Chapter 31: Care of Patients with Infectious Respiratory Problems Ignatavicius: Medical-Surgical Nursing, 8th Edition - Chapter 27: Lower Respiratory Problems Harding: Lewis's Medical-Surgical Nursing, 11th Edition

1. The nurse caring for a client with asthma would place the client in the a. Fowler position. b. lithotomy position. c. side-lying position. d. supine position.

A The nurse should place the client in the Fowler position and give oxygen as ordered.

The nurse performing a brief physical assessment of an anxious client with asthma would carefully inspect the chest wall primarily to a. evaluate the use of intercostal muscles. b. gain time to calm the client. c. observe the client for diaphoresis. d. verify bilateral chest expansion.

ANS: A The ongoing assessment of an asthmatic client includes evaluation of the accessory muscles of respiration. The nurse should assess the client frequently, observing the respiratory rate and depth. The breathing pattern is assessed for shortness of breath, pursed-lip breathing, nasal flaring, sternal and intercostal retractions, and a prolonged expiratory phase.

1. In assessing a client for emphysema, the nurse would know that a physical finding commonly associated with this condition is a. barrel chest. b. bulbous nose. c. spider angiomas. d. varicose veins.

ANS: A Clients with emphysema develop barrel-shaped chests. The anteroposterior (AP) diameter of the chest is enlarged, and the chest has hyper resonant sounds during percussion.

10. The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients

ANS: A Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inpatient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with established goals.

1. A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"

ANS: A Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information.

A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

ANS: A, B, C Amoxicillin, ciprofloxacin, and doxycycline are all possible treatments for inhalation anthrax. Ethambutol is used for tuberculosis. SMX-TMP is commonly used for urinary tract infections and other common infections.

10. A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm3 d. White blood cell (WBC) count: 12,500/mm3

ANS: B INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.

10. A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a. Collect a sputum sample for culture by deep suctioning. b. Inform the client that antibiotics will be needed for 60 days. c. Place the client on Airborne Precautions immediately. d. Tell the client that directly observed therapy is needed.

ANS: B This client has manifestations of early inhalation anthrax. For treatment, after IV antibiotics are finished, oral antibiotics are continued for at least 60 days. Sputum cultures are not needed. Anthrax is not transmissible from person to person, so Standard Precautions are adequate. Directly observed therapy is often used for tuberculosis.

1. The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Cohort the "clients" in the same area of the unit. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.

ANS: B Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Clients can be cohorted together in the same set of rooms on one part of the unit to use distancing to help prevent the spread of the disease. The other actions are not appropriate.

1. The nurse would prepare a client with emphysema who has a ruptured emphysematous bleb for a. chest percussion. b. chest tube insertion. c. incentive spirometry. d. intubation.

ANS: B Spontaneous pneumothorax may develop from rupture of an emphysematous bleb. This results in a closed pneumothorax and requires chest tube insertion for reexpansion of the lung.

The nurse working with a depressed client who has COPD realizes many factors negatively affect the client's quality of life, including (SATA) a. familial support systems. b. loss of control over their bodies. c. reduced activity tolerance. d. social isolation.

ANS: B, C, D; Familial support systems should help with quality of life.

1. The nurse is caring for a client with a pulmonary embolism who is receiving heparin and must have an arterial blood gas (ABG) sample drawn. The nurse would arrange to remain in the room to be available to hold pressure on the puncture site for at least a. 1 minute. b. 2 minutes. c. 5 minutes. d. 10 minutes.

ANS: D; When invasive studies such as ABGs are necessary, pressure is applied to the site for at least 10 minutes.

1. A client who experienced a pulmonary embolus is receiving heparin therapy. The client will now also start receiving sodium warfarin (Coumadin). When the client asks the nurse why both medications are being given, the best response by the nurse is a. "It takes several days for the warfarin to become therapeutic." b. "Most clients go home on both drugs for maximal treatment." c. "The heparin is not working to dissolve the blood clot, so we are adding warfarin." d. "You are right to ask. You are at increased risk of bleeding with both drugs."

ANS: A Administration of sodium warfarin is begun about 3 to 5 days before heparin is stopped to provide a transition to oral anticoagulants. Warfarin has a long half-life and if the heparin was stopped too early, the client would not be protected. It is important to note that heparin does not dissolve the blood clot.

10. A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.

ANS: A The nurse needs to obtain further information about the spouse's specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining isolation precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse it's safe to visit is demeaning of the spouse's feelings.

1. A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

ANS: A The treatment regimen for TB ranges from 6 to 12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.

1. Important health promotion measures the nurse should encourage the client with COPD to consider are a. getting influenza and pneumonia vaccinations. b. increasing ambient humidity in the house or apartment. c. installing a UV filter in the heating and air conditioning system. d. moving to an area of the country with a dry climate.

ANS: A Vaccinations are recommended to help prevent infectious illness. Influenza vaccination should be given annually. The pneumonia vaccine is recommended for clients 65 years and older and for those younger than 65 if their VEV1 is <40% of predicted value.

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours

ANS: A, B, C, D The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse should perform frequent respiratory system assessments. Antipyretic medications are also used. Suction is only used when needed and is not done deeply to prevent tissue injury.

1. A nonsmoking client has been diagnosed with mild asthma. The nurse instructs the client to try to identify and reduce or eliminate exposure to triggers, which may include (Select all that apply) a. being overly excited. b. household pets. c. physical exercise. d. perfumes. e. second-hand smoke.

ANS: A, B, C, D, E All of the options can induce an asthma attack. When people with asthma are exposed to extrinsic allergens and irritants, their airways become inflamed, producing shortness of breath, chest tightness, and wheezing. Identification of irritants is essential, and irritants should be eliminated in a reasonable fashion, one at a time, to assess the effect of their removal on manifestations.

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

ANS: A, C, D, E Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.

1. A client experiencing a pulmonary embolus has pleuritic pain and hemoptysis. The nurse would assess the presence of hemoptysis as an indication of a. alveolar damage. b. hemorrhage in the sinuses. c. hemothorax. d. ruptured vessels in the trachea.

ANS: A; Hemoptysis is an indication that the atelectasis has caused alveolar damage.

1. A client has chronic obstructive pulmonary disease (COPD). In reviewing this client's laboratory values, the nurse would not be surprised to see a/an a. decreased sedimentation rate. b. elevated RBC count. c. normochromic anemia. d. therapeutic INR.

ANS: B To compensate for chronic hypoxia, the client will develop polycythemia (increased RBCs).

10. A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a. Ask the client what foods cause trouble swallowing. b. Assess the client for pain when swallowing. c. Determine if the client can swallow saliva. d. Palpate the client's jaw while swallowing.

ANS: B Odynophagia is painful swallowing. The nurse should assess the client for this either by asking or by having the client attempt to drink water. It is not related to specific foods and is not assessed by palpating the jaw. Being unable to swallow saliva is not odynophagia, but it would be a serious situation.

10. A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.

ANS: B Polymerase chain reaction testing is used to diagnose pertussis, which this client is showing manifestations of. Hospitalization may or may not be needed but is not the most important action. The client may or may not be able to produce sputum, but sputum cultures for this disease must be obtained via deep suctioning. Blood cultures will be negative.

1. Which teaching point is most important for the client with bacterial pharyngitis? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.

ANS: B Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.

1. A client tells the nurse that he read something about "dead space" in an article about emphysema and asks the nurse to explain it to him. The nurse's most accurate answer would be the following: a. "Any part of your lungs that contains mucous secretions is called dead space." b. "Dead space is an area of your lung that does not participate in air exchange." c. "Parts of the lower airway that serve as a conduit for fresh air." d. "This is a small area of necrotic tissue that can cause infection."

ANS: B As the alveoli and septa collapse, pockets of air form between the alveolar spaces (blebs) and within the lung parenchyma (bullae). This process leads to increased ventilatory dead space, resulting from areas that do not participate in gas or blood exchange.

1. An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."

ANS: B It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive manifestations are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has manifestations of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

A client with COPD has severe shortness of breath at rest and arterial oxygen tension (PaO2) of 35 mm Hg. When oxygen via nasal cannula is prescribed, the nurse would assess the client cautiously because a. regulating oxygen settings can be done by unlicensed staff. b. some clients with COPD have CO2 narcosis. c. skin damage under the nasal cannula is common. d. the client may try to sneak a cigarette and get burned.

ANS: B Some clients with COPD and hypercapnia may be oxygen-sensitive; that is, their PaCO2 levels may rise when given supplemental oxygen, leading to suppression of the central nervous system and lethargy. This phenomenon is known as CO2 narcosis. Clients with hypercapnia need to be monitored closely for their response to oxygen administration.

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3

ANS: B, C Rifampin can cause liver damage, evidenced by the client's high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this client's problem.

A nurse caring for an elderly client with COPD alters care knowing that in the older population (Select all that apply) a. COPD is not a common problem in the elderly. b. impaired nutrition is a common problem in the elderly. c. multiple co-morbidities may be present that complicate care. d. sensory disturbances may hinder their ability to provide self-care. e. there may be more problems with drug-drug interactions.

ANS: B, C, D, E COPD is a common problem in the elderly; it is a leading cause of hospitalizations in older persons. Options b through e are all correct statements about COPD and age-related considerations.

A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor-Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

ANS: C First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. Fexofenadine is a second-generation antihistamine.

After providing instructions to a client with newly diagnosed COPD who is learning to take a steroid medication by inhaler, the nurse would determine that proper technique has been learned when the client a. breathes out forcefully with an open mouth. b. gently rolls the canister in the hands before use. c. holds the breath for 5 to 10 seconds after inhalation. d. starts to discontinue the medication once manifestations subside.

ANS: C The client should hold the aerosol vapor for 5 to 10 seconds after inhalation.

1. A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. "Ice packs may help with the facial pain." b. "Limit fluids to dry out your sinuses." c. "Try warm, moist heat packs on your face." d. "We will schedule you for a computed tomography scan this week."

ANS: C This client has rhinosinusitis. Comfort measures for this condition include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.

1. A client has a history of recurring respiratory tract infections and presents today with cough and purulent sputum. The client also complains of longstanding fatigue and weakness. The nurse would assess the client further for a. a viral infection. b. asthma. c. bronchiectasis. d. tracheobronchitis.

ANS: C Bronchiectasis is an extreme form of obstructive bronchitis causing permanent abnormal dilation and distortion of bronchi and bronchioles. It occurs most often after recurrent inflammatory conditions. This client is presenting with the major manifestations and because of the history of recurrent infections, the nurse should be suspicious for this problem.

A client receives a beta-adrenergic bronchodilator and supplemental oxygen when entering the ED for treatment of asthma, but the client's condition remains unchanged. The nurse would anticipate that the client will a. be coached immediately in pursed-lip breathing. b. receive increased intravenous fluids. c. receive intravenous (IV) steroids. d. undergo "stat" pulmonary function tests.

ANS: C Emergency management of the asthmatic client begins with inhaled beta-adrenergic drugs. If the asthma does not abate, nebulized atropine sulfate or IV steroids may be given. None of the other three options are related; pulmonary function tests (PFTs) can be done when the client is stable. Pursed-lip breathing might be helpful in the setting of an acute attack when no medications are nearby.

10. A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a. "I need to take extra vitamin C while on INH." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."

ANS: C INH needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin (Rifadin).

10. A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

ANS: C Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients is important to detect the onset of possible pneumonia but do not prevent it.

1. A client is being worked up for possible pulmonary hypertension. The nurse prepares the client for the definitive diagnostic test for this condition, which is a. arterial blood gas measurements. b. pulmonary function studies. c. right heart catheterization. d. spiral computed tomography.

ANS: C Right heart catheterization is required both to diagnose pulmonary hypertension and to stage its severity.

1. A nurse is conducting community wellness seminars and teaches that a primary prevention activity for chronic obstructive pulmonary disease (COPD) is a. avoiding alcohol. b. genetic testing. c. not smoking. d. regular exercise.

ANS: C Smoking is the primary risk factor for COPD. Other risk factors include air pollution, second-hand smoke, a history of childhood respiratory tract infections, and heredity. Occupational exposure to certain industrial pollutants may also be a risk factor.

A nurse is auscultating the lungs of a client who presented to the emergency department complaining of an asthma attack. The nurse hears no wheezing. The nurse should conclude that the client a. does not really have asthma. b. is not having a bad attack. c. may have severe airway constriction. d. needs increased IV fluids.

ANS: C The inability to auscultate wheezing in an asthmatic client with acute respiratory distress may be an ominous sign. It may indicate that the small airways are too constricted to allow any air flow. The client may require immediate, aggressive medical intervention.

When counseling a client with asthma who has been advised to make several major life changes, the nurse should encourage the client to consider each suggestion carefully because a. clients may be able to simply increase their medications and not make changes. b. no doctor has all the answers about reducing exacerbations. c. the benefit of the change may be offset by the stress it causes. d. there are controversies about lifestyle changes needed in asthma.

ANS: C There are many lifestyle suggestions a client might have recommended, but the nature of the changes often produces Decisional Conflict. Nurses need to respect their client's choices and realize that some major choices such as giving up a beloved pet may cause so much stress and upheaval that the benefits the client would receive are offset.

10. A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: What action by the nurse takes priority? a. Assess the client for possible items to which he or she is allergic. b. Call the primary care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.

ANS: C This "allergy test" is actually a positive tuberculosis test. The client should be placed on Airborne Precautions immediately. The other options do not take priority over preventing the spread of the disease.

1. The ambulatory care nurse would arrange for periodic monitoring of blood levels for a client with COPD who is beginning to use a. beclomethasone (Vanceril). b. ipratropium (Atrovent). c. theophylline (Theo-Dur). d. zafirlukast (Accolate).

ANS: C; It is necessary to monitor blood levels in the client taking theophylline to prevent the client from developing toxicity.

10. A client has the diagnosis of "valley fever" accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on? a. Intravenous amphotericin B b. Long-term anti-inflammatories c. No specific treatment d. Oral fluconazole (Diflucan)

ANS: D "Valley fever," or coccidioidomycosis, is a fungal infection. Many people do not need treatment and the disease resolves on its own. However, the presence of joint and muscle pain indicates a moderate infection that needs treatment with antifungal medications. IV amphotericin is reserved for pregnant women and those with severe infection. Anti-inflammatory medications may be used to treat muscle aches and pain but are not used long term.

A client with COPD is in the hospital. When planning care, which diagnosis takes priority? a. Activity Intolerance b. Anxiety c. Imbalanced Nutrition d. Impaired Gas Exchange

ANS: D All are pertinent diagnoses for the client with COPD. But following the ABCs (airway, breathing, circulation), Impaired Gas Exchange takes priority.

1. A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

ANS: D Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have manifestations of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client should be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

1. The nurse is assessing the lab work of a client with a pulmonary embolism. The client's INR is 5.8. The most appropriate action by the nurse is to a. call the physician and ask to increase the Coumadin. b. document the findings as normal and continue care. c. encourage the client to order green leafy vegetables for dinner. d. institute safety precautions for the client.

ANS: D The optimal INR ratio for heparin therapy is 2.5 to 3. A reading of 5.8 is much too high and puts the client at risk for bleeding episodes. The nurse should place the client on safety precautions. The next dose of Coumadin may need to be held or reduced. The client should not alter the amount of green leafy vegetables in the diet because they contain vitamin K, which works to antagonize the effects of Coumadin.

10. A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

ANS: D Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate.

1. A client experiencing severe chest pain from a pulmonary embolism has been medicated for pain but appears anxious and restless. The additional nursing measure that most likely would assist the client in dealing with fear is a. asking the client not to focus on the pain. b. explaining the monitoring devices to the client. c. reassuring the client the pain medication will work soon. d. remaining at the bedside with the client.

ANS: D Emotional support can reduce anxiety and lessen dyspnea. This helps reduce oxygen demand. The nurse should stay with the client and provide calm, efficient nursing care. The other measures are not necessarily wrong, and might work for some clients, but staying in the room and offering a comforting presence is the best alternative.

1. A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a. "Are any family members also ill?" b. "Have you traveled recently?" c. "How long have you been ill?" d. "What is your occupation?"

ANS: D Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax seen in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately. The other questions are appropriate for anyone with an infection.

1. A nurse is drawing a blood sample from a client's central line and the client suddenly becomes dyspneic and complains of chest pain. The priority action by the nurse is to a. obtain blood pressure readings in both arms. b. notify the physician immediately. c. put the client in a left lateral Trendelenburg position. d. terminate the procedure and clamp the central line.

ANS: D This client is probably experiencing a venous air embolism from the open central line. The priority action is to stop the procedure and clamp the line. Then the nurse should position the client in Trendelenburg and rotate the client to the left side to trap the air in the apex of the heart. The nurse can attempt to aspirate the air from the distal port of the catheter. Someone else should notify the physician while the nurse remains with the client.

1. A nurse evaluates that goals for self-care teaching have been met when the client with asthma states a. "Coughing at night is an expected side effect of bronchodilators." b. "Follow up visits with the doctor every year are important for monitoring." c. "I won't change the dosages of my medications without talking to the doctor." d. "If my peak flow measurements drop I will increase my medications."

ANS: D Through appropriate use of the peak flow meter and medications, clients with asthma should be able to anticipate most exacerbations. Peak flow values fall about 24 hours before manifestations develop. Clients should be taught to increase their routine medications in anticipation of asthma exacerbations. Coughing at night is an indicator of poor control. Follow-up visits need to be planned every 1-6 months.

10. A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age Crackles and rhonchi heard WBC: 5,200/mm3 History of diabetes throughout the lungs PaO2 on room air 65 On insulin twice a day Dullness to percussion LLL mm Hg Reports new-onset Afebrile dyspnea and Oriented to person only productive cough

All actions are appropriate for this client who has manifestations of pneumonia. However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics.