual abnormalities such as red-green color discrimination. C. Explain that orange discolored urine and tears are normal while taking this medication. D. Advise the patient to stop the drug and report the symptoms to the health care provider.
C. Explain that orange discolored urine and tears are normal while taking this medication.
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? A. Assist the patient to sit upright in a chair. B. Splint the patient's chest during coughing. C. Medicate the patient with prescribed morphine. D. Observe the patient use the incentive spirometer.
C. Medicate the patient with prescribed morphine.
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? A. Encourage increased intake of whole grains. B. Increase the patient's intake of fruits and fruit juices. C. Offer high-calorie snacks between meals and at bedtime. D. Assist the patient in choosing foods with high vegetable and mineral content.
C. Offer high-calorie snacks between meals and at bedtime.
A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next? A. Administer bicarbonate. B. Complete a head-to-toe assessment. C. Place the patient on high-flow oxygen. D. Obtain repeat arterial blood gases (ABGs).
C. Place the patient on high-flow oxygen.
A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? A. Encourage increased incentive spirometer use. B. Encourage the patient to increase oral fluid intake. C. Put on sterile gloves and use a sterile catheter to suction. D. Preoxygenate the patient for 3 minutes before suctioning.
C. Put on sterile gloves and use a sterile catheter to suction.
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease? A. Treat workers with pulmonary fibrosis. B. Teach about symptoms of lung disease. C. Require the use of protective equipment. D. Monitor workers for coughing and wheezing.
C. Require the use of protective equipment.
A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? A. Use of long-acting b-adrenergic medications B. Side effects of sustained-release theophylline C. Self-administration of inhaled corticosteroids D. Complications associated with oxygen therapy
C. Self-administration of inhaled corticosteroids
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? A. Document the presence of a large air leak. B. Notify the surgeon of a possible pneumothorax. C. Take no further action with the collection device. D. Adjust the dial on the wall regulator to decrease suction.
C. Take no further action with the collection device.
The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? A. Decongestants can be used to relieve swelling. Correct B. Blowing the nose should be avoided to decrease the nosebleed risk. C. Taking a hot shower will increase sinus drainage and decrease pain. D. Saline nasal spray can be made at home and used to wash out secretions. E. You will be more comfortable if you keep your head in an upright position.
C. Taking a hot shower will increase sinus drainage and decrease pain. D. Saline nasal spray can be made at home and used to wash out secretions. E. You will be more comfortable if you keep your head in an upright position.
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? A. Teach about the reason for the blood tests. B. Schedule an appointment for a chest x-ray. C. Teach about the need to get sputum specimens for 2 to 3 consecutive days. D. Instruct the patient to expectorate three specimens as soon as possible.
C. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? A. Providing supportive care to patients diagnosed with pertussis B. Teaching family members about the need for careful hand washing C. Teaching patients about the need for adult pertussis immunizations D. Encouraging patients to complete the prescribed course of antibiotics
C. Teaching patients about the need for adult pertussis immunizations
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? A. The patient lets the spouse provide tracheostomy care. B. The patient allows the nurse to suction the tracheostomy. C. The patient asks how to clean the tracheostomy stoma and tube. D. The patient uses a communication board to request "No Visitors."
C. The patient asks how to clean the tracheostomy stoma and tube.
The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most helpful in confirming a diagnosis of chronic bronchitis? A. The patient tells the nurse about a family history of bronchitis. B. The patient's history indicates a 30 pack-year cigarette history. C. The patient complains about a productive cough every winter for 3 months. D. The patient denies having any respiratory problems until the last 12 months.
C. The patient complains about a productive cough every winter for 3 months.
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? A. The Mantoux test had an induration of 7 mm. B. The chest-x-ray showed infiltrates in the lower lobes. C. The patient is being treated with antiretrovirals for HIV infection. D. The patient has a cough that is productive of blood-tinged mucus.
C. The patient is being treated with antiretrovirals for HIV infection.
The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful? A. The patient shakes the device before use. B. The patient attaches a spacer to the Diskus. C. The patient rapidly inhales the medication. D. The patient performs huff coughing after inhalation.
C. The patient rapidly inhales the medication.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline? A. The patient reports a recent 15-pound weight gain. B. The patient denies any shortness of breath at present. C. The patient takes cimetidine (Tagamet) 150 mg daily. D. The patient complains about coughing up green mucus.
C. The patient takes cimetidine (Tagamet) 150 mg daily.
The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? A. The patient has chronic inflammatory bowel disease. B. The patient has a history of pneumonia 6 months ago. C. The patient takes propranolol (Inderal) for hypertension. D. The patient uses acetaminophen (Tylenol) for headaches.
C. The patient takes propranolol (Inderal) for hypertension.
The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse? A. The oxygen saturation is 94%. B. The blood pressure is 98/56 mm Hg. C. The patient's central IV line is disconnected. D. The international normalized ratio (INR) is prolonged.
C. The patient's central IV line is disconnected.
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective? A. Bronchial breath sounds are heard at the right base. B. The patient coughs up small amounts of green mucus. C. The patient's white blood cell (WBC) count is 9000/µL. D. Increased tactile fremitus is palpable over the right chest.
C. The patient's white blood cell (WBC) count is 9000/µL.
The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? A. The student starts at the apices of the lungs and moves to the bases. B. The student compares breath sounds from side to side avoiding bony areas. C. The student places the stethoscope over the posterior chest and listens during inspiration. D. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.
C. The student places the stethoscope over the posterior chest and listens during inspiration.
A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? A. "Are you afraid that the surgery will be very painful?" B. "Did you have bad experiences with previous surgeries?" C. "Surgery is the treatment of choice for stage I lung cancer." D. "Tell me what you know about the various treatments available."
D. "Tell me what you know about the various treatments available."
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? A. Standard four-drug therapy for TB B. Need for annual repeat TB skin testing C. Use and side effects of isoniazid (INH) D. Bacille Calmette-Guérin (BCG) vaccine
C. Use and side effects of isoniazid (INH)
The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? A. Pulse oximetry reading of 91% B. Respiratory rate of 26 breaths/minute C. Use of accessory muscles in breathing D. Peak expiratory flow rate of 240 L/minute
C. Use of accessory muscles in breathing
A patient is scheduled for pulmonary function testing. Which action should the nurse take to prepare the patient for this procedure? A. Give the rescue medication immediately before testing. B. Administer oral corticosteroids 2 hours before the procedure. C. Withhold bronchodilators for 6 to 12 hours before the examination. D. Ensure that the patient has been NPO for several hours before the test.
C. Withhold bronchodilators for 6 to 12 hours before the examination.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? A. "Is there any family history of TB?" B. "How long have you lived in the United States?" C. "Do you take any over-the-counter (OTC) medications?" D. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"
D. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"
A 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary function testing (PFT) for this condition, what is the most important question the nurse should ask? A. "Are you claustrophobic?" B. "Are you allergic to shellfish?" C. "Do you have any metal implants or prostheses?" D. "Have you taken any bronchodilators in the past 6 hours?"
D. "Have you taken any bronchodilators in the past 6 hours?"
The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement? A. "I will make an appointment to see the doctor every year." B. "I will stop taking the prednisone if I experience a dry cough." C. "I will not worry if I feel a little short of breath with exercise." D. "I will call the health care provider right away if I develop a fever."
D. "I will call the health care provider right away if I develop a fever."
The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful? A. "I can take 800 mg ibuprofen for pain control." B. "I will safely remove and reapply nasal packing daily." C. "My nose will look normal after 24 hours when the swelling goes away." D. "I will keep my head elevated for 48 hours to minimize swelling and pain."
D. "I will keep my head elevated for 48 hours to minimize swelling and pain."
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? A. "I am going to buy a rib binder to wear during the day." B. "I can take shallow breaths to prevent my chest from hurting." C. "I should plan on taking the pain pills only at bedtime so I can sleep." D. "I will use the incentive spirometer every hour or two during the day."
D. "I will use the incentive spirometer every hour or two during the day."
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? A. "I have not had any acute asthma attacks during the last year." B. "I became short of breath an hour before coming to the hospital." C. "I've been taking Tylenol 650 mg every 6 hours for chest-wall pain." D. "I've been using my albuterol inhaler more frequently over the last 4 days."
D. "I've been using my albuterol inhaler more frequently over the last 4 days."
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the best response by the nurse? A. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." B. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." C. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally." D. "You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."
D. "You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."
After change-of-shift report, which patient should the nurse assess first? A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet B. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? A. Arrange for a friend to administer the medication on schedule. B. Give the patient written instructions about how to take the medications. C. Teach the patient about the high risk for infecting others unless treatment is followed. D. Arrange for a daily noon meal at a community center where the drug will be administered.
D. Arrange for a daily noon meal at a community center where the drug will be administered.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? A. Start giving the patient discharge teaching on the day of admission. B. Have the patient repeat the instructions immediately after teaching. C. Accomplish the patient teaching just before the scheduled discharge. D. Arrange for the patient's caregiver to be present during the teaching.
D. Arrange for the patient's caregiver to be present during the teaching.
The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next? A. Palpate the anterior chest and observe for barrel chest. B. Encourage the patient to turn, cough, and deep breathe. C. Review the chest x-ray report for evidence of pneumonia. D. Auscultate anterior and posterior breath sounds bilaterally.
D. Auscultate anterior and posterior breath sounds bilaterally.
When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? A. Weak cough effort B. Barrel-shaped chest C. Dry mucous membranes D. Bilateral crackles at lung bases
D. Bilateral crackles at lung bases
A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? A. Complicated grieving related to expectation of death B. Ineffective coping related to unknown outcome of illness C. Deficient knowledge related to lack of education about COPD D. Chronic low self-esteem related to increased physical dependence
D. Chronic low self-esteem related to increased physical dependence
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first? A. Administer anticoagulant drug therapy. B. Notify the patient's health care provider. C. Prepare patient for a spiral computed tomography (CT). D. Elevate the head of the bed to a semi-Fowler's position.
D. Elevate the head of the bed to a semi-Fowler's position.
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? A. Schedule the procedure 1 hour after the patient eats. B. Maintain the patient in the lateral position for 20 minutes. C. Perform percussion before assisting the patient to the drainage position. D. Give the ordered albuterol (Proventil) before the patient receives the therapy.
D. Give the ordered albuterol (Proventil) before the patient receives the therapy.
A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first? A. Notify the clinic health care provider. B. Obtain aerobic culture specimens of the drainage. C. Ask the patient about how the cotton got into the nose. D. Have the patient occlude the left nare and blow the nose.
D. Have the patient occlude the left nare and blow the nose.
The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? A. Hand washing is the primary way to prevent spreading the condition to others. B. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions. C. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. D. Identification and avoidance of environmental triggers are the best way to avoid symptoms.
D. Identification and avoidance of environmental triggers are the best way to avoid symptoms.
A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority? A. Hyperthermia related to infectious illness B. Impaired transfer ability related to weakness C. Ineffective airway clearance related to thick secretions D. Impaired gas exchange related to respiratory congestion
D. Impaired gas exchange related to respiratory congestion
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? A. Emergency pericardiocentesis B. Stabilization of the chest wall with tape C. Administration of an inhaled bronchodilator D. Insertion of a chest tube with a chest drainage system
D. Insertion of a chest tube with a chest drainage system
A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? A. Monitor for bleeding. B. Maintain adequate IV fluid intake. C. Suction tracheostomy every eight hours. D. Keep the patient in semi-Fowler's position.
D. Keep the patient in semi-Fowler's position.
A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching? A. Storage of oxygen tanks will require adequate space in the home. B. Travel opportunities will be limited because of the use of oxygen. C. Oxygen flow should be increased if the patient has more dyspnea. D. Oxygen use can improve the patient's prognosis and quality of life.
D. Oxygen use can improve the patient's prognosis and quality of life.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? A. Codeine B. Guaifenesin (Robitussin) C. Acetaminophen (Tylenol) D. Piperacillin/tazobactam (Zosyn)
D. Piperacillin/tazobactam (Zosyn)
Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? A. Hyperresonance B. Tripod positioning C. Accessory muscle use D. Reduced chest expansion
D. Reduced chest expansion
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? A. Milk the chest tube gently to remove any clots. B. Clamp the chest tube momentarily to check for the origin of the air leak. C. Assist the patient to deep breathe, cough, and use the incentive spirometer. D. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
D. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? A. Supine with the head of the bed elevated 30 degrees B. In a high-Fowler's position with the left arm extended C. On the right side with the left arm extended above the head D. Sitting upright with the arms supported on an over bed table.
D. Sitting upright with the arms supported on an over bed table.
Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? A. Teach the patient to avoid the use of over-the-counter expectorants. B. Assist the patient with chest physiotherapy and postural drainage. C. Notify the health care provider immediately about any bloody or foul-smelling sputum. D. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.
D. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.
The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? A. Avoid giving patient warm liquids to drink. B. Assess patient for allergies to penicillin antibiotics. C. Teach the patient about the need to sleep in a warm, dry environment. D. Teach patient to "swish and swallow" prescribed oral nystatin (Mycostatin).
D. Teach patient to "swish and swallow" prescribed oral nystatin (Mycostatin).
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? A. Titrate oxygen to keep saturation at least 90%. B. Discuss a high-protein, high-calorie diet with the patient. C. Suggest the use of over-the-counter sedative medications. D. Teach the patient how to effectively use pursed lip breathing.
D. Teach the patient how to effectively use pursed lip breathing.
The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action? A. The bicarbonate level (HCO3-) is 31 mEq/L. B. The arterial oxygen saturation (SaO2) is 92%. C. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. D. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
D. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? A. The patient attaches a spacer before using the inhaler. B. The patient coughs vigorously after using the inhaler. C. The patient activates the inhaler at the onset of expiration. D. The patient removes the facial mask when misting has ceased.
D. The patient removes the facial mask when misting has ceased.
The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful? A. The patient inhales rapidly through the peak flow meter mouthpiece. B. The patient takes montelukast (Singulair) for peak flows in the red zone. C. The patient calls the health care provider when the peak flow is in the green zone. D. The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone.
D. The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone.
The nurse completes an admission assessment on a patient with asthma. Which information given by patient is most indicative of a need for a change in therapy? A. The patient uses albuterol (Proventil) before any aerobic exercise. B. The patient says that the asthma symptoms are worse every spring. C. The patient's heart rate increases after using the albuterol (Proventil) inhaler. D. The patient's only medications are albuterol (Proventil) and salmeterol (Serevent).
D. The patient's only medications are albuterol (Proventil) and salmeterol (Serevent).
A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? A. Chest x-ray shows no upper lobe infiltrates. B. TB medications have been taken for 6 months. C. Mantoux testing shows an induration of 10 mm. D. Three sputum smears for acid-fast bacilli are negative.
D. Three sputum smears for acid-fast bacilli are negative.
Which information will the nurse include in the asthma teaching plan for a patient being discharged? A. Use the inhaled corticosteroid when shortness of breath occurs. B. Inhale slowly and deeply when using the dry powder inhaler (DPI). C. Hold your breath for 5 seconds after using the bronchodilator inhaler. D. Tremors are an expected side effect of rapidly acting bronchodilators.
D. Tremors are an expected side effect of rapidly acting bronchodilators.
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? A. UAP splint the patient's chest during coughing. B. UAP assist the patient to ambulate to the bathroom. C. UAP help the patient to a bedside chair for meals. D. UAP lower the head of the patient's bed to 15 degrees.
D. UAP lower the head of the patient's bed to 15 degrees.
The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be most appropriate for the nurse to include in the plan of care? A. Stop exercising when short of breath. B. Walk until pulse rate exceeds 130 beats/minute. C. Limit exercise to activities of daily living (ADLs). D. Walk 15 to 20 minutes daily at least 3 times/week.
D. Walk 15 to 20 minutes daily at least 3 times/week.
The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? A. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% B. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% C. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% D. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
D. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
