Respiratory Exam
after the nurse has received change-of-shift report, which patient should the nurse assess first?
A patient with possible lung cancer who has just returned after bronchoscopy
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 breaths/min c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema
A pt with respiratory rate of 38 BPM
The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? a. A 76-yr-old nursing home resident b. A 36-yr-old female patient who is pregnant c. A 42-yr-old patient who has a 15 pack-year smoking history d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-yr-old patient who has allergies to penicillin and cephalosporins
A, B, D
The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.
A, B, D, C
The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.
A, B, D, C
The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? a. Decongestants can be used to relieve swelling. b. 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.
A, C, D, E
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg b. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm H
A.
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 crackles and wheezes heard bilaterally c. Complaint of sharp chest pain with deep breathing d. Respiratory rate 28 breaths/minute while ambulating
A. Cough productive of bloody, purulent mucus
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 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?
Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx? a. "I will need to buy a water bottle to carry with me." b. "I should not use any lotions on my neck and throat." c. "Until the radiation is complete, I may have diarrhea." d. "Alcohol-based mouthwashes will help clean my mouth."
A. I will need to buy a water bottle to carry with me
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus c. Hyperresonance to percussion b. Dry, nonproductive cough d. A grating sound on auscultation
A. Increased tactile fremitus
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 pts breath sounds
A patient who has been 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 HCP
The nurse is caring 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. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Pain level is 5 (on 0 to 10 scale) with a deep breath. d. Respiratory rate is 24 breaths/minute when lying flat
A. O2 sat is 88%
The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to 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.
A. Observe for distended neck veins
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. Paradoxical chest movement c. Heart rate of 110 beats/minute b. Complaint of chest wall pain d. Large bruised area on the chest
A. Paradoxical chest movement
Which information about prevention of lung disease should the nurse include for a patient with a 42 pack-year history of cigarette smoking? a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer
A. Resources for support in smoking cessation
14. 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. Use and side effects of isoniazid b. Standard four-drug therapy for TB c. Need for annual repeat TB skin testing d. Bacille Calmette-Guérin (BCG) vaccine
A. Use and side effects of isoniazid
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 sclera b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices
A. Yellow-tinged sclera
The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? a. Methylprednisolone (Solu-Medrol) 60 mg IV b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) d. Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)
A. methylprednisolone 60mg IV
The nurse monitors a patient in the emergency department 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 supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). 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 pateint.
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 c. Absence of wheezes or crackles b. Pulse oximetry reading of 92% d. Respiratory rate of 18 breaths/min
B. Absence of wheezes or crackles
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 should the nurse take? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.
B. Admin the prescribed morphine
Which action should the nurse take first when a patient develops epistaxis? a. Pack the affected nare tightly with an epistaxis balloon. b. Apply squeezing pressure to the nostrils for 10 minutes. c. Obtain silver nitrate that may be needed for cauterization. d. Instill a vasoconstrictor medication into the affected nare
B. Apply squeezing pressure to the nostrils for 10 minutes.
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 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. Chronic low self-esteem related to physical dependence c. Ineffective coping related to unknown outcome of illness d. Deficient knowledge related to lack of education about COPD
B. Chronic low self-esteem related to physical dependence
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax
B. Continue to monitor the collection device
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.
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient's ventilation? a. Have the patient rest in bed with the head elevated to 15 to 20 degrees. b. Encourage the patient to sit up at the bedside in a chair and lean forward. c. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed. d. Place the patient in the Trendelenburg position with pillows behind the head
B. Encourage the pt to sit up at the bedside in a chair and lean forward
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 discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. "I will drink lots of juices and other fluids to stay well hydrated." b. "I can use nasal decongestant spray until the congestion is gone." c. "I can take acetaminophen (Tylenol) to treat my sinus discomfort." d. "I will watch for changes in nasal secretions or the sputum that I cough up."
B. I can use nasal decongestant spray until the congestion is gone
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 my health care provider if I still feel tired after a week." b. "I will continue to do deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I will cancel my follow-up chest x-ray appointment if I feel better next week."
B. I will continue to do deep breathing and coughing exercises at home
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/min, and the current peak flow is 420 L/min. 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 (Ventolin HFA). 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 pt to use the prescribed albuterol
A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important? a. Teach the patient to keep the mask on during meals. 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 corrugated tubing every hour
B. Keep the air entrainment ports clean and unobstructed
16. The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate? a. Minimize O2 use to avoid O2 dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer O2 according to the patient's level of dyspnea. d. Avoid administration of O2 at a rate of more than 2 L/min.
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. O2 saturation is >90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute.
B. O2 saturation is >90%
Which action should the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed
B. Place a patient with altered conciousness in a side-lying position.
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 in a private hospital room c. Monitoring patient serology results to identify the infecting organism d. Increasing the O2 flow rate to keep the O2 saturation over 90%
B. Placing the pt on droplet precautions 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 sedatives. b. Position the patient sitting up on the side of the bed. c. Obtain a collection device to hold 3 liters of pleural fluid. d. Remind the patient not to eat or drink anything for 6 hours
B. Position the patient sitting up on the side of the bed
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 directed. c. Teach the patient to provide tracheostomy self-care. d. Determine the need for tracheostomy tube replacement.
B. Suction the tracheostomy when directed.
The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety? a. Titrate O2 to keep saturation at least 90%. b. Teach the patient how to use pursed-lip breathing. c. Discuss a high-protein, high-calorie diet with the patient. d. Suggest the use of over-the-counter sedative medication
B. Teach the pt how to use pursed lip breathing
A patient with chronic obstructive pulmonary disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? a. Change the O2 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 pt 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 nonsteroidal antiinflammatory drugs (NSAIDs)
B. Use a swab to obtain a sample for a reapid strep antigen test.
A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering getting married and wondering about having children. Which initial response by the nurse is best? a. "Are you aware of the normal lifespan for patients with CF?" b. "Would like more 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. Would like more information to help you with that decision?
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 rapidly inhales the medication. c. The patient attaches a spacer to the Diskus. d. The patient performs huff coughing after inhalation.
B. the patient rapidly inhales the med
which assessment finding indicates that the nurse should take immediate action for an older patient?
Bilateral basilar crackles
The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse? a. The O2 saturation is 90%. b. The blood pressure is 98/56 mm Hg. c. The epoprostenol (Flolan) infusion is disconnected.
C
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, 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 drug-resistant TB. b. Schedule directly observed therapy. c. Ask the patient whether medications have been taken as directed. d. Discuss the need for an injectable antibiotic with the health care provider.
C. Ask the patient whether medications have been taken as directed
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 fenstrated tube.
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Teach pursed-lip breathing technique. c. Assist the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula
C. Assist the pt to splint the chest when coughing.
After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Arrange for arterial blood gases to be drawn immediately. b. Cover stoma with sterile gauze and ventilate through stoma. c. Attempt to reinsert the tracheostomy tube with the obturator in place. d. Assess the patient's oxygen saturation and notify the health care provider.
C. Attempt to reinsert the tracheostomy tube with the obturator in place.
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 is the best initial response by the nurse? a. "Are you ready to talk with your family members about dying now?" b. "Would you like to talk to the hospital chaplain about your feelings?" c. "Can you tell me what it is that makes you think you will die so soon?" d. "Do you think that taking an antidepressant medication would be helpful?"
C. Can you tell me what it is that makes you think you will die so soon?
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 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 who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? a. Ask the patient about any visual changes in red-green color discrimination. b. Question the patient about experiencing shortness of breath, hives, or itching. 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 when taking this medication
The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding? a. Chest pain c. Peripheral edema b. Finger clubbing d. Elevated temperature
C. Finger clubbing
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction
C. Frequent use of incentive spirometer
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. Give the prescribed albuterol (Ventolin HFA) before the therapy. d. Perform percussion before assisting the patient to the drainage position.
C. Give the prescribed albuterol before the therapy
A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Have you taken any bronchodilators today?" d. "Do you have any metal implants or prostheses?
C. Have you taken any bronchodilators today?
A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a. Monitor the incision for bleeding. b. Maintain adequate IV fluid intake. c. Keep the patient in semi-Fowler's position. d. Teach the patient to suction the tracheostomy
C. Keep the pt in semi- Fowler's position
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles 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 pt with prescribed morphine
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 take the bus instead of driving." b. "I will stay indoors whenever possible." c. "My spouse will sleep in another room." d. "I will keep the windows closed at home."
C. My spouse will sleep in another room
A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction should the nurse include in the discharge teaching? a. Travel is not possible with the use of O2 devices. b. O2 flow should be increased if the patient has more dyspnea. c. O2 use can improve the patient's prognosis and quality of life. d. Storage of O2 requires large metals tanks that each last 4 to 6 hours
C. O2 use can improve the pts prognosis and quality of life
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. Patient's chest x-ray indicates clear lung fields. b. Heart rate is between 60 and 100 beats/minute. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg.
C. Patient reports a decrease in exertional dyspnea
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent 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 O2 therapy
C. Self-admin of inhaled corticosteroids
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. Evaluate the patient's use of pancreatic enzymes. c. Teach the patient about administration of insulin. d. Give oral hypoglycemic medications before meals
C. Teach the pateint about admin of insulin
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 the patient about providing specimens for 3 consecutive days. d. Instruct the patient to collect several separate sputum specimens today.
C. Teach the pt about providing specimens for 3 consecutive days.
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. "Tell me what you know about the treatments available." d. "Surgery is the treatment of choice for stage I lung cancer."
C. Tell me what you know about the treatments available
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 indicates that this identified problem is resolving? a. The patient allows the nurse to suction the tracheostomy. b. The patient's spouse provides the daily tracheostomy care. c. The patient asks 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 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 removes the facial mask when misting stops. d. The patient activates the inhaler at the onset of expiration
C. The patient removes the facial mask when misting stops
31. 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 for hypertension
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 is 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 patients WBC count is 9000
he nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most specific in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patient indicates a 30 pack-year cigarette smoking history. c. The patient reports a productive cough for 3 months every winter. d. The patient denies having respiratory problems until the past 12 months.
C. The pt reports a productive cough for 3 months every winter
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-lb weight gain. b. The patient denies shortness of breath at present. c. The patient takes cimetidine (Tagamet HB) daily. d. The patient complains of coughing up green mucus
C. The pt takes cimetidine daily
Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. "Avoid upper body exercise to prevent dyspnea." b. "Stop exercising if you start to feel short of breath." c. "Use the bronchodilator before you start to exercise." d. "Breathe in and out through the mouth while you exercise."
C. Use the bronchodilator before you start to exercise
A patient is scheduled for spirometry. 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 6-12 hours before the exam
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the most accurate response by the nurse? a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c. "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration." d. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally."
C. You will have a permanent opening into your neck, and you will need rehabillitation for some type of voice restoration.
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 O2 therapy
C. appropriate use of cough suppressants
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 protein snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable content
C. offer high-calorie protein snacks between meals and at bedtime
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.
C. put on sterile gloves and use a sterile catheter to suction.
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 pts about the need for adult pertussis immunizations
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/min c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/min
C. use of accessory muscles in breathing
A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client?
Chest tube insertion
A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpating of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following?
Crepitus
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. 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-fowlers position
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
he 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
A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 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 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
A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.
D. Perform chest physiotherapy every 4 hours
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. Sputum smears for acid-fast bacilli are negative.
D. Sputum smears for acid-fast bacilli are negative.
A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.
D. Tape a nonporous dressing on three sides over the wound
The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? a. Assess patient for allergies to penicillin antibiotics. b. Teach the patient to sleep in a warm, dry environment. c. Avoid giving the patient warm food or warm liquids to drink. d. Teach patient to "swish and swallow" prescribed oral nystatin
D. Teach the patient to swish and swallow prescribed oral nystatin
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 has a cough that is productive of blood-tinged mucus. d. The patient is being treated with antiretrovirals for HIV infection.
D. The patient has a cough that is productive of blood-tinged mucus
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 an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.
D. The pt uses and albuterol inhaler for peak flows in the yellow zone
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 assist the patient to ambulate to the bathroom. b. UAP help splint the patient's chest during coughing. c. UAP transfer 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 pt 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 appropriate for the nurse to include in the plan of care? a. Stop exercising when you feel 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 a day at least 3 times/week
D. Walk 15-20 minutes a day at least 3x a week
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. "Do you take any over-the-counter (OTC) medications?" b. "Do you have any family members with a history of TB?" c. "How long has it been since you moved to the United States?" d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"
D. did you recieve the BCG vaccine for TB
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 completes an admission assessment on a patient with asthma. Which information given by patient is indicates a need for a change in therapy? a. The patient uses albuterol (Ventolin HFA) before 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 (Ventolin HFA) inhaler. d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol
D. the pt only med are albuterol and salmeterol
A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax?
Dry cough
The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a. Using oral antihistamines for 2 weeks before the allergy season may prevent reactions. b. Identifying and avoiding environmental triggers are the best way to prevent symptoms. c. Frequent hand washing is the primary way to prevent spreading the condition to others. d. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.
Identifying and avoiding environmental triggers are the best way to prevent symptoms
A nurse is caring for a client who has a chest tube. The nurse noted that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take?
Immerse the end of the chest tube in a bottle of sterile water.
A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first?
Initiate bag-valve-mask ventilation.
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
Inspiratory crackles at the bases
a patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. which intervention will the nurse implement directly after the procedure?
Keep the patient NPO until the gag reflex returns.
A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client?
Lung cancer usually has metastasized before the client presents with symptoms.
A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are PH 7.50 PaCo2 27 and HCO3 25. the nurse should identify that the client has which of the following imbalances?
Respiratory Alkalosis
A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the client?
Sitting while leaning forward over the bedside table
A nurse is caring for a client who has a tracheostomy with an inflated cuff. Which of the following indicates that the nurse should suction the client's airway secretions?
The nurse auscultates coarse crackles in the lung fields.
A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching?
Use pursed-lip breathing during periods of dyspnea.
the nurse observed that a patient with respiratory disease experiences a decrease in SPO2 from 93 to 98% while the patient is ambulating. What is the priority action of the nurse?
admin PRN supplemental o2
A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications?
aspiration of water
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the pt?
briefly ask specific questions about this episode of respiratory distress
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.
A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first?
encourage deep breathing and coughing
A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon?
frequent swallowing
A nurse is caring for a client who has a 20 year history of COPD and is receiving oxygen at 2L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take?
increase the oxygen flow and request an ABG determination
the nurse prepared a pt with left-sides pleural effusion for a thoracentesis. How should the nurse position the pt?
sitting upright with the arms supported on an over bed table
A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism?
stabbing chest pain
A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?
"A tissue sample might be obtained during the procedure." The nurse should inform the client that a tissue sample might be obtained during the procedure for biopsy testing.
A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider?
increased coughing
the nurse observed a student who is listening to a patients lungs. which action by the student indicates a need to review rexpiratory assessment skill?
the student listens during the inspiratory phase, then moves the stethoscope
A nurse is assessing a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider?
inspiratory stridor
A nurse is providing teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client under the impact of the surgery?
"I understand that I will have a permanent tracheotomy after the surgery"
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. "My nose will look normal after 24 to 48 hours." b. "I can take 800 mg ibuprofen every 6 hours for pain." c. "I will remove and reapply the nasal packing every day." d. "I will elevate my head for 48 hours to minimize swelling."
"I will elevate my head for 48 hours to minimize swelling"
the nurse teaches a patient about pulmonary spirometry testing. which statement, if made by the patient, indicates teaching was effective?
"I will inhale deeply and blow out hard during the test."
A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include?
"Lie on your back with your head elevated 30 degrees when resting." The nurse should instruct the client to rest in the semi-fowler's position to prevent aspiration of nasal secretions.
A nurse on a medical surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus?
A client who has a chest tube following pneumothorax.
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." b. "I need to have smoke and carbon monoxide detectors installed." c. "I can participate in my prior fitness activities except swimming." d. "I should wear a Medic-Alert bracelet to identify me as a neck breather."
A. "I must keep the stoma covered with an occlusive dressing.
A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation?
A. Discuss ways the client can reduce the number of cigarettes smoked per day
The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient reports level 8 (0 to 10 scale) pain. d. The patient's temperature is 100.1° F (37.8° C).
A. The oxygen saturation is 89%
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 8 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 8 hours
15. Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? a. A patient who is complaining of a sore throat and has a muffled voice b. A patient who has a "scratchy throat" and a positive rapid strep antigen test c. A patient who is receiving radiation for throat cancer and has severe fatigue d. A patient with a history of a total laryngectomy whose stoma is red and inflamed
A. A patient who is complaining of a sore throat and has a muffeled voice
A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider
A. Auscultate for breath sounds
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
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated? a. Use a hand-held manometer to measure cuff pressure. b. Review the health record for the prescribed cuff pressure. c. Suction the patient through a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before removing the nonfenestrated inner cannula
A. Use a hand-held manometer to measure cuff pressure.
After 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 cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%
A. Weak cough effort
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). The nurse should plan to teach the patient about a. a1-antitrypsin testing. c. use of the nicotine patch. b. leukotriene modifiers. d. continuous pulse oximetry.
A. a2-antitrypsin testing
Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Obtain O2 saturation using pulse oximetry. b. Monitor for increased O2 need with exercise. c. Teach the patient about safe use of O2 at home. d. Adjust O2 to keep saturation in prescribed parameters.
A. obtain o2 sat using pulse ox
37. The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-yr-old patient with tuberculosis (TB) who has four medications due in 15 minutes d. A 35-yr-old patient who was admitted with pneumonia and has a temperature of 100.2° F (37.8° C
B. 46 y/o pt on bed rest who is complaining of sudden onset of shortness of breath
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 c. Peak flow reading 75% of normal b. Flushing and dizziness d. Respiratory rate 24 breaths/minute
B. Flushing and dizziness
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. Teach the patient signs of hypoglycemia. b. Have the patient add dietary salt to meals. c. Suggest decreasing intake of dietary fat and calories. d. Instruct the patient about pancreatic enzyme replacements
B. Have the pt add dietary salt to meals
A patient seen in the asthma clinic has recorded daily peak flow rates 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 scheduled follow-up appointment
C. Admin a bronchodilator and recheck the peak flow.
A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Repeat warnings about the high risk for infecting others several times. b. Give the patient written instructions about how to take the medications. c. Arrange for a daily meal and drug administration at a community center. d. Arrange for the patient's friend to administer the medication on schedule
C. Arrange for a daily meal and drug admin at a community center
A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority?
Confirming the gag reflex
A nurse is caring for a patient who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?
Eat high-calorie foods first.
After change-of-shift report, which patient should the nurse assess first? a. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. A 28-yr-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. A 40-yr-old with a pleural effusion who is complaining of severe stabbing chest pain d. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion
D
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 c. Bronchodilator administration b. Stabilization of the chest wall d. Chest tube connected to suction
D. Chest tube connected to suction
The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective? 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. Iwill cal the health care provider right away if i develop a fever
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
A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons?
Draining blood and fluid from the pleural space
A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as a priority?
Ensure an adequate airway
A nurse is caring for a client whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first?
Evaluate the client for stridor
A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information?
I'll call the doctor if I see any blood in my urine or stool
A nurse is providing instructions about purses-lip breathing for a client who has COPD. with emphysema. This breathing technique accomplishes which of the following?
Promotes carbon dioxide elimination
A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include?
Try to drink at least 2 to 3 liters of fluid per day
the nurse analyzed the results of a patient's ABG. which finding would require immediate action?
the partial pressure of oxygen and atriel blood is 59 mm Hg.
A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication?
Tinnitus