Day 4: Test Taking Strategy

The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse should check to see that the oxygen flow rate is prescribed at which rate? 1. 2 to 3 liters per minute 2. 4 to 5 liters per minute 3. 6 to 8 liters per minute 4. 8 to 10 liters per minute

1. 2 to 3 liters per minute Rationale:In carbon dioxide narcosis, the central chemoreceptors lose their sensitivity to increased levels of carbon dioxide and no longer respond by increasing the rate and depth of respiration. For these clients, the stimulus to breathe is a decreased arterial oxygen concentration. In the client with COPD, a low arterial oxygen level is the client's primary drive for breathing. If high levels of oxygen are administered, the client may lose the respiratory drive, and respiratory failure results. Thus, the nurse checks the flow of oxygen to see that it does not exceed 2 to 3 liters per minute, unless a specific health care provider prescription indicates a different flow of the oxygen. Test-Taking Strategy(ies):Focus on the subject, COPD. Recalling the pathophysiology that occurs in COPD and that a low arterial oxygen level is the client's primary drive for breathing will direct you to the option with the lowest oxygen liter flow.Review:chronic obstructive pulmonary disease (COPD).

A client diagnosed with emphysema has an arterial blood gas (ABG) drawn. The results indicate a pH of 7.31. Based on the pH result, the nurse interprets that which condition is present? 1. Acidosis 2. Alkalosis 3. Compensation 4.Decompensation

1. Acidosis Rationale:Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. There are not adequate data in the question to determine compensation or decompensation status. Test-Taking Strategy(ies):Focus on the subject, pH of the blood. Recalling the physiology related to the blood pH will direct you to option 1. Eliminate options 3 and 4 because there is not sufficient information in the question to determine this.Review:Arterial blood gas (ABG).

When a client with a chest injury is suspected of experiencing a pleural effusion, the nurse should assess for which typical manifestations of this respiratory problem? Select all that apply. 1. Dry cough 2. Moist cough 3. Dyspnea at rest 4.Productive cough 5.Dyspnea on exertion 6.Nonproductive cough

1. Dry cough 5.Dyspnea on exertion 6.Nonproductive cough Rationale:A pleural effusion is the collection of fluid in the pleural space. Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift. Test-Taking Strategy(ies):Focus on the subject, pleural effusion. Specific knowledge that pleural effusion is in the pleural space and not the airway helps eliminate options 2 and 3 (moist productive cough does not occur). Remembering that dyspnea

Which actions should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation? 1. Practice meticulous hand hygiene. 2. Maintain the head of the bed elevation at 10 degrees. 3.Perform suctioning of oral cavity secretions every 4 hours. 4.Have the respiratory therapist change the ventilator circuit tubing every 4 hours.

1. Practice meticulous hand hygiene. Rationale:Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. To prevent aspiration of colonized secretions from the oral cavity, the client will need more frequent oral cavity suctioning and at least 30 degrees head of the bed elevation. The more frequently the circuit is broken, the greater the risk for pathogen entry. Test-Taking Strategy(ies):Focus on the subject, preventing VAP. The correct option provides evidence-based nursing care. The remaining options are quantitatively inappropriate.Review:actions to prevent ventilator-associated pneumonia (VAP).

A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP), 85/50 mm Hg; pulse, 96 beats per minute; respirations, 26 breaths per minute. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs should the nurse expect? 1. BP 85/50 mm Hg, pulse 60 beats per minute, respirations 26 breaths per minute 2. BP 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute 3. BP 130/70 mm Hg, pulse 104 beats per minute, respirations 20 breaths per minute 4. BP 110/40 mm Hg, pulse 110 beats per minute, respirations 20 breaths per minute

2. BP 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute Rationale:The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with heart failure. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. The remaining choices do not reflect the physiological changes attributed to this medication. Test-Taking Strategy(ies):Focus on the subject, the physiologic changes that occur with digoxin administration. Recalling that digoxin slows the heart rate will assist in eliminating options 3 and 4, which show an increase in the heart rate. Next recalling that digoxin improves cardiac output will assist in eliminating option 1, which does not show improvement in blood pressure.Review:the therapeutic effects of digoxin

A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which is the earliest clinical manifestation of acute respiratory distress syndrome (ARDS) the nurse should monitor for? 1. Cyanosis with accompanying pallor 2. Diffuse crackles and rhonchi on chest auscultation 3. Increase in respiratory rate from 18 to 30 breaths per minute 4. Haziness or "white-out" appearance of lungs on chest radiograph

3. Increase in respiratory rate from 18 to 30 breaths per minute Rationale:ARDS usually develops within 24 to 48 hours after an initiating event, such as chest trauma. In most cases, tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventilation. Cyanosis and pallor are late findings and are the result of severe hypoxemia. Breath sounds in the early stages of ARDS are usually clear but then progress to diffuse crackles and rhonchi as pulmonary edema occurs. Chest radiographic findings may be normal during the early stages but will show diffuse haziness or "white-out" appearance in the later stages. Test-Taking Strategy(ies):Note the strategic word, earliest. Remember that with ARDS initial presenting symptoms are tachypnea, dyspnea, and restlessness as hypoxia develops. Knowing the definition of tachypnea and possible etiologies will direct you to the correct option.Review:the early clinical manifestations of acute respiratory distress syndrome (ARDS).

A client has been diagnosed with left tension pneumothorax. Which finding observed by the nurse indicates that the pneumothorax is rapidly worsening? Select all that apply. 1. Hypertension 2. Flat neck veins 3. Increased cyanosis 4. Tracheal deviation to the right 5. Diminished breath sounds on the left 6. Observable asymmetry of the thorax

3. Increased cyanosis 4. Tracheal deviation to the right 5. Diminished breath sounds on the left 6. Observable asymmetry of the thorax Rationale:A tension pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), tracheal deviation to the unaffected side, asymmetry of the thorax, decreased to absent breath sounds on the affected side, worsening cyanosis, and worsening dyspnea. The increased intrathoracic pressure causes the blood pressure to fall, not rise. Test-Taking Strategy(ies):Focus on the subject, tension pneumothorax, and note the words "rapidly worsening." Pain and hypertension are the least specific indicators and are eliminated first. From the remaining options, remember that a tension pneumothorax causes the trachea to be pushed in the opposite direction, to the unaffected side.Review:the complications of tension pneumothorax.

A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder? 1. Thyroid cancer 2. Acute laryngitis 3. Laryngeal cancer 4. Bronchogenic cancer

3. Laryngeal cancer Rationale:Hoarseness is a common early sign of laryngeal cancer, but not of thyroid or bronchogenic cancer. Hoarseness that persists for 8 weeks is not associated with an acute problem, such as laryngitis. Test-Taking Strategy(ies):Focus on the subject, persistent hoarseness. Begin to answer this question by eliminating option 2, because an acute problem would not generally last for 8 weeks. From the remaining options, recall that the vocal cords are in the larynx when selecting the correct option.Review:the signs of laryngeal cancer.

The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding? 1. Loud wheezing 2. Wheezing on expiration 3. Noticeably diminished breath sounds 4. Increased displays of emotional apprehension

3. Noticeably diminished breath sounds Rationale:Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress being experienced. Test-Taking Strategy(ies):Note the subject, evidence of worsening respiratory status in a client being treated for an asthma attack. Use Maslow's Hierarchy of Needs theory to eliminate option 4. Next, use the ABCs—airway, breathing, and circulation. Remember that diminished breath sounds indicate obstruction and impending respiratory failure; this will direct you to the correct option. Also note that options 1 and 2 are comparable or alike and address wheezing.Review:care of the client experiencing an asthma attack.

A client attached to mechanical ventilation suddenly becomes restless and pulls out the endotracheal tube. Which action should the nurse take first? 1. Call a code. 2. Prepare for reintubation. 3. Call the primary health care provider. 4. Assess the client for spontaneous breathing.

4. Assess the client for spontaneous breathing. Rationale:If unexpected extubation occurs, the nurse would first assess the client for airway patency, spontaneous breathing, and vital signs. The nurse would remain with the client, call for assistance, and prepare for reintubation. No data in the question indicate that a code needs to be called. Test-Taking Strategy(ies):Focus on the subject, a client who removes an endotracheal tube. Note the strategic word, first. Use the ABCs—airway, breathing, and circulation—to answer the question. This will direct you to the correct option.Review:Mechanical ventilation.

A client is suspected of having a diagnosis of pulmonary tuberculosis. The nurse should assess the client for which signs/symptoms of tuberculosis? 1. High fever and chest pain 2. Increased appetite, dyspnea, and chills 3. Weight gain, insomnia, and night sweats 4. Low-grade fever, fatigue, and productive cough

4. Low-grade fever, fatigue, and productive cough Rationale:The client with pulmonary tuberculosis generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles Test-Taking Strategy(ies):Focus on the subject, tuberculosis, specifically its signs and symptoms. Remember that when an option has more than 1 part, all of the parts of that choice must be correct if the entire option is to be correct. Eliminate options 2 and 3 that relate to increased appetite and weight gain. From the remaining choices, it is necessary to know that the fever will be low grade.Review:assessment findings related to pulmonary tuberculosis.

The nurse has taught the client with pleurisy about measures to promote comfort during recuperation. The nurse determines that the client has understood the information if the client states the need to follow which instruction? 1. Try to take only small, shallow breaths. 2. Take as much pain medication as possible. 3. Lie on the unaffected side as much as possible. 4.Splint the chest wall during coughing and deep breathing.

4.Splint the chest wall during coughing and deep breathing. Rationale:The client with pleurisy should splint the chest wall during coughing and deep breathing. Taking small, shallow breaths promotes atelectasis. The client should take medication cautiously so that adequate coughing and deep breathing are performed and an adequate level of comfort is maintained. The client may also lie on the affected side to minimize the movement of the affected chest wall. Test-Taking Strategy(ies):Focus on the subject, to promote comfort in a client with pleurisy. Eliminate taking small, shallow breaths because of the closed-ended word "only." From the remaining options, noting the word splint will direct you to the correct option.Review:the measures that will promote comfort in a client with pleurisy.

The nurse has just administered a purified protein derivative (PPD) tuberculin skin test (Mantoux test) to a client who is at low risk for developing tuberculosis. The nurse determines that the test is positive if which occurs? 1. An induration of 15 mm 2. The presence of a wheal 3. A large area of erythema 4. Itching at the injection site

1. An induration of 15 mm Rationale:An induration of 10 mm or more is considered positive for clients in low-risk groups. The presence of a wheal would indicate that the skin test was administered appropriately. Erythema or itching at the site is not indicative of a positive reaction. Test-Taking Strategy(ies):Focus on the subject, a positive Mantoux test, and note that the client is at low risk for developing tuberculosis. This will direct you to the correct option.Review:Mantoux tuberculin skin test.

The ambulatory care nurse is assessing a client with chronic sinusitis. The nurse determines that which manifestations reported by the client are related to this problem? Select all that apply. 1. Anosmia 2. Chronic cough 3. Blurry vision 4. Nasal stuffiness 5. Purulent nasal discharge 6. Headache that worsens in the evening

1. Anosmia 2. Chronic cough 4. Nasal stuffiness 5. Purulent nasal discharge Rationale:Chronic sinusitis is characterized by anosmia (loss of smell), a chronic cough resulting from nasal discharge, nasal stuffiness, persistent purulent nasal discharge, and headache that is worse upon arising after sleep. Blurred vision is not associated directly to this condition. Test-Taking Strategy(ies):Focus on the subject, chronic sinusitis. Think about the pathophysiology associated with this disorder. This will assist in determining the signs and symptoms and will direct you to the correct option. Remember that headache is worse upon arising after sleep.Review:the manifestations of chronic sinusitis.

The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first? 1. Apply oxygen. 2. Administer morphine sulfate. 3. Start an intravenous (IV) line. 4. Obtain an electrocardiogram (ECG).

1. Apply oxygen. Rationale:The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first. Test-Taking Strategy(ies):Note the strategic word, first. Use the ABCs—airway, breathing, and circulation. This will direct you to the correct option.Review:care of the client with pulmonary embolism.

Which actions should the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply 1. Explain the procedure to the client. 2. Obtain the specimen early in the morning. 3. Have the client brush his teeth before expectoration. 4. Instruct the client to take deep breaths before coughing. 5. Place the lid of the culture container face down on the bedside table.

1. Explain the procedure to the client. 2. Obtain the specimen early in the morning. 3. Have the client brush his teeth before expectoration. 4. Instruct the client to take deep breaths before coughing. Rationale:The nurse always explains a procedure to the client. The specimen is obtained early in the morning whenever possible because increased amounts of sputum collect in the airways during sleep. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for best sputum production. Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings Test-Taking Strategy(ies):Focus on the subject, the procedure for obtaining a sputum culture. Read each option carefully. Visualizing the procedures for using the basic principles of aseptic technique will direct you to eliminate option 5.Review:the procedure for sputum collection.

The nurse notes that a large number of clients reporting the presence of flulike symptoms are being seen in the clinic. Which recommendations should the nurse provide to these clients to minimize their risk for further illness? Select all that apply. 1. Get plenty of rest. 2. Increase intake of liquids. 3. Get a flu shot immediately. 4. Take antipyretics for fever. 5. Consume a well-balanced diet.

1. Get plenty of rest. 2. Increase intake of liquids. 4. Take antipyretics for fever. 5. Consume a well-balanced diet. Rationale:Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics may also be used for symptom management. Immunizations against influenza are a prophylactic measure and are not used to treat flu symptoms. Test-Taking Strategy(ies):Focus on the subject, interventions for influenza. Recalling that a flu shot is a prophylactic measure will assist in directing you to the correct option.Review:measures for the client with flu-like symptoms.

A postoperative client begins to drain small amounts of bright red blood from the tracheostomy tube 24 hours after a laryngectomy. Which priority action should the nurse implement? 1. Notify the surgeon. 2. Increase the frequency of suctioning. 3. Add moisture to the oxygen delivery system. 4. Document the character and amount of drainage.

1. Notify the surgeon. Rationale:Immediately after laryngectomy, a small amount of bleeding occurs from the tracheostomy that resolves within the first few hours. Otherwise, bleeding that is bright red may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potential life-threatening situation, and the surgeon is notified to further evaluate the client and suture or repair the bleed. The other options do not address the urgency of the problem. Failure to notify the surgeon places the client at risk. Test-Taking Strategy(ies):Note the strategic word, priority. The additional information provided—bright red blood and 24 hours after the surgery—should indicate that a potential complication exists and directs you to the correct option.Review:the complications after laryngectomy.

The nurse is admitting a 56-year-old client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD) and learns that the client received immunization for pneumococcal pneumonia 6 years ago. Which consideration is essential to include in the plan of care during the client's hospital admission? 1. Offer revaccination to the client. 2. Document the previous immunization on the client record. 3. Instruct the client that this vaccine provides lifelong immunity. 4. Explain to the client that he can be revaccinated only during the fall months.

1. Offer revaccination to the client. Rationale:During the history-taking of a client diagnosed with a respiratory disorder, the nurse should ask if the client had been previously vaccinated for influenza (flu) and had received pneumococcal pneumonia vaccine. Revaccination with pneumococcal pneumonia vaccine is currently advised in a client with COPD if the client received the vaccine more than 5 years previously and if the client was younger than 65 years of age at the time of vaccination. Although documentation would be done, this is not the essential action at this time. This vaccine does not provide lifelong immunity in a 56-year-old client who received the vaccine 6 years ago. The pneumococcal pneumonia vaccine is administered any time during the year. Test-Taking Strategy(ies):Note the strategic word, essential, and focus on the subject, pneumococcal pneumonia vaccination. Recognize that this client does not have lifelong immunity and some type of intervention besides documentation is needed. Eliminate options 3 and 4, knowing that pneumococcal pneumonia vaccine can be administered any time of the year and does not provide lifelong immunity to this client.Review:criteria for immunization with pneumococcal pneumonia vaccine and chronic obstructive pulmonary disease (COPD).

A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. The nurse immediately implements which expected prescription for this client? Select all that apply. 1. Supplemental oxygen 2. High-Fowler's position 3. Semi-Fowler's position 4. Morphine sulfate intravenously 5. Two tablets of acetaminophen with codeine 6. Meperidine hydrochloride intravenously

1. Supplemental oxygen 3. Semi-Fowler's position 4. Morphine sulfate intravenously Rationale:Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation. Test-Taking Strategy(ies):Note the strategic word, immediately. Eliminate option 2 first because a high-Fowler's position could place the client at risk for development of new thrombi. From the remaining options, recall that morphine is used for its vasodilating effects as well as its opioid effects for a client experiencing chest pain.Review:management of a client with pulmonary embolus.

A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation? 1. Weight loss 2. Bilateral crackles 3. Distended neck veins 4. Peripheral pitting edema

2. Bilateral crackles Rationale:The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure. Test-Taking Strategy(ies):Focus on the subject, pulmonary edema, and note the words "left-sided" heart failure. Knowing that blood flow is stagnant behind the area of failure allows you to eliminate each of the incorrect options. To remember the signs and symptoms of heart failure, remember "left, lungs" and "right, systemic." Option 2 relates to the lungs.Review:the signs of left-sided heart failure and pulmonary edema.

A client diagnosed with acute respiratory distress syndrome (ARDS) had recently been placed on a ventilator. The current arterial blood gas results are Po2 of 75 mm Hg (75 mm Hg), Pco2 of 30 mm Hg (30 mm Hg), pH of 7.45, Sao2 of 90%, and HCO3 of 20 mEq/L (20 mmol/L). The nurse analyzes these results and determines that which acid-base condition exists? 1. Compensated metabolic acidosis 2. Compensated respiratory alkalosis 3. Uncompensated metabolic acidosis 4. Uncompensated respiratory alkalosis

2. Compensated respiratory alkalosis Rationale:Remember that when a respiratory condition exists, an opposite effect will be found between the pH and the Pco2. In respiratory alkalosis, the pH will be elevated, with a decrease in the Pco2 level. In this case the pH is at the high end of normal range (7.35 to 7.45). When the pH is within normal range, the condition is compensated. Test-Taking Strategy(ies):Focus on the subject, ARDS. Remember that when the pH is within normal range the condition is compensated. This will assist in eliminating options 3 and 4. The normal pH is 7.35 to 7.45. In acidosis the pH is down, and in alkalosis the pH is elevated. Therefore, eliminate option 1.Review:Acute respiratory distress syndrome (ARDS) and compensated respiratory alkalosis.

A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation. Which factor contributed most to the change in client status? 1. Decreased fat intake 2. Decreased fluid intake 3. Sleeping soundly during the night 4. Anxiety about the upcoming pulmonologist visit

2. Decreased fluid intake Rationale:The client with exacerbation of COPD has ineffective coughing and excess sputum in the airways. The nurse assesses the client for contributing factors such as dehydration and a lack of knowledge of proper coughing techniques. The reduction of these factors helps limit exacerbations of the disease. Decreased fat intake, sleeping soundly, and anxiety related to scheduled pulmonologist visit are not directly associated with this change in condition. Test-Taking Strategy(ies):Note the strategic word, most. Also note the subject, exacerbation of COPD. This calls to mind the concept of sputum production and clearance. Evaluate each of the options in terms of the potential ability to inhibit sputum production or clearance. The fluid intake is the only factor that could affect the viscosity of secretions, thus affecting airway clearance.Review:chronic obstructive pulmonary disease (COPD).

A client who has just experienced a pulmonary embolism is restless and appears very anxious. Which approach should the nurse use when communicating with this client? 1. Explaining each treatment in great detail 2. Giving simple, clear directions and explanations 3. Having the family reinforce the nurse's directions 4.Speaking very little to the client until the anxiety is decreased

2. Giving simple, clear directions and explanations Rationale:The client who has suffered pulmonary embolism is fearful and apprehensive. The nurse effectively communicates with this client by staying with the client; providing simple, clear, and accurate information; and displaying a calm, efficient manner. The remaining options are likely to produce more anxiety for the client and the family. Test-Taking Strategy(ies):Focus on the subject, communicating with a restless and anxious client. Use therapeutic communication techniques. Eliminate option 1 because of the words great detail. Next, eliminate option 4 because of the words speaking very little. From the remaining options, having the family reinforce the directions may place stress on the family and provide too much sensory input for the client. This will direct you to the correct option.Review:Communication strategies for the client who is restless and anxious.

The nurse is caring for a client brought to the emergency department because of a burn injury that occurred in the basement of the home. Which initial finding indicates the presence of an inhalation injury? 1. Tachycardia 2.The presence of singed nasal hair 3.Expectoration of sputum tinged with blood 4.Absent breath sounds in the lower lobes bilaterally

2.The presence of singed nasal hair Rationale:Inhalation injuries are most common when a fire occurs in a closed space. The findings are singed nasal hairs, facial burns, and sputum tinged with carbon. Additionally, auscultation of wheezing suggests an inhalation injury. Tachycardia is not a specific manifestation of a burn inhalation injury. Test-Taking Strategy(ies):Focus on the subject, inhalation injury, and note the strategic word, initial, in the question. The initial observation that the nurse should make is identified in the correct option.Review:Findings in a burn inhalation injury.

The nurse is caring for a client diagnosed with pneumonia. When considering the client's safety, when will the nurse plan to take the client for a short walk? 1. After the client eats lunch 2. After the client has a brief nap 3. After the client uses the metered-dose inhaler 4. After assessing the client's oxygen saturation

3. After the client uses the metered-dose inhaler Rationale:The nurse should schedule activities for the client with pneumonia after the client has received respiratory treatments or medications. After the administration of bronchodilators (often administered by metered-dose inhaler), the client has the best oxygen exchange possible and would tolerate the activity best. Still, the nurse implements activity cautiously, so as not to increase the client's dyspnea. The client would become fatigued after eating; therefore, this is not a good time to ambulate the client. Although the client may be rested somewhat after a nap, the respiratory status of the client may not be at its best. Although monitoring oxygen saturation is appropriate, the intervention itself does not affect the client's respiratory function Test-Taking Strategy(ies):Focus on the subject, ambulation of the respiratory client. Use the ABCs—airway, breathing, and circulation. The use of bronchodilator medication would widen the air passages, allowing for more air to enter the client's lungs.Review:care of the client with pneumonia.

A client diagnosed with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. What intervention should the nurse implement for this procedure to be beneficial? 1. Obtain baseline arterial blood gases. 2. Obtain baseline pulse oximetry levels. 3. Apply the mask to the face with a snug fit. 4. Remove the mask for deep breathing exercises.

3. Apply the mask to the face with a snug fit. Rationale:The CPAP face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client's airways. The nurse obtains baseline respiratory assessments and arterial blood gases to evaluate the effectiveness of therapy, but these are not done to increase the effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating, or drinking. This removes the benefit of positive pressure in the airway each time it is removed. Test-Taking Strategy(ies):Focus on the subject, continuous positive airway pressure (CPAP). Options 1 and 2 do not make the therapy more effective and are eliminated. From the remaining options, knowing that positive pressure must be maintained to be effective will direct you to the correct option.

The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take? 1. Determine the need to increase the oxygen. 2. Reassure the client that there is no need to worry. 3. Conduct further assessment of the client's respiratory status. 4. Call emergency services to take the client to the emergency department.

3. Conduct further assessment of the client's respiratory status. Rationale:With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is "no need to worry" is inappropriate. Calling emergency services is a premature action.

The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding? 1. Equal bilateral chest expansion 2. Respiratory rate of 22 breaths per minute 3. Diminished breath sounds on the affected side 4. Few scattered wheezes, unchanged from baseline

3. Diminished breath sounds on the affected side Rationale:After thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of these manifestations should be reported to the primary health care provider. Options 1 and 2 are normal findings. Option 4 indicates a finding that is unchanged from the baseline. Test-Taking Strategy(ies):Focus on the subject, respiratory status. Eliminate options 1 and 2 first because they are normal findings. Option 4 is an abnormality, but note that the wheezes are unchanged from the client's baseline. Option 3 is the abnormal finding.Review:the signs of complications after a thoracentesis.

A client admitted to the hospital with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (COPD) has had an arterial blood gas (ABG) test done. Which result should the nurse expect to note? 1. Auscultate breath sounds. 2. Check the settings on the ventilator. 3. Check the client's oxygen saturation level. 4. Ensure that the high-pressure alarm has stopped sounding.

1. Auscultate breath sounds. Rationale:After suctioning a client either with or without an artificial airway, the nurse auscultates the breath sounds to determine the extent to which the airways have been cleared of respiratory secretions. Option 3 may provide data about the client's oxygenation status but does not determine effectiveness of the procedure. Also, options 2 and 4 will not determine effectiveness of the procedure. Test-Taking Strategy(ies):Focus on the subject, determining effectiveness of suctioning a tracheostomy. Note the strategic word, effectiveness. Recalling that the purpose of suctioning is to clear the airways of secretions will direct you to the correct option.Review:Suctioning.

The nurse is caring for an adult client diagnosed with acute respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse should next examine the results of serum electrolytes to determine if which electrolyte imbalance is present? 1. Hypokalemia 2. Hyponatremia 3. Hypercalcemia 4.Hyperchloremia

1. Hypokalemia Rationale:Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth; headache; lightheadedness; vertigo; mental status changes; paresthesias—such as tingling of the fingers and toes; hypokalemia; hypocalcemia; tetany; and convulsions. Clinical manifestations do not include hyponatremia, hypercalcemia, or hyperchloremia. Test-Taking Strategy(ies):Focus on the subject, electrolyte imbalance in a client with respiratory alkalosis. Note the strategic word, next. Specific knowledge of the signs and symptoms of respiratory alkalosis is needed to answer the question. Remember that hypokalemia occurs in respiratory alkalosis.Review:Respiratory alkalosis.

The home care nurse is visiting a client who has been experiencing nosebleeds with the onset of winter. Which action by the client should lead the nurse to determine that the client has followed the suggestion to reduce nosebleeds? 1. Installed a humidifier 2. Started to damp dust 3. Had the furnace serviced 4. Had the chimney cleaned

1. Installed a humidifier Rationale:Nosebleeds may occur during the winter because of decreased humidity in the home. The use of a humidifier helps alleviate this problem. Environmental allergens can be reduced by having the chimney cleaned and by dusting with a damp cloth. Having the furnace serviced will detect the leakage or presence of carbon monoxide, which is harmful to the client. Test-Taking Strategy(ies):Focus on the subject, the factors contributing to nosebleeds. Dust and chimney soot do not typically cause nosebleeds, so options 3 and 4 are eliminated first. From the remaining options, recall that dry air is a more likely cause of nosebleeds than is a malfunctioning or improperly serviced furnace, making installing of a humidifier the option of choice.Review:Nosebleeds

A client at risk for respiratory failure is receiving oxygen via nasal cannula at 6 L per minute. Arterial blood gas (ABG) results indicate pH 7.29, Pco2 49 mm Hg, Po2 58 mm Hg, and HCO3 18 mEq/L. What intervention should the nurse anticipate that the primary health care provider will prescribe for respiratory support for this client? 1. Intubating for mechanical ventilation 2. Keeping the oxygen at 6 L per minute via nasal cannula 3. Lowering the oxygen to 4 L per minute via nasal cannula 4. Adding a partial rebreather mask to the current prescription

1. Intubating for mechanical ventilation Rationale:If respiratory failure occurs and supplemental oxygen cannot maintain acceptable Pao2 and Paco2 levels, endotracheal intubation and mechanical ventilation are necessary. The client is exhibiting respiratory acidosis, metabolic acidosis, and hypoxemia. Lowering or keeping the oxygen at the same liter flow will not improve the client's condition. A partial rebreather mask will raise CO2 levels even further. Test-Taking Strategy(ies):Focus on the subject, ABG analysis in a client at risk for respiratory failure. Note the ABG values. Noting that the oxygen level is low will eliminate options 2 and 3. Knowing that the Pco2 is high will eliminate option 4 because a partial rebreather mask will raise CO2 levels even further.Review:arterial blood gas (ABG) and the treatment for respiratory failure.

A client with significant flail chest has arterial blood gases (ABGs) that reveal a Pao2 of 68 and a Paco2 of 51. Two hours ago the Pao2 was 82 and the Paco2 was 44. Based on these changes, which item should the nurse assure easy access to in order to help ensure client safety? 1. Intubation tray 2. Injectable lidocaine 3. Chest tube insertion set 4. Portable chest x-ray machine

1. Intubation tray Rationale:Flail chest occurs from a blunt trauma to the chest. The loose segment from the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall. The client with flail chest has painful, rapid, shallow respirations while experiencing severe dyspnea. The laboratory results indicate worsening respiratory acidosis. The effort of breathing and the paradoxical chest movement have the net effect of producing hypoxia and hypercapnia. The client develops respiratory failure and requires intubation and mechanical ventilation, usually with positive end-expiratory pressure (PEEP); therefore, an intubation tray is necessary. None of the other options have a direct purpose with the client's current respiratory status. Test-Taking Strategy(ies):Focus on the subject, flail chest. Review the changes in the ABG values. Recall that a falling arterial oxygen level and a rising carbon dioxide level indicate respiratory failure. The usual treatment for respiratory failure is intubation, which will lead you to the correct option.Review:the complications of flail chest and the signs of respiratory failure

A client is recovering from acute respiratory distress syndrome (ARDS). The nurse determines that the client's condition is improved upon reading which entry in the medical record? 1. Pao2 84, no infiltrates on chest x-ray 2.Pao2 66, bilateral white-outs on chest x-ray 3.Pao2 72, left-sided white-out on chest x-ray 4.Pao2 86, bibasilar atelectasis on chest x-ray

1. Pao2 84, no infiltrates on chest x-ray Rationale:The client's condition is most improved with increasing oxygen levels and a chest x-ray that shows clearing of prior abnormalities. An arterial oxygen level of 80 to 100 is normal, and the chest x-ray should be clear (or without infiltrates). Option 4 indicates that the client has developed atelectasis in the lung bases, whereas options 2 and 3 do not show clinical improvement. Test-Taking Strategy(ies):Focus on the subject, signs of improvement in ARDS. Use specific knowledge of the normal arterial oxygen levels and the results of a normal chest x-ray. Note the words no infiltrates on chest x-ray to direct you to the correct option.Review:Acute respiratory distress syndrome (ARDS).

The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client's anxiety? 1. Staying with the client 2. Distracting the client with television 3. Interpreting the arterial blood gas report 4. Encouraging the client to cough and breathe deeply

1. Staying with the client Rationale:Staying with the client has a twofold benefit. First, it relieves the anxiety of the dyspneic client. In addition, the nurse must stay with the client to observe respiratory status after the application of the occlusive dressing. It is possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax, which would result in a sudden decline in respiratory status and a mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Option 2 is nontherapeutic. Interpreting the arterial blood gas report and promoting coughing and deep breathing have no immediate benefits for the client who is in distress. Test-Taking Strategy(ies):Note the strategic word, best. Focus on the subject, relieving the anxiety of a client who has an open pneumothorax. Eliminate option 2 first because the client is in distress. From the remaining options, use therapeutic nursing measures to direct you to the correct option.Review:the measures used to relieve anxiety and open pneumothorax.

The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How should the nurse correctly analyze these results? 1. The results are positive for active tuberculosis. 2. The results indicate a less virulent strain of tuberculosis. 3. The results are inconclusive until a repeat sputum specimen is sent. 4. The results are unreliable unless the client has also had a positive tuberculin skin test (TST).

1. The results are positive for active tuberculosis. Rationale:Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue confirms the diagnosis of active tuberculosis. Options 2 and 3 are incorrect statements. The TST test is performed to assist in diagnosing. Test-Taking Strategy(ies):Focus on the subject, tuberculosis. Recall that culture of the bacteria from sputum confirms the diagnosis. Because tuberculosis affects the respiratory system, it would make sense that the bacteria would be found in the sputum if the client had active disease, thereby confirming the diagnosis.Review:the diagnostic tests associated with active tuberculosis (TB).

After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the case of this client's pleural effusion? 1. Trauma 2. Infection 3. Liver failure 4.Heart failure

1. Trauma Rationale:Pleural fluid from an effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure. Test-Taking Strategy(ies):Focus on the subject, pleural effusion with a high red blood cell count. Recall that infection would be accompanied by white blood cells, not red, to eliminate option 2. Remember that in liver and heart failure, the fluid portion of the serum would accumulate to direct you to eliminate options 3 and 4.Review:the causes of pleural effusion.

A client arrives in the emergency department, who was found unconscious in a closed garage while the car engine was on. Which test should the nurse expect the primary health care provider to prescribe to confirm the diagnosis? 1. Pulse oximetry 2. Carboxyhemoglobin level 3. Complete blood cell count 4.Computed tomography (CT) scan of the head

2. Carboxyhemoglobin level Rationale:The diagnosis of carbon monoxide (CO) poisoning is confirmed by measurement of carboxyhemoglobin levels in the client's blood. The nurse should be suspicious of carbon monoxide poisoning based on the client report. Pulse oximetry readings are unreliable because of the detection of CO-hemoglobin as oxyhemoglobin. A complete blood cell count may provide useful information but will not confirm the diagnosis. The neurological system may be affected by CO poisoning, but this will be detected by assessment of clinical manifestations. A computed tomography (CT) scan of the head will not confirm the diagnosis or provide any useful information, unless a structural defect or injury in the head is a concern. Test-Taking Strategy(ies):Focus on the subject, diagnostic test to confirm CO poisoning. Note the word confirm. Note the relationship between the words carbon monoxide (CO) poisoning in the question and the correct option.Review:Content related to carbon monoxide (CO) poisoning.

A client breathing independently with a tracheostomy is coughing up copious secretions onto the tracheostomy dressing. The nurse plans which intervention to reduce the risk of respiratory infection in this client? 1. Clean the inner cannula every 24 hours. 2. Change the tracheostomy dressing as needed. 3. Decrease the client's fluid intake to reduce secretions. 4. Change the oxygen mask every 8 hours instead of every 24 hours.

2. Change the tracheostomy dressing as needed. Rationale:Tracheostomy dressings should be changed whenever they get wet or damp. A soiled dressing promotes microorganism growth and enhances tissue irritation and breakdown. The oxygen mask may be cleaned if it becomes soiled between mask and tubing changes, which are usually done every 24 hours. Tracheostomy care, including cleaning the inner cannula, should be done at least every 8 hours. It could be harmful to the client to limit fluids, because thicker secretions are harder to expectorate, and this could result in an increased chance of infection. Test-Taking Strategy(ies):Focus on the data in the question. Note that the potential source of infection for this client would be the secretions that accumulate on the dressing. With this in mind, eliminate options 1 and 4 first as being the least helpful. From the remaining options, recalling that fluids are needed to expectorate secretions or that damp or wet dressings are sources of bacterial growth will direct you to the correct option.Review:Care of the client with a tracheostomy.

A client admitted to the hospital with a diagnosis of Pneumocystis jiroveci pneumonia is prescribed intravenous (IV) pentamidine. What intervention should the nurse plan to implement to safely administer the medication? 1.Infuse over 1 hour and allow the client to ambulate. 2. Infuse over 1 hour with the client in a supine position. 3. Administer over 30 minutes with the client in a reclining position. 4. Administer by IV push over 15 minutes with the client in a supine position.

2. Infuse over 1 hour with the client in a supine position. Rationale: IV pentamidine is an antifungal medication infused over 1 hour with the client supine to minimize severe hypotension and dysrhythmias. Options 1, 3, and 4 are inaccurate in either the length of time that pentamidine is administered or the client's position. Test-Taking Strategy(ies):Focus on the subject, the procedure for administering pentamidine. Eliminate options 3 and 4 first because these time frames are too short for safe administration of this IV medication. From the remaining options, recalling that the medication causes hypotension will direct you to option 2, which addresses both the supine position and the longest time of administration.

A client enters the emergency department after accidental inhalation of steam. What should the nurse assess first? 1. Neurological status 2. Level of consciousness 3.Temperature via the rectal route 4.Respiratory status and lung sounds

2. Level of consciousness Rationale:Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and generally appear erythematous and edematous with mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after burn injury. Assessment of respiratory status is the priority. Although the nurse would check the client's temperature and the client's neurological status, respiratory status is the priority. Test-Taking Strategy(ies):Focus on the strategic word, first. Focus on the type of burn injury described in the question. Eliminate options that are comparable or alike in that they focus on the neurological status Use the ABCs—airway, breathing, and circulation—to assist in directing you to the correct option from those remaining.Review:Care of the client with a burn injury.

A hospitalized client diagnosed with active pulmonary tuberculosis has been receiving multidrug therapy for the past month and is being prepared for discharge. Which finding indicates that respiratory isolation is no longer required and that medication therapy has been effective? 1. Stools are clay colored. 2. Sputum cultures are negative. 3. Tuberculin skin test is negative. 4. Nausea and vomiting have stopped.

2. Sputum cultures are negative. Rationale:The primary laboratory test for pulmonary tuberculosis is a sputum culture. A negative culture indicates the effectiveness of treatment. Clay-colored stools, nausea, and vomiting are side effects of the medication that is used to treat tuberculosis; their presence or absence does not measure the therapeutic effectiveness of the medication. The tuberculin skin test is a screening tool rather than a diagnostic test for tuberculosis. Because the tuberculin skin test indicates exposure to the organism but not active disease, the test results will remain positive. Test-Taking Strategy(ies):Note the strategic word, effective. Remember that the absence of infectious organisms is a desired outcome in clients with communicable diseases. The sputum is the only laboratory test that will determine the absence of infectious organisms.Review:pulmonary tuberculosis.

The registered nurse is observing a new nurse suction a client with a tracheostomy. Which action, if performed by the new nurse, indicates the need for further teaching? 1. Provides 100% preoxygenation before inserting the suction catheter 2.Uses a suction catheter with a lumen that is larger than the tracheostomy 3.Assesses oxygen saturation and heart rate and rhythm before suctioning 4.Adjusts suction pressure until the dial reads 120 to 150 mm Hg pressure with the tubing occluded

2.Uses a suction catheter with a lumen that is larger than the tracheostomy Rationale:The procedure for suctioning a client with a tracheostomy requires that the suction catheter with a lumen that is no larger than one-half the size of the tracheostomy be used in order to work effectively. One hundred percent preoxygenation should be provided before inserting the suction catheter. Oxygen saturation and heart rate and rhythm should be assessed before suctioning to use as a baseline measurement during the procedure. Suction pressure should be adjusted to 120 to 150 mm Hg with the tubing occluded. Test-Taking Strategy(ies):Focus on the subject, suctioning a client with a tracheostomy. Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect action as the answer. Visualize each of the options. Using a suction catheter that is larger than the tracheostomy will not allow the catheter to pass through; this will assist in directing you to this option.

A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the right lower lobe, expecting to note which type of breath sounds? 1. Absent 2. Vesicular 3. Bronchial 4.Bronchovesicular

3. Bronchial Rationale:Bronchial sounds are normally heard over the trachea. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi. Test-Taking Strategy(ies):Focus on the subject, breath sounds in a client with lower lobe pneumonia. Recalling that vesicular breath sounds are normal in the lung periphery and bronchovesicular sounds are normally heard over the main bronchi helps eliminate options 2 and 4. From the remaining options, recall that pneumonia transmits bronchial breath sounds, so they are heard over the area of consolidation.Review:assessment findings in pneumonia.

A client diagnosed with pneumonia reports a decreased sense of taste that has greatly affected the motivation to eat and drink. Which intervention should the nurse implement to help increase the client's appetite? 1. Offer in-between meal snacks. 2. Provide three large meals daily. 3. Provide mouth care before meals. 4.Offer to sit with the client during meals.

3. Provide mouth care before meals. Rationale:The client with pneumonia may experience decreased taste sensation as a result of sputum expectoration. To minimize this adverse effect, the nurse should provide oral hygiene before meals. The client should also have small, frequent meals because of dyspnea. The remaining options will not address the issue of impaired sense of taste. Test-Taking Strategy(ies):Focus on the subject, anorexia and increasing the client's appetite. Eliminate options 1, 2, and 4 because they are comparable or alike and will not increase the client's appetite. Additionally, as a general measure, small frequent meals are better tolerated than large meals.Review:anorexia and pneumonia.

The nurse is teaching the client with asthma how to perform a peak expiratory flow rate measurement. Which action should the nurse instruct the client to take? 1. Inhale an average-size breath. 2. Blow out as slowly as possible. 3. Record the final position of the indicator on the meter. 4. Form a loose seal with the mouth around the mouthpiece.

3. Record the final position of the indicator on the meter. Rationale:A peak expiratory flow rate meter is used to provide an objective measure of the client's peak expiratory flow. The client is instructed to take the deepest possible breath, form a tight seal around the mouthpiece with the lips, and exhale forcefully and rapidly. The final position of the indicator on the meter is recorded. Test-Taking Strategy(ies):Focus on the subject, use of a peak flow meter. Visualizing this piece of equipment and how and why it is used will assist in directing you to the correct option. Remember that the final position of the indicator on the meter is recorded.Review:Peak flow meter.

The client diagnosed with asthma awakens frequently during the night with chest tightness, wheezing, and coughing. How should the nurse interpret these assessment findings? 1. The client is exhibiting signs of heart failure. 2.The client may need to be prescribed a sleep aid. 3.The client may need a longer-acting bronchodilator. 4.The client is exhibiting signs of sleep apnea and needs follow-up.

3.The client may need a longer-acting bronchodilator. Rationale:The client with asthma may frequently awaken during the night with chest tightness, wheezing, and coughing, and this often indicates the need for a longer-acting bronchodilator. Based on the client's medical history, further assessment is required before determining the need for a sleep aid. The client is not exhibiting signs of heart failure or sleep apnea. Test-Taking Strategy(ies):Focus on the subject in the question, a client with asthma who is experiencing symptoms during the night. Recalling that bronchodilators are often prescribed to control asthma symptoms will assist in directing you to the correct option.Review:Asthma.

The nurse places a hospitalized client with a diagnosis of active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room? 1. Wash the hands. 2. Wash the hands and wear a gown and gloves. 3.Wash the hands and place a high-efficiency particulate air (HEPA) respirator over the nose and mouth. 4.The nurse needs no special precautions, but the client is instructed to cover his or her mouth and nose when coughing or sneezing.

3.Wash the hands and place a high-efficiency particulate air (HEPA) respirator over the nose and mouth. Rationale:Tuberculosis is a highly communicable disease caused by Mycobacterium tuberculosis. The nurse wears a HEPA respirator when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Option 1 is an incomplete action. Option 2 is also inaccurate and incomplete. Gowning is only indicated when there is a possibility of contaminating clothing. Option 4 is an incorrect statement because special precautions are needed. Test-Taking Strategy(ies):Focus on the subject, caring for the client with tuberculosis. Recalling the route of transmission and the need for airborne precautions will direct you to the correct option.Review:airborne precautions and tuberculosis

The nurse assesses the breath sounds of a client diagnosed with pleurisy and documents the finding as a pleural friction rub located in the left lung. The nurse bases the assessment on which characteristic of a pleural friction rub? 1. A gurgling noise heard on expiration 2. A musical or hissing noise heard on inspiration 3. Crackles heard during inspiration and expiration 4. A creaking or grating noise heard on inspiration and expiration

4. A creaking or grating noise heard on inspiration and expiration Rationale:Pleural friction rubs are the result of pleural inflammation often associated with pleurisy, pneumonia, or pleural infarct. A pleural friction rub is described as a creaking or grating noise similar to that made by two pieces of leather rubbing together. A pleural friction rub is audible on inspiration and expiration over the area of inflammation. Option 1 describes rhonchi. Option 2 describes the characteristic of wheezes. Option 3 describes crackles, and they are audible when there is a sudden opening of small airways that contain fluid. Test-Taking Strategy(ies):Focus on the subject, pleural friction rub. Correlate a pleural friction rub with a creaking or grating noise to assist you in remembering what these sounds would produce.Review:Pleural friction rub.

The nurse is teaching a client with hypertension about items that contain sodium and reviews a written list of items sent from the cardiac rehabilitation department. The nurse tells the client that which item is lowest in sodium content? 1. Antacids 2. Laxatives 3. Toothpaste 4. Demineralized water

4. Demineralized water Rationale:Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Clients are advised to read labels for sodium content. Sodium intake can be increased with the use of several types of products, including toothpaste and mouthwashes; over-the-counter medications such as analgesics, antacids, cough remedies, laxatives, and sedatives; and softened water, as well as some mineral waters. Test-Taking Strategy(ies):Focus on the subject, the item that is lowest in sodium. Noting the word demineralized, which means having the minerals taken out of, will direct you to option 4.Review:items that are low and high in sodium

A client with a diagnosis of an acute respiratory infection and sinus tachycardia is admitted to the hospital. The nurse should develop a plan of care for the client and include which intervention? 1. Limiting oral and intravenous fluids 2. Measuring the client's pulse once each shift 3. Providing the client with short, frequent walks 4. Eliminating sources of caffeine from meal trays

4. Eliminating sources of caffeine from meal trays Rationale:In sinus tachycardia, the heart rate is greater than 100 beats per minute. Sinus tachycardia is often caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia and could exacerbate the condition. Measuring the client's pulse during each shift will not decrease the heart rate. Additionally, the pulse should be taken more frequently than once each shift. Test-Taking Strategy(ies):Focus on the subject, sinus tachycardia. Recalling the causes of tachycardia will direct you to the correct option. Remember that caffeine is a stimulant and will increase the heart rate.Review:care of the client with tachycardia.

The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which is the appropriate client concern? 1. Lack of knowledge about COPD 2. Difficulty coping related with a situational crisis 3. Negative self-image because of neurological deficit 4. Restricted verbal communication because of a physical barrier

4. Restricted verbal communication because of a physical barrier Rationale:A client with COPD may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support the remaining options. Test-Taking Strategy(ies):Focus on the subject, that the client is experiencing extreme dyspnea during an interview. Based on this, option 4 is the only option that addresses this subject.Review:communication in a client with a chronic obstructive pulmonary disease (COPD).

A client is diagnosed with a flail chest. Which characteristics related to breathing should the nurse observe for in the client? 1. Cyanosis and slow respirations 2.Slight bradypnea with shallow breaths 3.Pallor and paradoxical chest movement 4.Severe dyspnea and paradoxical chest movement

4. Severe dyspnea and paradoxical chest movement Rationale:The client with flail chest is in obvious respiratory distress. The client has severe dyspnea and cyanosis accompanied by paradoxical chest movement. Respirations are shallow, rapid, and grunting in nature. Test-Taking Strategy(ies):Focus on the subject, flail chest. Remember that for an option to be correct, all parts of that choice must also be correct. With this in mind, eliminate options 2 and 3 that contain the words

The nurse has been preparing a client diagnosed with chronic obstructive pulmonary disease for discharge. Which statement by the client indicates the need for further teaching about nutrition? 1. "I will rest a few minutes before I eat." 2."I will not eat as much cabbage as I once did." 3."I will certainly try to drink 3 L of fluid every day." 4."It's best to eat three large meals a day, so that I will get all my nutrients."

4."It's best to eat three large meals a day, so that I will get all my nutrients." Rationale:Large meals distend the abdomen and elevate the diaphragm, which may interfere with breathing for the client diagnosed with chronic obstructive pulmonary disease. Resting before eating may decrease the fatigue that is often associated with chronic obstructive pulmonary disease. Gas-forming foods may cause bloating, which interferes with normal diaphragmatic breathing. Adequate fluid intake helps liquefy pulmonary secretions.

The nurse witnesses a pedestrian being hit by an automobile. The nurse assesses the victim and notes responsiveness and a flail chest involving at least three ribs. Which action should the nurse take to assist the client's respiratory status until help arrives? 1. Assist the victim to sit up. 2. Remove the victim's shirt. 3.Turn the client onto the side with the flail chest. 4.Apply firm but gentle pressure with the hands to the flail segment.

4.Apply firm but gentle pressure with the hands to the flail segment. Rationale:Flail chest occurs from blunt chest trauma. If flail chest is present, the nurse applies firm yet gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the client's respiratory status. The nurse does not move an injured person because of the risk of worsening an undetected spinal cord injury. Removing the victim's shirt is of no value in this situation and could chill the victim, which is counterproductive. Injured persons should be kept warm until help arrives at the scene. Test-Taking Strategy(ies):Focus on the subject, flail chest management. Use knowledge of the principles of respiration and emergency nursing care to answer this question. Eliminate options that suggest that the client should be moved. From the remaining options, recalling that the client should be kept warm will direct you to the correct option.Review:Emergency care of the client with flail chest

The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action? 1. Breathes in and then holds the breath for 30 seconds 2. Loosens the abdominal muscles while breathing out 3.Inhales with puckered lips and exhales with the mouth open wide 4.Breathes so that expiration is two to three times as long as inspiration

4.Breathes so that expiration is two to three times as long as inspiration Rationale:COPD is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing. Test-Taking Strategy(ies):Focus on the subject, pursed-lip breathing in a client with chronic obstructive pulmonary disease (COPD). Visualize each of the actions in the options. Recalling that a major purpose of pursed-lip breathing is to prevent air trapping during exhalation will direct you to the correct option.Review:the principles of pursed-lip breathing and chronic obstructive pulmonary disease (COPD).

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. Which action should the nurse take next? 1. Call a code. 2. Administer a bronchodilator. 3. Contact the primary health care provider. 4.Disconnect the suction source from the catheter.

4.Disconnect the suction source from the catheter. Rationale:The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse would immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse would then connect the oxygen source to the catheter. The primary health care provider is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if this situation occurs during suctioning. Test-Taking Strategy(ies):Focus on the subject, complications during suctioning, and note the strategic word, next. Eliminate any option that requires a primary health care provider's prescription. From the remaining options, visualize the situation presented in the question. Noting that the nurse is unable to remove the suction catheter from the client's trachea will direct you to the correct option.Review:Suctioning.

The nurse is going to suction an adult client with a tracheostomy who has respiratory secretions. Which intervention should the nurse implement to perform this procedure safely? 1. Setting the suction pressure range between 160 and 180 mm Hg 2. Applying continuous suction in the airway for up to 20 seconds 3.Occluding the Y-port of the suction catheter while advancing it 4.Hyperoxygenating the client by asking the client to take 4 to 5 deep breaths

4.Hyperoxygenating the client by asking the client to take 4 to 5 deep breaths Rationale:To perform suctioning, the nurse hyperoxygenates the client by asking client to take 4 to 5 deep breaths, using a manual resuscitation bag, or the sigh mechanism if the client is on a mechanical ventilator. The safe suction range for an adult is 100 to 120 mm Hg. The nurse uses intermittent suction in the airway for up to 10 to 15 seconds. The nurse advances the suction catheter into the tracheostomy without occluding the Y-port; suction is never applied while introducing the catheter because it would traumatize mucosa and remove oxygen from the respiratory tract. Test-Taking Strategy(ies):Visualize this procedure. Recalling that suction is applied intermittently and on catheter withdrawal only will eliminate options 2 and 3. From the remaining options, use the ABCs—airway, breathing, and circulation—to direct you to the correct option.Review:the procedure for suctioning.

The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and assesses the client to determine the cause of the alarm but is unable to do so. What is the immediate nursing action? 1. Call a code. 2. Call the respiratory therapist. 3. Call the primary health care provider. 4.Ventilate the client manually with a resuscitation bag.

4.Ventilate the client manually with a resuscitation bag. Rationale:Mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. Alarm systems must be activated and functional at all times. The nurse must recognize an emergency and intervene promptly so that complications are prevented. If the cause of an alarm cannot be determined, the nurse ventilates the client manually with a resuscitation bag until the problem is corrected by a second nurse, the respiratory therapist, or primary health care provider. Test-Taking Strategy(ies):Note the strategic word, immediate. Focus on the subject, a low-exhaled volume (low-pressure) alarm sounding on a ventilator. Thinking about the purpose of the ventilator will easily direct you to the correct option. Remember that a ventilator provides oxygen to the client. The nurse needs to ventilate a client manually if an emergency such as this occurs. Also note that the remaining options are comparable or alike in that they all suggest calling someone or something.Review:Mechanical ventilator.