Exam 1 - Practice Questions
Chapter 24: Assessment of the Respiratory System
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Chapter 25: Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy
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The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour? ________
880 units. If there are 20,000 units of heparin in500 mL of D5W, there are 40 units in each mL: 20,000 ÷ 500 = 40 units If 22 mL are infused per hour, then 880 units of heparin are infused each hour: 40 units × 22 = 880 TEST-TAKING HINT: The test taker must know how to calculate heparin drips from two aspects: the question may give the mL/hr and the test taker has to determine units/hr or the question may give units/hr and the test taker has to determine mL/hr. Remember to learn how to use the drop-down calculator on the computer.
The nurse observes the unlicensed nursing assistant (NA) entering an airborne isolation room and leaving the door open. Which action would be the nurse's best response? 1. Close the door and discuss the NA's action when the NA comes out of the room.2. Make the NA come back outside the room and then reenter closing the door.3. Say nothing to the NA but report the incident to the nursing supervisor.4. Enter the client's room and discuss the matter with the NA immediately.
Answer: 1. Close the door and discuss the NA's action when the NA comes out of the room. Closing the door reestablishes the negative air pressure, which prevents the air from entering the hall and contaminating the hospital environment. When correcting an individual, it is always best to do so in a private manner. The employee is an adult and as such should be treated with respect and corrected accordingly. Problems should be taken care of at the lowest level possible. The nurse is responsible for any task delegated, including the appropriate handling of isolation. Correcting staff should never be done in the presence of the client. This undermines the nursing assistant and creates doubt of the staff's competency in the client's mind. TEST-TAKING HINT: An action must be taken; the test taker must determine which action would have the desired results with the least amount of disruption to client care. Correcting the nursing assistant in this manner has the greatest chance of creating a win-win situation.
The nurse is preparing to administer medications to the following clients. Which medication would the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hanging the heparin bag to a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.
Answer: 3. Hanging the heparin bag to a client with a PT/PTT of 12.9/98. A normal PTT is 39 seconds; therefore, 58-78 is 1.5 to 2 times the normal value and is within the therapeutic range. A PTT of 98 means the client is not clotting and the medication should be held. An INR of 2-3 is therapeutic; therefore, the nurse would administer this medication. This is an elevated blood glucose level; therefore, the nurse should administer the insulin. This is a normal blood pressure and the nurse should administer the medication. TEST-TAKING HINT: This question is asking the test taker to select a distracter that has assessment data that are unsafe for administering the medication. The test taker must know normal laboratory values to administer medication safely.
Which referral is most appropriate for a client diagnosed with end-stage COPD? 1. The Asthma Foundation of America. 2. The American Cancer Society. 3. The American Lung Association. 4. The American Heart Association.
Answer: 3. The American Lung Association. The American Lung Association has information helpful for a client with COPD. The other options may have information useful for other clients, but none have information about COPD available for COPD clients.
The client is admitted with a diagnosis of rule out tuberculosis. Which type of isolation procedures should the nurse implement? 1. Standard Precautions. 2. Contact Precautions. 3. Droplet Precautions. 4. Airborne Precautions.
Answer: 4. Airborne Precautions. Tuberculosis bacteria are capable of disseminating over distances on air currents. Clients with tuberculosis are placed in negative air pressure rooms where the air in the room is not allowed to cross- contaminate the air in the hallway. Standard precautions are used to prevent expo- sure to blood and body secretions on all clients. TB is caused by airborne bacteria. Contact precautions are used for wounds. Droplet precautions are used for infections that are spread by sneezing or coughing but are not transmitted over distances of more than three (3) to four (4) feet. TEST-TAKING HINT: Standard precautions and contact precautions can be ruled out as the correct answer if the test taker is aware that TB is usually a respiratory illness. This at least gives the reader a 1:2 chance of selecting the correct answer if the answer is not known.
A nurse is assessing a client with lung cancer. What non-pulmonary signs and symptoms would the nurse be aware of? (Select all that apply.) a. Gynecomastia in male patients b. Frequent shaking and sweating relieved by eating c. Positive Chvostek and Trousseau signs d. "Moon" face and "buffalo" hump e. Expectorating purulent sputum f. General edema
Answer: a, b, d, f. a. Gynecomastia in male patients b. Frequent shaking and sweating relieved by eating d. "Moon" face and "buffalo" hump f. General edema Lung cancer often is associated with paraneoplastic syndromes. Symptoms of these include gynecomastia from ectopic follicle-stimulating hormone release, hypoglycemia from ectopic insulin production (shaking and sweating relieved by eating), and Cushing syndrome (moon facies and buffalo hump) from ectopic adrenocorticotropic hormone. General edema can be caused by antidiuretic hormone.
A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the client regarding this drug? (Select all that apply.) a. Contact the primary health care provider if preexisting gout becomes worse. b. Report any changes in vision immediately to the health care provider. c. Avoid drinking alcoholic beverages due to the chance of liver damage. d. Do not take antacids or eat within 2 hours after taking this medication. e. You will take this medication along with some others for 8 weeks. f. Take this medicine with a full glass of water.
Answer: a, b, e, f. a. Contact the primary health care provider if preexisting gout becomes worse. b. Report any changes in vision immediately to the health care provider. e. You will take this medication along with some others for 8 weeks. f. Take this medicine with a full glass of water. The nurse would teach the client that preexisting gout may get worse and the client should report this as medications for gout may need to be adjusted. The nurse would also inform the client about the multi- drug routine used for TB. Optic neuritis can occur with this drug so the client needs to report visual changes right away. The medication should be taken with a full glass of water. Drinking while taking ethambutol causes severe nausea and vomiting. Avoiding antacids and food (within 2 hours) is a precaution with isoniazid.
A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this client's evaluation? (Select all that apply.) a. Examination of mucous membranes and nail beds b. Measurement of rate, depth, and rhythm of respirations c. Auscultation of bowel sounds for abnormal sounds d. Check peripheral veins for distention while at rest e. Determine the client's need and use of oxygen f. Ability to perform activities of daily living
Answer: a, b, e, f. a. Examination of mucous membranes and nail beds b. Measurement of rate, depth, and rhythm of respirations e. Determine the client's need and use of oxygen f. Ability to perform activities of daily living A home health nurse would assess the client's respiratory status and adequacy of ventilation including an examination of mucous membranes and nail beds for evidence of hypoxia, measurement of rate, depth and rhythm of respirations, auscultation of lung fields for abnormal breath sounds, checking neck veins for distention with the client in a sitting position, and determining the client's needs and use of supplemental oxygen. The home health nurse would also determine the client's ability to perform his or her own ADLs. Auscultation of bowel sounds and assessment of peripheral veins are not part of a focused assessment for a client with COPD.
A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for airway loss related to aspirated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24 year old with a traumatic brain injury b. A 36 year old who fractured his left femur c. A 58 year old getting radiation therapy d. A 66 year old who is a quadriplegic e. An 80-year-old who is aphasic
Answer: a, c, d, e. a. A 24 year old with a traumatic brain injury c. A 58 year old getting radiation therapy d. A 66 year old who is a quadriplegic e. An 80-year-old who is aphasic Thickly crusted, dry secretions that potentially can cause asphyxiation and airway obstruction (inspissated secretions or mucoid impaction) are seen most often in clients who have an altered mental status and level of consciousness (brain injury), are dehydrated, are unable to communicate (aphasic), are unable to cough effectively (quadriplegic), or are at risk for aspiration. Clients with femur fractures and receiving radiation therapy are not as high of a risk. The location of the radiation is not known.
A nurse in the emergency department is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? a. Absence of breath sounds b. Expiratory wheezing c. Inspiratory stridor d. Ronchi
Answer: a. Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.
A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time
Answer: a. Applying suction while inserting the catheter. Suction would only be applied while withdrawing the catheter. The other actions are appropriate.
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 that 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.
Answer: a. Ask the spouse to explain the fear of visiting in further detail. 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 that it's safe to visit is demeaning of the spouse's feelings.
A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? a. Assess the client's airway. b. Irrigate the client's skin. c. Brush any visible dust off the skin. d. Call poison control for guidance
Answer: a. Assess the client's airway. With any burn client, assessing and maintaining the airway is paramount. Airway tissues can swell quickly, cutting off the airway. The fertilizer would then be brushed off before irrigation. Poison control may or may not need to be called.
An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best? a. Assess the client's lung sounds. b. Assign a different AP to the client. c. Report the AP to the manager. d. Request thicker liquids for meals.
Answer: a. Assess the client's lung sounds. The best action is to check the client's oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse would notify the primary health care provider of possible aspiration and would consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.
A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the follow findings should the nurse recognize as an indication of a pulmonary embolism (PE)? a. Sudden onset of dyspnea b. Tracheal deviation c. Bradycardia d. Difficulty swallowing
Answer: a. Sudden onset of dyspnea Clinical manifestations of a PE have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.
A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on 4 clients. for which of the following clients should the nurse clarify the provider's prescription? a. pt w/ epistaxis b. pt w/ amyotrophic lateral sclerosis c. pt w/ pneumonia d. pt w/ emphysema
Answer: a. pt w/ epistaxis The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.
a nurse is caring for a client who has a chest tube following a lobectomy. which of the following items should the nurse keep easily accessible for the client? a. Extra drainage system b. Suture removal kit c. Container of sterile water d. Non adherent pads
Answer: c. Container of sterile water The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.
Chapter 23: Concepts of Care for Patients with Skin Problems
Burns section only
Chapter 29: Critical Care of Patients With Respiratory Emergencies
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The emergency department (ED) manager is reviewing client charts to determine how well the staff perform 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.
Answer: a. Antibiotics started before admission. Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inclient 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.
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what would the nurse ensure? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.
Answer: d. The upper peak airway pressure limit alarm is on. The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent barotrauma to the lungs. Alarms are never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.
A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of the medication? a. Hallucinations b. Pruritus c. Hand and foot syndrome d. Tinnitus
Answer: d. Tinnitus An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.
Chapter 26: Concepts of Care for Patients With Noninfectious Upper Respiratory Problems
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Chapter 27: Concepts of Care for Patients With Noninfectious Lower Respiratory Problems
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Chapter 28: Concepts of Care for Patients With Infectious Respiratory Problems
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A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure that informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.
Answer: b. Ensure that informed consent is on the chart. Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.
A nurse is assessing a client who has lung cancer. which of the following manifestations should the nurse expect? a. Blood-tinged sputum b. Decreased tactile fremitus c. Resonance with percussion d. Peripheral edema
Answer: a. blood-tinged sputum The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.
A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? a. Pericardial friction rub b. Weight gain c. Night sweats d. Cyanosis of the fingertips
Answer: c. Night sweats Night sweats, fevers, anorexia and weight loss are clinical manifestations of tuberculosis. A pericardial friction rub is a clinical manifestation of rheumatic carditis. Cyanosis of the fingertips is a clinical manifestation of Raynaud's disease.
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.
Answer: d. Validate that informed consent has been given by the client. A thoracentesis is an invasive procedure with many potentially serious complications. The nurse would ensure signed informed consent has been obtained. Verifying that the client understands complications and explaining the procedure to be performed will be done by the primary health care provider, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.
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
Answer: d. Visiting nurses for directly observed therapy 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.
A nurse is planning care for a client who has asthma. which of the following meds should the nurse plan to administer during an acute asthma attack? a. cromolyn sodium b. prednisone c. fluticasone/salmeterol d. albuterol
Answer: d. albuterol The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.
A nurse is caring for a client who's postoperative and has an RR of 9/min secondary to general anesthesia effects incisional pain. which of the following ABG values indicates the client is experiencing respiratory acidosis? a. pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L b. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L c. pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L d. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L
Answer: d. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22mEq/L These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.
A nurse is caring for an older adult client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis
Answer: b. Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because patients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.
Which statement by the client indicates the discharge teaching for the client diagnosed with a pulmonary embolus is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a medic alert band at all times."
Answer: 4. "I will wear a medic alert band at all times." The client should wear a medic alert band at all times so that if any accident or situation occurs, the health-care providers will know the client is receiving anticoagulant therapy.
While obtaining a client's health history, the client states, "I am allergic to avocados, molds, and grass." Which responses by the nurse are best? (Select all that apply.) a. "What happens when you are exposed to those things? b. "How do you treat these allergies?" c. "When was the last time you ate foods containing avocados?" d. "I will document this in your record so all so everyone knows." e. "Have you ever been in the hospital after an allergic response?" f. "How do manage to avoid grass and mold?"
Answer(s): a, b, d, e a. "What happens when you are exposed to those things? b. "How do you treat these allergies?" d. "I will document this in your record so all so everyone knows." e. "Have you ever been in the hospital after an allergic response?" Nurses would assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse would also document the allergies in a prominent place in the client's medical record. Asking about the last time the client ate avocados does not provide any pertinent information for the client's plan of care. Asking how a client manages to avoid environmental allergies in this fashion also does not provide any pertinent information.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? (Select all that apply.) 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change invasive lines once a week. 5. Administer antibiotics as prescribed.
Answer: 1, 2, 3, and 5. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 5. Administer antibiotics as prescribed. Hand washing is the number-one intervention used to prevent infection, which is priority for the client with a burn. Aseptic techniques minimize risk of cross-contamination and spread of bacteria. Aseptic techniques minimize risk of cross-contamination and spread of bacteria. Antibiotics reduce bacteria. Invasive lines and tubing should be changed daily. TEST-TAKING HINT: Alternative-type questions require the test taker to choose all options that apply. Infection is a priority for clients with burns.
The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? (Select all that apply). 1. Place the client on oxygen by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1000 mL per day. 4. Restrict the client's smoking to two (2) to three (3) cigarettes per day. 5. Monitor the client's pulse oximetry readings every four (4) hours.
Answer: 1, 2, 5. 1. Place the client on oxygen by nasal cannula. 2. Plan for periods of rest during activities of daily living. 5. Monitor the client's pulse oximetry readings every four (4) hours. The client diagnosed with pneumonia will have some degree of gas-exchange deficit. Administering oxygen would help the client. Activities of daily living require energy and therefore oxygen consumption. Spacing the activities allows the client to rebuild oxygen reserves between activities. Pulse oximetry readings provide the nurse with an estimate of oxygenation in the periphery. Clients are encouraged to drink at least 2000 mL daily to thin secretions. Cigarette smoking depresses the action of the cilia in the lungs. Any smoking should be prohibited. TEST-TAKING HINT: Maslow's Hierarchy of Needs lists oxygenation as the top priority. Therefore the test taker should select interventions addressing oxygenation.
Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? (Select all that apply.) 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.
Answer: 1, 3, 4, 5. 1. Keep protamine sulfate readily available. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered. Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. Invasive procedures increase the risk of tissue trauma and bleeding. Stool softeners help prevent constipation and straining, which may precipitate bleeding from hemorrhoids. Firm pressure reduces the risk for bleeding into the tissues. TEST-TAKING HINT: Thrombolytic therapy is ordered to help dissolve the clot that resulted in the PE. Therefore, all nursing interventions should address bleeding tendencies. The test taker must select all interventions that are applicable in these alternative questions.
Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD? 1. "I need to get an influenza vaccine each year, even when there is a shortage." 2. "I need to get a vaccine for pneumonia each year with my influenza vaccine." 3. "If I reduce my cigarettes to six (6) a day, I won't have difficulty breathing." 4. "I need to restrict my drinking liquids to keep from having so much phlegm."
Answer: 1. "I need to get an influenza vaccine each year, even when there is a shortage." Clients diagnosed with COPD should receive the influenza vaccine each year. If there is a shortage, these clients have top priority. The pneumococcal vaccine should be administered every five (5) to seven (7) years. Reducing the number of cigarettes smoked does not stop the progression of COPD, and the client will continue to experience signs and symptoms such as SOB or dyspnea on exertion. Clients diagnosed with COPD should increase their fluid intake unless contraindicated for another health condition; the increased fluid assists the client in expectorating the thick sputum.
The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client into a sitting position at 90 degrees. 2. Administer oxygen at six (6) LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health care provider about the client's status.
Answer: 1. Assist the client into a sitting position at 90 degrees. The client should be assisted into a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain the client's safety. O2 will be applied as soon as possible, but the least amount possible; if levels are too high, the client might stop breathing. VS need to be monitored, but are not priority. The HCP needs to be notified, but the client must be treated first; the nurse should get assistance if possible so the nurse can treat this client quickly.
The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms would the nurse expect to find when assessing the client? 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention.
Answer: 1. Confusion and lethargy. The elderly client diagnosed with pneumonia may present with weakness, fatigue, lethargy, confusion, and poor appetite but not have any of the classic signs and symptoms of pneumonia. Fever and chills are classic symptoms of pneumonia, but they are usually absent in the elderly client. Frothy sputum and edema are signs and symptoms of heart failure, not pneumonia. The client has tachypnea (fast respirations), not bradypnea (slow respirations), and jugular vein distention accompanies heart failure. TEST-TAKING HINT: The question gives an age range—"elderly"—so age can be expected to affect the disease process—in this case, causing atypical symptoms. The prefix "brady" means "slow" when attached to a word. Knowing the definition of medical prefixes can assist the test taker in determining the correct answer.
The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine? 1. Elderly and chronically ill clients. 2. Child-care workers and children younger than age four (4) years. 3. Hospital chaplains and health-care workers. 4. School teachers and students living in a dormitory.
Answer: 1. Elderly and chronically ill clients. The elderly and chronically ill are at greatest risk for developing serious complications if they contract the influenza virus. It is recommended that people in contact with children receive the flu vaccine whenever possible, but these clients should be able to withstand a bout with the flu if their immune systems are functioning normally. It is probable that these clients will be exposed to the virus, but they are not as likely to develop severe complications with intact functioning immune systems. During flu season the more people that the individual comes into contact with, the greater the risk the client will be exposed to the influenza virus, but this group of people would not receive the vaccine before the elderly and chronically ill. TEST-TAKING HINT: Sometimes the test taker may think the answer is too easy and obvious, but the test taker should not try to second guess the question. Item writers are not trying to trick the test taker; they are trying to evaluate knowledge.
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.
Answer: 1. Encourage the client's family to bring favorite foods. The client needs sufficient nutrients for wound healing and increased metabolic requirements, and homemade nutritious foods are usually better than hospital food. This also allows the family to feel part of the client's recovery. The client should be provided a high-calorie, high-protein diet along with vitamins. The client should be weighed daily, and the goal is that the client loses no more than 5% of pre-burn weight. The nurse would make a referral to a dietitian, not a social worker. TEST-TAKING HINT: The nurse needs to be knowledgeable of different types of diets; this requires memorization.
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit.
Answer: 1. High risk for infection. Although this is a potential problem, it is priority because the body's protective barrier, the skin, has been compromised and there is an impaired immune response. This psychosocial client problem is important, but in the ICU the first priority is preventing infection so wound healing can occur. Burn wound edema, pain, and potential joint contractures can cause mobility deficits, but the first priority is preventing infection so wound healing can occur. Teaching is always important, but in the ICU the priority is the physiological integrity of the client. TEST-TAKING HINT: The adjectives "intensive care" mean the client is critically ill; therefore, a physiological problem is priority and options "2" and "4" can be eliminated. Although actual is usually higher priority than potential, in the case of a burn the risk for infection has to be priority.
The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) liters a day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.
Answer: 1. Increase fluid intake to two (2) to three (3) liters a day. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE. Pulmonary emboli are not caused by atherosclerosis; therefore, this is not an appropriate discharge instruction for a client with pulmonary embolism. Infection does not cause a PE; therefore, this is not an appropriate teaching instruction. Pneumonia and flu do not cause pulmonary embolism. TEST-TAKING HINT: The test taker must know that deep vein thrombosis is the most common cause of pulmonary embolus and preventing dehydration is an important intervention. The test taker can attempt to eliminate answers by trying to figure out which disease process is appropriate for the intervention.
The client is suspected of having a pulmonary embolus (PE). Which diagnostic test suggest the presence of a pulmonary embolus and requires further investigation? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging
Answer: 1. Plasma D-dimer test. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis ABGs evaluate oxygenation level, but they do not diagnose a pulmonary embolism. ACXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE. MRI is a noninvasive test that detects a deep vein thrombosis, but it does not diagnose a pulmonary embolus. TEST-TAKING HINT: The keys to answering this question are the words "confirms diagnosis." The test taker should eliminate "2" and "3" based on the fact that these are diagnostic tests used for many disease processes and conditions.
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms would the nurse look for when assessing the client? 1. Pleuritic chest discomfort and anxiety. 2. Asymmetrical chest expansion and pallor. 3. Leukopenia and CRT 3 seconds. 4. Substernal chest pain and diaphoresis.
Answer: 1. Pleuritic chest discomfort and anxiety. Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever, chills, dyspnea, and cough. Asymmetrical chest expansion occurs if the client has a collapsed lung from a pneumothorax or hemothorax, and the client would be cyanotic from decreased oxygenation. The client would have leukocytosis, not leukopenia, and a capillary refill time (CRT) of 3 seconds is normal. Substernal chest pain and diaphoresis are symptoms of MI. TEST-TAKING HINT: Options "1" and "4" have chest pain as part of the answer. The adjectives describing the chest pain determine the correct answer.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.
Answer: 1. Replace fluids and electrolytes. After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes. This is important, but it is not priority over fluid volume balance, and this is not a collaborative intervention because the nurse can do this independently. Output must be monitored, but this is an independent intervention. An escharotomy, an incision that releases scar tissue that prevents the body from being able to expand, enables chest excursion in circumferential chest burns. The client has not had time to develop eschar. TEST-TAKING HINT: A collaborative intervention is an intervention that requires an HCP's order or working with another discipline. Therefore, options "2" and "3" should be eliminated immediately.
The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy? 1. Vitamin C, 2000 mg daily. 2. Strict bed rest. 3. Humidification of the air. 4. Decongestant therapy.
Answer: 1. Vitamin C, 2000 mg daily. Alternative therapies are therapies that are not accepted medical practice. These may be encouraged as long as they do not interfere with the medical regimen. Vitamin C in large doses is thought to improve the immune system's functions. Bed rest is accepted standard advice for a client with a cold. Humidifying the air helps to relieve congestion and is a standard practice. Decongestant therapy is standard therapy for a cold. TEST-TAKING HINT: Only one of the answer options is not common advice for a client with a cold. When all options but one (1) match, then the one (1) odd one should be selected as the correct answer.
The 56-year-old client diagnosed with tuberculosis (TB) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? 1. "I will take my medication for the full three (3) weeks prescribed." 2. "I must stay on the medication for months if I am to get well." 3. "I can be around my friends because I have started taking antibiotics." 4. "I should get a TB skin test every three (3) months to determine if I am well."
Answer: 2. "I must stay on the medication for months if I am to get well." Compliance with treatment plans for TB includes multi-drug therapy for six (6) months to one (1) year for the client to be free of the TB bacteria. Clients diagnosed with TB will need to take the medications for six (6) months to a year. Clients are no longer contagious when three (3) morning sputum specimens are cultured negative, but this will not occur until after several weeks of therapy. TB skin test only determines possible exposure to the bacteria, not active disease. TEST-TAKING HINT: The test taker should determine if the time of three (3) weeks in "1," months in "2," or immediately in "3" is the correct time interval.
The client diagnosed with influenza is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription? 1. "These pills will make me feel better fast and I can return to work." 2. "The antibiotics will help prevent me from developing a bacterial pneumonia." 3. "If I had gotten this prescription sooner I could have prevented this illness." 4. "I need to take these pills until I feel better; then I can stop taking the rest."
Answer: 2. "The antibiotics will help prevent me from developing a bacterial pneumonia." Secondary bacterial infections often accompany influenza, and antibiotics are often prescribed to help prevent the development of a bacterial infection. A person with a viral infection should not return to work until the virus has run its course because the antibiotics help prevent complications of the virus, but they do not make the client get better faster. Antibiotics will not prevent the flu. Only the flu vaccine will prevent the flu. When people take portions of the antibiotic prescription and stop taking the remainder, an antibiotic-resistant strain of bacteria may develop, and the client may experience a return of symptoms—but this time, the antibiotics will not be effective. TEST-TAKING HINT: Knowing drug classifications and how the drugs within that classification work would assist the test taker to determine the correct answer. Antibiotics work to destroy bacterial invasions of the body.
The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases. 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.
Answer: 2. Assess skin color and temperature. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output. Arterial blood gases would be included in the client problem "impaired gas exchange." This would be appropriate for the client problem "high risk for bleeding." The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing. TEST-TAKING HINT: The test taker must think about which answer option addresses the problem of not getting enough blood out of the heart. Decreased blood to the extremities results in cyanosis and cold extremities.
The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain? 1. Number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medications. 4. Willingness to modify lifestyle.
Answer: 4. Willingness to modify lifestyle. The client's attitude toward lifestyle changes is the most important consideration in health promotion, in this case smoking cessation. The nurse should assess if the client is willing to consider cessation of smoking and carry out the plan. The number of years of smoking is information needed to treat the client but not most important. The risk factor for complications are important for planning care. Assessing the ability to deliver medications is an important consideration when teaching the client.
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers.
Answer: 2. Clean the client's wounds, body, and hair daily. Daily cleaning reduces bacterial colonization. Addressing pain will not address impaired skin integrity. This intervention would be appropriate for a "risk for infection" nursing diagnosis. Plants and flowers in water should be avoided because stagnant water is a source for bacterial growth. TEST-TAKING HINT: The intervention addresses the etiology of the nursing diagnosis of "open burn wounds," and the goal addresses the response "impaired skin integrity."
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.
Answer: 2. Deep partial thickness. Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema. Sunburn is an example of this depth of burn; a superficial partial-thickness burn affects the epidermis and the skin is reddened and blanches with pressure. Full-thickness burns are caused by flame, electric current, or chemical burns and include the epidermis, entire dermis, and sometimes subcutaneous tissue and may also involve connective tissue, muscle, and bone. First-degree burn is another name for a superficial partial-thickness burn. TEST-TAKING HINT: The adjectives in the stem are the most important words that assist the test taker when selecting a correct answer.
The nurse in a long-term care facility is planning the care for a client with a percutaneous gastrostomy (PEG) feeding tube. Which interventions would the nurse include in the plan of care? 1. Inspect the insertion line at the nare prior to instilling formula. 2. Elevate the head of the bed after feeding the client. 3. Place the client in the Sims position following each feeding. 4. Change the dressing on the feeding tube every three (3) days.
Answer: 2. Elevate the head of the bed after feeding the client. Elevating the head of the bed uses gravity to keep the formula in the gastric cavity and help prevent it from refluxing into the esophagus, which predisposes the client to aspiration. A gastrostomy tube is placed directly into the stomach through the abdominal wall; the nare is the opening of the nostril. The Sims position is the left lateral side-lying flat position. This position is used for administering enemas and can be used to prevent aspiration in clients sedated by anesthesia. The sedated client would not have a full stomach. Dressings on PEG tubes should be changed at least daily. If there is no dressing, the insertion site is still assessed daily. TEST-TAKING HINT: The test taker should try to picture the positioning of the client to determine the correct answer. In "4" the test taker should question if the time given, three (3) days, is the correct time interval for performing this intervention.
Which task is most appropriate for the nurse to delegate to an Unlicensed assistive personnel? 1. Feed a client who is postoperative tonsillectomy the first meal of clear liquids. 2. Encourage the client diagnosed with a cold to drink a glass of orange juice. 3. Obtain a throat culture on a client diagnosed with bacterial pharyngitis. 4. Escort the client diagnosed with laryngitis outside to smoke a cigarette.
Answer: 2. Encourage the client diagnosed with a cold to drink a glass of orange juice. Clients with colds are encouraged to drink 2000 mL of liquids a day. The unlicensed nursing assistant could do this. Tonsillectomies cause throat edema and difficulty swallowing; the nurse must observe the client's ability to swallow before this task can be delegated. Throat swabs for culture must be done correctly or false-negative results can occur. The nurse should obtain the swab. Clients with laryngitis are instructed not to smoke. Smoking is discouraged in all health- care facilities. Sending nursing personnel outside to encourage an unhealthy practice is not the best use of the personnel. TEST-TAKING HINT: Interventions that could require assessing, teaching, and evaluating should not be delegated. Levels of activities being delegated should be appropriate for the level of training of the staff member carrying out the task. Tasks delegated should conform to safe health-care practice.
The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amounts of thick white sputum. 2. Oxygen flowmeter set on eight (8) liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.
Answer: 2. Oxygen flowmeter set on eight (8) liters. Rationale: The nurse should decrease the O2 rate to two (2) or three (3) liters. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the O2 level increases, the drive to breathe may be eliminated. A large amount of thick sputum in a common symptom of COPD. It is common for COPD clients to use accessory muscles when inhaling. Clients with COPD commonly have the characteristic barrel chest from chronic hyperinflation and dyspnea.
The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first? 1. Administer oxygen ten (10) L via nasal cannula. 2. Place the client in a high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.
Answer: 2. Place the client in a high Fowler's position. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system. The client needs oxygen, but the nurse can do something that will help the client before applying oxygen. This is needed, but it is not the first intervention. Assessing the client is indicated, but it is not the first intervention in this situation. TEST-TAKING HINT: The test taker must select the option that will directly help the client breathe easier. Therefore, assessment is not the first intervention and option "4" can be eliminated as the correct answer. Oxygenation is important but positioning the client is the easiest and first intervention. The test taker should not immediately jump to conclusions. Always read the stem and think about what will help the client.
The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.
Answer: 2. Place the hand in cool water. Cool water gives immediate and striking relief from pain and limits local tissue edema and damage. Ice should never be applied to a burn because this will worsen the tissue damage by causing vasoconstriction. Blisters should be maintained intact to prevent infection. The client should be told to go to the ED, not the doctor's office, for burn care. TEST-TAKING HINT: The test taker should select an answer that directly cares for the client's body. This eliminates options "3" (blisters have not formed yet) and "4." Therefore, the test taker has to decide between cool water and ice.
The nurse observes the UAP removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement? 1. Praise the UAP because the prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the UAP in front of the client oxygen must be left in place at all times. 4. Discuss the UAP's action with the charge nurse so appropriate action can be taken.
Answer: 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. The client needs the O2, and the nurse should not correct the UAP in front of the client; it is embarrassing for the UAP and the client loses confidence in the staff. The client with COPD needs O2 at all times, especially when exerting energy such as ambulating to the bathroom. The nurse should not verbally correct a UAP in front of the client; the nurse should correct the behavior and then talk to the UAP in private. The primary nurse should confront the UAP and take care of the situation; continued unsafe client care would warrant notifying the charge nurse.
Which nursing assessment data support that the client has experienced a pulmonary embolism (PE)? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.
Answer: 2. Sudden onset of chest pain and dyspnea. The most common signs of a PE are sudden onset of chest pain when taking a deep breath and shortness of breath. TEST-TAKING HINT: The key to selecting "2" as the correct answer is sudden onset. The test taker would need to note "left-sided" in "3" to eliminate this as a possible correct answer, and "4" is nonspecific for a PE.
The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery? 1. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%. 2. The client has an oral temperature of 100.2°F and a dry cough. 3. There are one (1) to two (2) white blood cells in the urinalysis. 4. The client's current International Normalized Ratio (INR) is 1.0.
Answer: 2. The client has an oral temperature of 100.2°F and a dry cough. A low-grade temperature and a cough could indicate the presence of an infection, in which case the health-care provider would not want to subject the client to anesthesia and the possibility of further complications. The surgery would be postponed. The hemoglobin and hematocrit given are within normal range. This would not warrant notifying the health-care provider. One (1) to two (2) WBCs in a urinalysis is not uncommon because of the normal flora in the bladder. The INR indicates that the client's bleeding time is within normal range. TEST-TAKING HINT: In this question, all the answer options contain normal data except for one. The nurse would not call the health- care provider to notify him or her of normal values.
While feeding the client diagnosed with aspiration pneumonia, the client becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention would the nurse implement first? 1. Suction the client's nares. 2. Turn the client to the side. 3. Place the client in the Trendelenburg position. 4. Notify the health-care provider.
Answer: 2. Turn the client to the side. Turning the client to the side allows for the food to be coughed up and come out of the mouth, rather than be aspirated into the lungs. The nares are the opening of the nostrils. Suctioning, if done, would be of the posterior pharynx. Placing the client in the Trendelenburg position would increase the risk of aspiration. An immediate action is needed to protect the client. TEST-TAKING HINT: In a question that asks the test taker to determine the first action, all the answer options may be correct for the situation. The test taker must determine which has the greatest potential for improving the client's condition.
The home health-care nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse he has been blowing his nose frequently. Which question should the nurse ask the client? 1. "1. "Have you had the flu shot in the last two (2) weeks?" 2. "Are there any small children in the home?" 3. "Are you taking over-the counter-medicine for these symptoms?" 4. "Do you have any cold sores associated with your sneezing?"
Answer: 3. "Are you taking over-the counter-medicine for these symptoms?" A client diagnosed with hypertension should not take many of the over-the-counter medications because they work by causing vasoconstriction, which will in- crease the hypertension. Influenza is a viral illness that might cause these symptoms; however, the immunization should not give the client the illness. Coming into contact with small children in- creases the risk of developing colds and the flu, but the client has a problem—not just a potential one. Cold sores are actually an infection by the herpes simplex virus. Colds and cold-like symptoms are caused by the rhinitis virus or influenza virus. The term "cold sore" is a common term that still persists in the populace. TEST-TAKING HINT: The keys to answering this question are the words "hypertension" and "cold." Any time a client has a chronic illness, the client should discuss over-the-counter medications with the health-care provider or a pharmacist. Many of the routine medications for chronic illnesses interact with over-the- counter medications.
Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required? 1. "I should contact my health care provider if my sputum changes color or amount." 2. "I will take my bronchodilator regularly to prevent having bronchospasms." 3. "This metered-dose inhaler gives a precise amount of medication with each dose." 4. "I need to return to the HCP to have my blood drawn with my annual physical."
Answer: 4. "I need to return to the HCP to have my blood drawn with my annual physical." Rusty-colored sputum indicates blood in the sputum and requires further assessment by the nurse. The client with end-stage COPD has decreased peripheral O2 levels. The client's ABGs would normally indicate a low O2 level. The client who develops dyspnea on exertion should stop the exertion but does not require intervention by the nurse if the dyspnea resolves.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."
Answer: 3. "The graft will come from an animal, probably a pig." A xenograft or heterograft consists of skin taken from animals, usually porcine. This is the explanation for an autograft. This is the description of a homograft. This is "passing the buck"; the nurse can and should answer this question with factual information. TEST-TAKING HINT: The test taker should eliminate options to help determine the correct answers. Option "1" can be eliminated because skin from self would be auto-, not xeno-. Option "4" should be eliminated because the nurse should answer the question and not pass the buck.
The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.
Answer: 3. Administer the medication as ordered. A therapeutic INR is 2-3; therefore, the nurse should administer the medication. The client would not be experiencing abnormal bleeding with this INR.2. This is the antidote for an overdose of anticoagulant and the INR does not indicate this. There is no need to increase the dose; this result is within the therapeutic range. TEST-TAKING HINT: The test taker must know normal laboratory values; this is the only way the test taker will be able to answer this question. The test taker should make a list of laboratory values that must be memorized for successful test taking.
Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD? 1. Clubbing of the client's fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough.
Answer: 3. Chronic sputum production. Sputum production, along with cough and dyspnea on exertion, are the early signs/symptoms of COPD. Clubbing of fingers is the result of chronic hypoxemia, which is expected with chronic COPD but not recently diagnosed COPD. COPD clients have frequent respiratory infections. These clients have a productive cough, not a nonproductive cough.
The client has been diagnosed with chronic sinusitis. Which signs and symptoms would alert the nurse to a potentially life-threatening complication? 1. Muscle weakness. 2. Purulent sputum. 3. Nuchal rigidity. 4. Intermittent loss of muscle control.
Answer: 3. Nuchal rigidity. Nuchalrigidityisasign/symptomofmeningitis, which is a life-threatening potential complication of sinusitis resulting from the close proximity of the sinus cavities to the meninges. Muscle weakness is a sign/symptom of myalgia, but it is not a life-threatening complication of sinusitis. Purulent sputum would be a sign/symptom of a lung infection, but it is not a life-threatening complication of sinusitis. Intermittent loss of muscle control can be a symptom of multiple sclerosis, but it would not be a life-threatening complication of sinusitis. TEST-TAKING HINT: A basic knowledge of anatomy and physiology would help to answer this question. The sinuses lie in the head and surround the orbital cavity. Options "1" and "4" refer to muscle problems, so both could be ruled out as a wrong.
The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? 1. Administer the oral antibiotic STAT. 2. Order the meal tray to be delivered as soon as possible. 3. Obtain a sputum specimen for culture and sensitivity. 4. Have the unlicensed nursing assistant weigh the client.
Answer: 3. Obtain a sputum specimen for culture and sensitivity. To determine the antibiotic that will effectively treat an infection, specimens for culture are taken prior to beginning the medication. Administering antibiotics prior to cultures may make it impossible to determine the actual agent causing the pneumonia. Broad-spectrum IV antibiotics are priority, but before antibiotics are administered, it is important to obtain culture specimens to determine the correct antibiotic for the client's infection. Clients are placed on oral medications only after several days of IVPB therapy. Meal trays are not priority over cultures. Admission weights are important to determine appropriate dosing of medication, but they are not priority over sputum collection. TEST-TAKING HINT: Answer option "1" has a medication classification and a route, and the test taker should question if the route is appropriate for the client being admitted. Clients will not die from a delayed meal, but a client could die from delayed IV antibiotic therapy.
The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem "altered communication." Which intervention should the nurse implement? 1. Instruct the client to drink a mixture of brandy and honey several times a day. 2. Encourage the client to whisper instead of trying to speak at a normal level. 3. Provide the client with a blank note pad for writing any communication. 4. Explain that the client's aphonia may become a permanent condition.
Answer: 3. Provide the client with a blank note pad for writing any communication. The client with laryngitis is instructed to avoid all alcohol. Alcohol causes increased irritation of the throat. Whispering places added strain on the larynx. Aphonia, or inability to speak, is a temporary condition associated with laryngitis. TEST-TAKING HINT: Encouraging the use of alcohol, with the exception of a glass of red wine, is not accepted medical practice; there- fore, this option "1" could be eliminated. Option "4" has an absolute—"permanent"—in it and therefore could be eliminated from consideration.
The client is being discharged after being in the burn unit for six weeks. Which strategies should the nurse identify to promote the client's mental health?' 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist.
Answer: 3. Tell the client to remember that changes in lifestyle take time. The client needs to know that it will take time to adjust to life after burns and that returning to work, family role, sexual intimacy, and body image will take time. The client should resume previous activities gradually and should not stay home; the client should go out and begin to live again. The client should be honest with self, family, and friends about needs, hopes, and fears. The client should feel free to discuss feelings with family, friends, and the therapist. TEST-TAKING HINT: Even if the test taker is not familiar with the disease process, there are certain interventions that go with any chronic problem, such as getting back to normal life as soon as possible and being independent, but also getting help when needed and not expecting too much too soon.
The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)? 1. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain. 2. The six (6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication. 3. The 18-year-old client who had a Caldwell Luc procedure three (3) days ago and has purulent drainage on the drip pad. 4. The 45-year client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
Answer: 3. The 18-year-old client who had a Caldwell Luc procedure three (3) days ago and has purulent drainage on the drip pad. The postoperative client with purulent drainage could be developing an infection. The experienced nurse would be needed to assess and monitor the client's condition. This client is one (1)-day postoperative and has moderate pain, which is to be expected after surgery. A less experienced nurse can care for this client. A child about to go to surgery involving the throat area can be expected to have painful swallowing. This does not require the most experienced nurse. Any nurse that is capable of administering IVPB medications can care for this client. TEST-TAKING HINT: In this type of question the test taker must determine if the situation described is expected or within normal limits. The one (1) answer option that gives data that are not expected or within normal limits is the one (1) that will require a nurse with the greatest amount of knowledge and experience.
The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? 1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the lab. 2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. 3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.
Answer: 3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. The specimen needs to be taken to the lab within a reasonable time frame, but an unlicensed nursing assistant can take specimens to the lab. Clogged feeding tubes occur with some regularity. Delay in feeding a client will not result in permanent damage. Arterial oxygenation normal values are 80%-100%. TEST-TAKING HINT: Be sure to read all the answer options. Pulse oximetry readings do not give the same information as arterial blood gas readings.
The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care? 1. The client has no signs of respiratory distress. 2. The client shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.
Answer: 3. The client demonstrates intolerance to activity. The expected outcome should be that the client has tolerance for activity; because the client is not meeting the expected outcome, the plan of care needs revision. The expected outcome showing no signs of respiratory distress indicates the plan of care is effective and should be continued. An improved respiratory pattern indicates the plan should be continued. The client should participate in planning the course of care; the client is meeting the expected outcome.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20. 4. The client is able to perform active range-of-motion exercises.
Answer: 3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20. Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immediate intervention. The client should be premedicated with an analgesic because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. Also, these electrolytes are WNL and would not require immediate intervention. The client being able to perform range-of motion exercises does not warrant immediate intervention; this is a very good result. TEST-TAKING HINT: "Require immediate attention" means that the nurse must intervene independently or notify another health-care provider. The test taker must know how to interpret ABGs, and, even if the test taker is not familiar with the medication, metabolic acidosis requires intervention.
The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis. Which statement indicates the need for radiological evaluation instead of skin testing? 1. The client's first skin test indicates a purple flat area at the site of injection. 2. The client's second skin test indicates a red area measuring four (4) mm. 3. The client's previous skin test was read as positive. 4. The client has never shown a reaction to the tuberculin medication.
Answer: 3. The client's previous skin test was read as positive. If the client has ever reacted positively, then the client should have a chest x-ray to look for causation and inflammation. A purple flat area indicates that the client became bruised when the intradermal injection was given, but it has no bearing on whether the test is positive. A positive skin test is 10 mm or greater with induration, not redness. These are negative findings and do not indicate the need to have x-ray determination of disease. TEST-TAKING HINT: The test taker should note descriptive adjectives such as "purple," "flat," or "4 mm" before determining the correct answer. Option "4" has the absolute word "never" and absolutes usually indicate incorrect answers.
The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data would warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions. 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.
Answer: 3. The client's pulse oximeter reading is 90%. The normal pulse oximeter reading is 93%-100%. A reading of 90% indicates the client has an arterial oxygen level of around 60. These ABGs are within normal limits and would not warrant immediate intervention. Occasional premature ventricular contractions are not unusual for any client and would not warrant immediate intervention. A urinary output of 800 mL over 12 hours indicates an output of greater than 30 mL/ hour, and this would not warrant immediate intervention by the nurse. TEST-TAKING HINT: This question is asking the test taker to select assessment data that are abnormal, unexpected, or life threatening in relationship to the client's disease process.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Adequate peripheral circulation to both feet ensured.
Answer: 4. Adequate peripheral circulation to both feet ensured. The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes. An 18-gauge catheter with lactated Ringer's infusion should be initiated to maintain a urine output of at least 30 mL/hr. Wounds should be covered with a clean, dry sheet. The client should be transferred with adequate pain relief, which requires intravenous morphine. TEST-TAKING HINT: Note the adjectives "22-gauge" and "moist." If the test taker is unsure of the correct answer, then the test taker should determine which system is affected and see if that will help determine the right answer. A client's extremities and a neurovascular assessment are similar; therefore, the test taker should select option "4."
The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which would be an expected outcome for this problem? 1. Performs chest physiotherapy three (3) times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall and back several times during each shift.] 4. Alert and oriented to person, place, time, and events.
Answer: 4. Alert and oriented to person, place, time, and events. Impaired gas exchange results in hypoxia, the earliest sign and symptom of which is a change in the level of consciousness. Clients do not perform chest physiotherapy; this is normally done by the respiratory therapist. This is a staff goal, not a client goal. This would be a goal for self-care deficit but not for impaired gas exchange. This would be a goal for the problem of activity intolerance. TEST-TAKING HINT: The test taker should match the answer option to the listed nursing problem. Option "1" is a staff goal to accomplish. When writing goals for the client, it is important to remember they are written in terms of what is expected of the client. Options "2" and "3" are appropriately written client goals, but they do not evaluate gas exchange.
The client diagnosed with sinusitis who has undergone a Caldwell Luc procedure is complaining of pain. Which intervention should the nurse implement first? 1. Administer the narcotic analgesic IVP. 2. Perform gentle oral hygiene. 3. Place the client in a semi-Fowler's position. 4. Assess the client's pain.
Answer: 4. Assess the client's pain. Prior to intervening the nurse must assess to determine the amount of pain and possible complications occurring that could be masked if narcotic medication is administered. The client has complained of pain, and the nurse, after determining the severity of the pain and barring any complications in the client, will administer pain medication after completion of the assessment. Oral hygiene helps to prevent the development of infections and promotes comfort, but it will not relieve the pain. Placing the client in a Semi-Fowler's position will reduce edema of inflamed sinus tissue, but it will not immediately affect the client's perception of pain. TEST-TAKING HINT: Whenever there is an assessment answer among the answer options, the test taker should look carefully at what is being assessed. If the option says to assess the problem identified in the question, it will usually be the correct answer. Remember, the first step in the nursing process is assessment.
The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss? 1. Instruct the children to always keep a tissue or handkerchief with them. 2. Explain that children current with immunizations will not get a cold. 3. Tell the children that they should go to the doctor if they get a cold. 4. Include a demonstration of how to wash hands correctly.
Answer: 4. Include a demonstration of how to wash hands correctly. Hand washing is the single most useful technique for prevention of disease. It is not feasible for a child to always have a tissue or handkerchief available. There is no immunization for the common cold. Colds are actually caused by at least 200 separate viruses and the viruses mutate frequently. Colds are caused by a virus and antibiotics do not treat a virus; therefore, there is no need to go to a health-care provider. TEST-TAKING HINT: Answer option "1" contains the word "always," an absolute term, and in most questions, absolute adjectives, such as "always," "never," and "only," make that answer option incorrect.
The client has just been diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bed rest.
Answer: 4. Institute and maintain bed rest. Bed rest reduces metabolic demands and tissue needs for oxygen. The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants. The client's respiratory system will be assessed, not the gastrointestinal system. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE. TEST-TAKING HINT: The test taker must be aware of adjectives such as "oral" in option "1," which make this option incorrect. The test taker should apply the body system of the disease process to eliminate "2" as a correct answer.
The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? 1. The client's pulse oximeter reading is 92%. 2. The client's arterial blood gas level is 74. 3. The client has SOB when walking to the bathroom. 4. The client's sputum is rusty colored.
Answer: 4. The client's sputum is rusty colored.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4˚F, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in two (2) hours.
Answer: 4. The client's urinary output is 50 mL in two (2) hours. Fluid and electrolyte balance is the priority for a client with a severe burn. Fluid resuscitation must be maintained to keep a urine output of 30 mL/hr. Therefore, a 25-mL/hr output would warrant immediate intervention. Severe pain would be expected in a client with these types of burns; therefore, it would not warrant notifying the health-care provider. A pulse oximeter reading greater than 93% is WNL. Therefore, a 95% reading would not warrant notifying the health-care provider. The client's vital signs show an elevated temperature, pulse, and respiration, along with a low blood pressure, but these vital signs would not be unusual for a client with severe burns. TEST-TAKING HINT: The test taker must select an answer that is not expected for the client's disease or condition when being asked which data
A hospital nurse is participating in a drill during which many "clients" with inhalation anthrax are being admitted. What drugs would the nurse anticipate administering? (Select all that apply.) a. Vancomycin b. Ciprofloxacin c. Doxycycline d. Ethambutol e. Sulfamethoxazole-trimethoprim (SMX-TMP)
Answer: a, b, c. a. Vancomycin b. Ciprofloxacin c. Doxycycline Vancomycin, 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.
A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision f. Upper arm range of motion
Answer: a, b, d, e, f. a. Cognition b. Dexterity d. Range of motion e. Vision f. Upper arm range of motion The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and would be assessed. Upper arm mobility is required to perform tracheostomy self-care. Hydration is not directly related to the ability to perform self-care.
A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin
Answer: a, d. a. Stridor d. Ecchymosis behind the ear Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called "battle sign" and indicates basilar skull fracture. Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.
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?"
Answer: a. "Breathing so quickly can be dehydrating." Tachypnea and mouth breathing (from increased work of 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 that addresses this specific concern.
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home. f. No alcohol-based hand sanitizers are present.
Answer: a, b, c a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. Oxygen it enhances combustion, so precautions are needed whenever using it. The nurse would assess if the client allows smoking in the house, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety. Alcohol-based hand sanitizers are permitted.
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule f. Turning and positioning the client at least every 2 hours
Answer: a, b, c, d, f. a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol f. Turning and positioning the client at least every 2 hours The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is done as needed.
A client has been diagnosed with an empyema. What interventions would 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
Answer: a, b, c, d. a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed 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 would 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.
The nurse in the emergency department would arrange to transfer which burned clients to a burn center? (Select all that apply.) a. 15% partial-thickness burn b. Lightening injury c. 7% partial-thickness burn d. History of pulmonary edema e. Healthy 67 year old f. 4% partial-thickness burn to perineum
Answer: a, b, d, e, f. a. 15% partial-thickness burn b. Lightening injury d. History of pulmonary edema e. Healthy 67 year old f. 4% partial-thickness burn to perineum Clients with major burns are transferred to a burn center for specialized care. These include any partial-thickness burn over 10% TBSA; any lightening injury; a burn injury in a client with a history of pre-existing conditions that could complicate care or prolong recovery; adults over the age of 60; and burns to the face, hands, feet, genitalia, perineum, or major joints. The client with a 7% partial-thickness burn could be cared for in a hospital or a burn center.
A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture. Which statements would the nurse include in this patient's teaching? (Select all that apply.) a. "You will need to cut the wires if you start vomiting." b. "Eat six soft or liquid meals each day while recovering." c. "Use a Waterpik for dental hygiene until you can brush again. d. "Sleep in a semi-Fowler position after the surgery." e. "Gargle with mouthwash that contains hydrogen peroxide once a day."
Answer: a, b, c, d. a. "You will need to cut the wires if you start vomiting." b. "Eat six soft or liquid meals each day while recovering." c. "Use a Waterpik for dental hygiene until you can brush again. d. "Sleep in a semi-Fowler position after the surgery." The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client would also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowler position to assist in avoiding aspiration. Mouthwash with hydrogen peroxide is not a recommendation.
A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.
Answer: a, b, c, d. a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. The nurse would observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse would assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse would also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which would be changed by the surgeon the first time.
A client, who has become increasingly dyspneic over a year, has been diagnosed with pulmonary fibrosis. What information would the nurse plan to include in teaching this client? (Select all that apply.) a. The need to avoid large crowds and people who are ill b. Safety measures to take if home oxygen is needed c. Information about appropriate use of the drug nintedanib d. Genetic therapy to stop the progression of the disease e. Measures to avoid fatigue during the day f. The possibility of receiving a lung transplant if infection-free for a year
Answer: a, b, c, e a. The need to avoid large crowds and people who are ill b. Safety measures to take if home oxygen is needed c. Information about appropriate use of the drug nintedanib e. Measures to avoid fatigue during the day Pulmonary fibrosis is a progressive disorder with no cure. Therapy focuses on slowing progression and managing dyspnea. Clients need to avoid contracting infections so should be taught to stay away from large crowds and sick people. Home oxygen is needed and the nurse would teach safety measures related to oxygen. The drug nintedanib has shown to improve cellular regulation and slow progression of the disease. Gene therapy is not available. Energy conservation measures are also an important topic. Lung transplantation is an unlikely option due to selection criteria.
A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this client's teaching? (Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Use pursed-lip breathing during meals." f. "Choose soft, high-calorie, high-protein foods."
Answer: a, b, c, e, f a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." e. "Use pursed-lip breathing during meals." f. "Choose soft, high-calorie, high-protein foods." Clients with COPD often are malnourished for several reasons. The nurse would teach the client not to drink fluids before and with meals to avoid early satiety. The client needs to rest before eating, and eat smaller frequent meals: 4 to 6 a day. Pursed-lip breathing will help control dyspnea. Food that is easy to eat will be less tiring and the client should choose high-calorie, high-protein foods.
The nurse learns that which age-related changes increase the potential for complications of burns? (Select all that apply.) a. Thinner skin b. Slower healing time c. Decreased mobility d. Hyperresponsive immune response e. Increased risk of unnoticed sepsis f. Pre-existing conditions
Answer: a, b, c, e, f. a. Thinner skin b. Slower healing time c. Decreased mobility e. Increased risk of unnoticed sepsis f. Pre-existing conditions Age-related differences that can increase the risk of burns and complications of burns include thinner skin, slower healing, decreased mobility, increased risk of infection term-201that goes unnoticed, and pre-existing conditions that can complicate recovery. The older adult has decreased inflammatory and immune responses.
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the assistive personnel (AP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.
Answer: a, b, c, e. a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the assistive personnel (AP). c. Give simple explanations of what is happening. e. Stay with the client and speak in a quiet, calm voice. Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.
A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Alveolar recruitment e. Toxicity
Answer: a, b, c, e. a. Absorptive atelectasis b. Combustion c. Dried mucous membranes e. Toxicity Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Alveolar recruitment may be a benefit of high-flow nasal cannulas such as Vapotherm, which both humidifies and warms the oxygen.
A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure that the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.
Answer: a, b, d, e. a. Allow visitors at the client's bedside. b. Ensure that the client can communicate if awake. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more. There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.
A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse assess for? (Select all that apply.) a. Oral mucosa is gray or dark brown b. Pain when drinking grapefruit juice c. Persistent weight gain over the past 2 months d. Oral lesions that are over 2 weeks old e. Changes in the patient's voice quality
Answer: a, b, d, e. a. Oral mucosa is gray or dark brown b. Pain when drinking grapefruit juice d. Oral lesions that are over 2 weeks old e. Changes in the patient's voice quality Symptoms of head and neck cancer include color changes in the mouth or tongue to gray or dark brown; pain in the mouth, neck, and throat; burning sensation when drinking citrus juices; weight loss; oral lesions or soars that do not heal in 2 weeks; and hoarseness or changes in voice quality.
A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Ask the client to drink 2 L of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating chest physiotherapy device. e. Encourage diaphragmatic breathing. f. Administer the ordered mucolytic agent.
Answer: a, b, d, f. a. Ask the client to drink 2 L of fluids daily. b. Add humidity to the prescribed oxygen. d. Use a vibrating chest physiotherapy device. f. Administer the ordered mucolytic agent. Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating chest physiotherapy device can also help clients remove thick secretions but is usually used in clients with cystic fibrosis. Mucolytic agents help thin secretions, making them easier to bring up. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client's ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing f. Chronic anemia
Answer: a, b, d. a. Chest wall stiffness b. Decreased muscle strength d. Less lung elasticity Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity. Anemia can make it difficult to wean a client, but this is not a normal age-related change.
A nurse is assisting a provider who's performing a thoracentesis at the beside of a client. which of the following actions should the nurse take? (Select all that apply) a. Wear goggles and a mask during the procedure. b. Cleanse the procedure area with an antiseptic solution. c. Instruct the client to take deep breaths during the procedure. d. Position the client laterally on the affected side before the procedure. e. Apply pressure to the site after the procedure.
Answer: a, b, e. a. Wear goggles and a mask during the procedure. b. Cleanse the procedure area with an antiseptic solution. e. Apply pressure to the site after the procedure The nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid. The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure. The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung. The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid. The application of pressure decreases the risk for bleeding at the procedure site.
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. 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
Answer: a, c, d, e. a. A 22-year-old client with asthma c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension 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.
A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary artery hypertension. What actions would the nurse take to ensure the client's safety while on this medication? (Select all that apply.) a. Keep an intravenous line dedicated strictly to the infusion. b. Teach the client that this medication increases pulmonary pressures. c. Ensure that there is always a backup drug cassette available. d. Start a large-bore peripheral intravenous line. e. Use strict aseptic technique when using the drug delivery system.
Answer: a, c, e. a. Keep an intravenous line dedicated strictly to the infusion. c. Ensure that there is always a backup drug cassette available. e. Use strict aseptic technique when using the drug delivery system. Intravenous prostacyclin agents would be administered to a client with pulmonary artery hypertension through a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted even briefly; therefore, a backup drug cassette would also be available. The nurse would use strict aseptic technique when using the drug delivery system. The nurse would teach the client that this medication decreases pulmonary pressures and increases lung blood flow.
A 100-kg client has developed ARDS and needs mechanical ventilation. Which of the following are potentially correct ventilator management choices? (Select all that apply.) a. Tidal volume: 600 mL b. Volume-controlled ventilation c. PEEP based on oxygen saturation d. Suctioning every hour e. High-frequency oscillatory ventilation f. Limited turning for ventilator pressures
Answer: a, c, e. a. Tidal volume: 600 mL c. PEEP based on oxygen saturation e. High-frequency oscillatory ventilation The client with ARDS who needs mechanical ventilation benefits from "open lung" and lung protective strategies, such as using low tidal volumes (6 mL/kg body weight). Pressure-controlled ventilation is preferred due to the high pressures often required in these clients. PEEP usually starts at 5 cm H2O and adjusted to keep oxygen saturations in an acceptable range. Suctioning may need to be frequent due to secretions, but is not scheduled hourly. High-frequency oscillatory ventilation is an alternative to traditional modes of ventilation. Early mobility is encouraged as is turning and positioning the client.
The nurse is learning about endemic pulmonary diseases. Which diseases are matched with correct information? (Select all that apply.) a. Hanta virus: found in urine, droppings, and saliva of infected rodents. b. Aspergillosis: requires a prolonged course of antibiotics. c. Histoplasmosis: sources include soil containing bird and bat droppings. d. Blastomycosis: requires strict adherence to multi-antibiotic regimen. e. Cryptococcosis: has been eradicated due to strategic deforestation. f. Coccidioidomycosis: found in the southwest and far west of the United States.
Answer: a, c, f a. Hanta virus: found in urine, droppings, and saliva of infected rodents. c. Histoplasmosis: sources include soil containing bird and bat droppings. f. Coccidioidomycosis: found in the southwest and far west of the United States. Hanta virus is often seen in the southwest United States and is found in the urine, droppings, and saliva of infected rodents. Histoplasmosis is found in soil containing bird and bat droppings and on surfaces covered with bird droppings. Apergillosis is a common mold found both indoors and outdoors and is treated with a long course of antifungal drugs. Blastomycosis is a fungal disease requiring a prolonged course of antifungal medications. Cryptococcosis is a fungus found on trees and in the soil beneath trees, but has not been eradicated with strategic deforestation. Coccidioidomycosis is found in the southwest and far west of the United States, plus Mexico, and Central and South America.
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements would the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."
Answer: a, d, e a. "I held the client's morning bronchodilator medication." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands." To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours (depending on the suspected cause), the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside or the respiratory lab. A treadmill is not used for this test.
A nurse teaches a client who is interested in smoking cessation. Which statements would the nurse include in this client's teaching? (Select all that apply.) a. "Find an activity that you enjoy and will keep your hands busy." b. "Keep snacks like potato chips on hand to nibble on." c. "Identify a consequence for yourself in case you backslide." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking." f. "Set a quit date and stick to it."
Answer: a, d, e, f a. "Find an activity that you enjoy and will keep your hands busy." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking." f. "Set a quit date and stick to it." The nurse would teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least eight glasses of water each day, to make a list of reasons for quitting smoking, and to set a firm quit date and stick to it. The nurse would also encourage the client not to be upset if he or she backslides and has a cigarette but to try to determine what conditions caused him or her to smoke.
A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Don't go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.
Answer: a, d, e. a. Create a communication system. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves. The client with a tracheostomy may be shy and hesitant to go out in public. The client needs to have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Apply water-soluble lip balm to the client's lips b. Ensuring that the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy f. Holding the new tracheostomy tube while the RN changes the ties
Answer: a, d. a. Applying water-soluble lip balm to the client's lips d. Reminding the client to cough and deep breathe often The AP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring that the humidity is adequate and suctioning through the tracheostomy are nursing functions. When needed, a second licensed person assists with holding the tracheostomy tube during tie changes; some hospitals require a second licensed person during the first 72 hours after placement.
A nurse admits a client from the emergency department. Client data are listed below: Hx: ° 70 years of age ° History of diabetes ° On insulin twice a day ° Reports new onset dyspnea and productive cough Physical: ° Crackles and rhonchi heard throughout the lungs ° Dullness to percussion LLL ° Afebrile ° Oriented to person only Relevant Labs: ° WBC 5,200/mm^3 (5.2 ́109/L) ° PaO2 on room air 85 mmHg Based on the above data, what action by the nurse is the priority? a. Administer oxygen at 4 L per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.
Answer: a. Administer oxygen at 4 L per nasal cannula. All actions are appropriate for this client who has signs and symptoms 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.
A nurse developing a plan of care for a client who has active TB. which of the following isolation precautions should the nurse include in the plan? a. Airborne b. Neutropenic c. Contact d. Droplet
Answer: a. Airborne The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask.
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication would the nurse being most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium
Answer: a. Alteplase Alteplase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows that this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.
a nurse in an ED is caring for a client who's experiencing a pulmonary embolism. which of the following actions should the nurse take first? a. Apply supplemental oxygen. b. Increase the rate of IV fluids. c. Administer pain medication. d. Initiate cardiac monitoring.
Answer: a. Apply supplemental oxygen When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.
A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Replaces the oxygen tubing with a different type. d. Turn the client every 2 hours or as needed.
Answer: a. Apply water-soluble ointment to nares and lips. Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client's lips and nares. The AP would not adjust the oxygen flow rate or replace the tubing. Turning the client is not related to comfort measures for oxygen.
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other signs of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.
Answer: a. Assess for other signs of hypoxia. Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse would conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately.
Answer: a. Assess the cause of the agitation. The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary but not as a first step. Ensuring the client is adequately oxygenated is the priority.
A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next? a. Assess the client for obstructive sleep apnea. b. Arrange a home sleep apnea test. c. Encourage the client to begin exercising. d. Schedule a polysomnography
Answer: a. Assess the client for obstructive sleep apnea. Hypertension not responding to medications can be a sign of obstructive sleep apnea (OSA). The nurse would assess the client using an evidence-based tool, such as the STOP-Bang Sleep Apnea Questionnaire, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, and the Multiple Sleep Latency Test. If the results of the assessment indicate OSA may be a problem, the nurse would consult the primary health care provider for further testing. An at-home sleep-study is often done prior to a polysomnography. Excessive weight can contribute to OSA so exercising is always encouraged, but this is not specific to assessing for OSA.
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client's face is puffy and the eyelids are swollen. What action by the nurse takes best? a. Assess the client's oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.
Answer: a. Assess the client's oxygen saturation. This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse would first assess the client's oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 L per nasal cannula d. Complete bedrest with frequent repositioning
Answer: a. Assistance with activities of daily living A client with dyspnea and the inability to complete activities such as climbing a flight of stairs without pausing has class IV dyspnea. The nurse would provide assistance with activities of daily living. These clients would be encouraged to participate in activities as tolerated. They would not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.
Answer: a. Collect the nasal drainage on a piece of filter paper. The client with nasal drainage after facial trauma could have a skull fracture resulting in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper and tests positive for glucose. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the patient's risk for infection.
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler position. d. Administer prescribed albuterol.
Answer: a. Document the findings. Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse would document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal.
While responding to questions in a health history, the client reports that he usually expectorates about 2 ounces of thin, clear, colorless sputum daily, usually on getting up in the morning. What is the nurse's best action related to this finding? a. Document the report as the only action. b. Arrange for the client to have a tuberculosis testing. c. Collect a sputum sample for laboratory analysis. d. Alert the PCP about this finding.
Answer: a. Document the report as the only action.
A nurse in an urgent care clinical is collecting data from a patient who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? a. Dry cough b. Rhinitis c. Sore throat d. Swollen lymph nodes
Answer: a. Dry cough A dry cough is a clinical manifestation found in the prodromal stage of having inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis.
A nurse is planning care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? a. Eat high-calorie foods first b. Increase intake of water at meal times c. Perform active range-of-motion exercises before meals d. Keep saltine crackers nearby for snacking
Answer: a. Eat high-calorie foods first Although it is important for a client who has COPD to maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the client should limit intake of water at mealtimes to reduce the feeling of early satiety.
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
Answer: a. Educating the client on adherence to the treatment regimen The treatment regimen for TB often ranges from 26 weeks, but can be up to 2 years, making adherence problematic for many people. The nurse would 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.
A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action would the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.
Answer: a. Encourage oral rinsing after fluticasone administration. The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse would document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity is not necessary to care for this client.
A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process would the nurse correlate with this client's history and clinical signs and symptoms? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucous glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output
Answer: a. Increased pulmonary pressure creating a higher workload on the right side of the heart Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left-heart failure and is not directly caused by a 40-year smoking history.
A client in the emergency department has several broken ribs and reports severe pain. What care measure will best promote comfort? a. Prepare to assist with intercostal nerve block. b. Humidify the supplemental oxygen. c. Splint the chest with a large ACE wrap. d. Provide warmed blankets and warmed IV fluids.
Answer: a. Prepare to assist with intercostal nerve block. Uncomplicated rib fractures generally are simple to manage; however, opioids may be needed for pain. For severe pain, an intercostal nerve block is beneficial. The client needs to be able to breathe deeply and cough so as not to get atelectasis and/or pneumonia. Humidifying the oxygen will not help with the pain. Rib fractures are not wrapped or splinted in any way because this inhibits chest movement. Warmed blankets and warm IV fluids are nice comfort measures, but do not help with severe pain.
A nurse is providing teaching to a patient about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end maximum inhalation? a. Total lung capacity b. Vital lung capacity c. Functional residual capacity d. Residual volume
Answer: a. Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.
A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. the nurse should identify that which of the following assessments is the priority? a. presence of gag reflex b. pain level rating using 0 to 10 scale c. hydration status d. appearance of the IV insertion site
Answer: a. presence of gag reflex The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.
Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? (Select all that apply.) 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.
Answer: all of the above (1, 2, 3, 4, 5). The client diagnosed with COPD has difficulty exchanging O2 with CO2, which is manifested by physical signs such as fingernail clubbing and respiratory acidosis as seen on ABGs. The client should avoid extremes in temperatures. Warm temperatures cause an increase in the metabolism and increase the need for O2. Cold temperatures cause bronchospasms. The client has increased respiratory effort during activities and can be fatigued. Activities should be timed so rest periods are scheduled to prevent fatigue. The client may have difficulty adapting to the role changes brought about because of the disease process. Many cannot maintain the activities involved in the meeting responsibilities at home and at work. Clients should be assessed for these issues. Clients often lose weight because of the effort expended to breathe.
A nurse is assessing a client's history of particular matter exposure. What questions are consistent with the I PREPARE tool? (Select all that apply.) a. Investigate all history of known exposures. b. Determine if breathing problems are worse at work. c. Ask the client what type of heating is in the home. d. Gather details about the geographic location of the client's home. e. Have client list all previous jobs and work experiences. f. Assess what hobbies the client and family enjoy.
Answer: all of the above (a, b, c, d, e, f) All questions are appropriate for the I PREPARE model of particulate matter exposure. The R and final E stands for resources/referrals and educate.
A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.) a. Hypertension b. Stroke c. Weight gain d. Diabetes e. Cognitive deficits f. Pulmonary disease
Answer: all of the above (a, b, c, d, e, f). The long-term effects of untreated sleep apnea include increased risk for hypertension, stroke, cognitive deficits, weight gain, diabetes, and pulmonary and cardiovascular disease.
The nurse is preparing to teach a community group about warning signs of lung cancer. What information does the nurse include? (Select all that apply.) a. Over 10-pack-year history of smoking b. Persistent coughing c. Rusty or blood-tinged sputum d. Dyspnea e. Hoarseness f. Fatigue
Answer: b, c, d, e. b. Persistent coughing c. Rusty or blood-tinged sputum d. Dyspnea e. Hoarseness Some common signs of lung cancer include persistent cough, rusty or blood-tinged sputum, dyspnea, and hoarseness. Fatigue is common to many conditions. Smoking history is a risk factor for lung cancer.
A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.) a. Provide a clear liquid breakfast. b. Verify that the informed consent was obtained. c. Document the client's allergies. d. Review laboratory results. e. Hold the client's bronchodilator. f. Monitor the client for at least 24 hours afterwards.
Answer: b, c, d, f b. Verify that the informed consent was obtained. c. Document the client's allergies. d. Review laboratory results. f. Monitor the client for at least 24 hours afterwards. Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep the client NPO for 4 to 8 hours prior to the procedure or per agency policy to prevent aspiration, document allergies, and review laboratory results including complete blood count and bleeding times. There is no reason to hold the client's bronchodilator prior to this procedure. The nurse will monitor the client at least every 4 hours for 24 hours.
A nurse assesses a client with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the client's activity tolerance? (Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?" f. "How does your activity compare to this time last year?"
Answer: b, c, e, f. b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" e. "Have you lost any weight lately?" f. "How does your activity compare to this time last year?" Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously. The nurse would ask the client to compare his or her current level of activity with that of a month or even a year ago.
The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP. What information does the nurse include? (Select all that apply.) a. Insurance will cover the cost if you wear it at least 4 hours a day. b. Once the delivery mask is adjusted, do not loosen the straps. c. The CPAP provides pressure that holds your upper airways open. d. You need to clean the mask at least once a week to prevent infection. e. The humidification increases the risk of fungal infections. f. Be patient when first using the system, it can be frustrating at first.
Answer: b, c, e, f. b. Once the delivery mask is adjusted, do not loosen the straps. c. The CPAP provides pressure that holds your upper airways open. e. The humidification increases the risk of fungal infections. f. Be patient when first using the system, it can be frustrating at first. A CPAP for OSA provides pressure that keeps the upper airway open. A properly fitting mask or nasal pillows is necessary to provide the pressure. Humidification in the system leads to an increased risk for fungal infections. Patients may have anxiety about using the equipment and worry about it being disruptive; most clients have a period of adjustment when first starting to use a CPAP. Medicare will usually cover the cost if the client wears the CPAP at least 6 hours a day. The mask or pillows should be cleaned daily.
A nurse is teaching a client how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? (Select all that apply.) a. "Open your mouth and breathe deeply." b. "Use your abdominal muscles to squeeze air out of your lungs." c. "Breath out slowly without puffing your cheeks." d. "Focus on inhaling and holding your breath as long as you can." e. "Exhale at least twice the amount of time it took to breathe in." f. "Lie on your back with your knees bent."
Answer: b, c, e. b. "Use your abdominal muscles to squeeze air out of your lungs." c. "Breath out slowly without puffing your cheeks." e. "Exhale at least twice the amount of time it took to breathe in." A nurse would teach a client to close his or her mouth and breathe in through his or her nose, purse his or her lips and breathe out slowly without puffing his or her cheeks, and use his or her abdominal muscles to squeeze out every bit of air. The nurse would also remind the client to use pursed-lip breathing during any physical activity, to focus on exhaling, and to never hold his or her breath. Lying on the back with bent knees is the preferred position for diaphragmatic breathing.
A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which statements indicate that the client correctly understood the teaching? (Select all that apply.) a. "I will vigorously blow my nose multiple times each day." b. "Nasal saline sprays will help to prevent rebleeding." c. "I will wait at least 1 month before resuming weight lifting." d. "Ibuprofen will decrease nasal swelling and pain." e. "I will apply a small amount of petroleum jelly to my nares."
Answer: b, c, e. b. "Nasal saline sprays will help to prevent rebleeding." c. "I will wait at least 1 month before resuming weight lifting." e. "I will apply a small amount of petroleum jelly to my nares." A nurse would teach a client to avoid vigorous nose blowing, the use of aspirin or other NSAIDs, and strenuous activities such as heavy lifting for at least 1 month. The nurse would also teach the client to apply petroleum jelly sparingly to the nares for lubrication and comfort, and to use nasal saline sprays and humidification to prevent rebleeding.
A client in the emergency department is taking rifampin 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 (6.7 mmol/L) b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L (130 mmol/L) e. White blood cell (WBC) count: 72,000/mm3 (72 ́ 109/L)
Answer: b, c. b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds 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 assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.) a. Bradycardia b. New-onset cough c. Purulent sputum d. Tachypnea e. Pain with respirations f. Rapid, shallow respirations
Answer: b, d, e b. New-onset cough d. Tachypnea e. Pain with respirations Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset "nagging" cough, and pain that is worse at the end of inhalation and the end of exhalation on the affected side. Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected side of the chest that does not move in and out with respirations. Purulent sputum is a symptom of infection.
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site
Answer: b, d, e, f. b. Tracheal deviation d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum and pain at the insertion site are not signs/symptoms that would require immediate intervention.
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-age client with an exacerbation of asthma d. Older client who is 1 day post-hip replacement surgery e. Young obese client with a fractured femur f. Middle-age adult with a history of deep vein thrombosis
Answer: b, d, e. b. Client with a new spinal cord injury on a rotating bed d. Older client who is 1 day post-hip replacement surgery e. Young obese client with a fractured femur Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.
A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding? a. "Are you taking any medications or herbal supplements?" b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?"
Answer: b. "Do you have any chronic breathing problems?" The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral (side-to-side) diameter. This ratio normally is about 1:1.5. When the AP diameter approaches the lateral diameter, and the ratio is 1:1, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic emphysema. It can also be seen in people who have lived at a high altitude for many years. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and would be asked first.
A clinic nurse is reviewing care measures with a client who has asthma, Step 3. What statement by the client indicates the need to review the information? a. "I still will use my rapid-acting inhaler for an asthma attack." b. "I will always use the spacer with my dry powder inhaler." c. "If I am stable for 3 months, I might be able to reduce my drugs." d. "My inhaled corticosteroid must be taken regularly to work well."
Answer: b. "I will always use the spacer with my dry powder inhaler." Dry powder inhalers are not used with a spacer. The other statements are accurate.
A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in a place following thoracic surgery w/ newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? a. "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration." b. "I will notify the provider if there is continuous bubbling in the water seal chamber." c. "I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery." d. "I will notify the provider if there are several small, dark-red blood clots in the tubing."
Answer: b. "I will notify the provider if there is continuous bubbling in the water seal chamber." Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.
A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. which of the following statements by a staff nurse indicates an understanding of the teaching? a. "I will use clean technique when suctioning a client's endotracheal tube." b. "I will use a rotating motion when removing the suction catheter." c. "I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube." d. "I will suction a client's endotracheal tube every 2 hours."
Answer: b. "I will use a rotating motion when removing the suction catheter." The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.
A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient's teaching? a. "Add peppermint oil to the humidifier to relax the airway." b. "Make sure you clean the humidifier to prevent infection." c. "Keep the humidifier filled with water at all times." d. "Use the humidifier when you sleep, even during daytime naps."
Answer: b. "Make sure you clean the humidifier to prevent infection." Priority teaching related to the use of a room humidifier focuses on infection control. Clients would be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil would not be added to a humidifier. The humidifier would be refilled with water as needed and would be used while awake and asleep.
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 primary health care provider orders a chest x-ray. The family member questions why this is needed since the symptoms 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."
Answer: b. "Older people often have vague symptoms, so an x-ray is essential." 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 signs and symptoms 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 symptoms of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond? a. "I will consult the speech therapist to ensure you are swallowing properly." b. "This is normal after surgery. What types of food do you like to eat?" c. "I will ask the dietitian to change the consistency of the food in your diet." d. "Replacement of protein, calories, and water is very important after surgery."
Answer: b. "This is normal after surgery. What types of food do you like to eat?" Many clients experience changes in taste after surgery. The nurse would identify foods that the client wants to eat to ensure that the client maintains necessary nutrition. Although the nurse would collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the patient's concerns.
A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%
Answer: b. 21% Oxygen content of atmospheric or "room air" is about 21%.
A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client would the nurse assess first? a. A 46 year old with a 30-pack-year history of smoking b. A 52 year old in a tripod position using accessory muscles to breathe c. A 68 year old who has dependent edema and clubbed fingers d. A 74 year old with a chronic cough and thick, tenacious secretions
Answer: b. A 52 year old in a tripod position using accessory muscles to breathe The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how effectively the client is breathing and provide interventions to minimize respiratory distress. The other clients are not in acute distress.
A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately? a. Albumin: 5.1 g/dL (7.4 mcmol/L) b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/million/μL (5.2 ́ 1012/L) d. White blood cell (WBC) count: 12,500/mm3 (12.5 ́ 109/L)
Answer: b. Alanine aminotransferase (ALT): 180 U/L 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.
A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action? a. Bronchodilator—stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. c. Corticosteroid—relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. d. Cromone—disrupts the production of pathways of inflammatory mediators.
Answer: b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that activates beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta^2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators.
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the chest tube is dislodged. Which action by the nurse is best? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the primary health care provider. d. Reinsert the tube using sterile technique.
Answer: b. Cover the insertion site with sterile gauze. Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse would not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The nurse does not need to assess the site at this moment. The primary health care provider would be called to reinsert the chest tube or prescribe other treatment options.
A nurse is assessing a client who's 4 hr postoperative following a total laryngectomy. which of the following findings is the priority for the nurse to report to the provider? a. Bleeding at the surgical site b. Decreased oxygen saturation c. Urinary retention d. Increased pain level
Answer: b. Decreased oxygen saturation When using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia because of airway obstruction.
A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the client's oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.
Answer: b. Determine if the client can switch to a nasal cannula during the meal. Oxygen is a drug that needs to be delivered constantly. The nurse would determine if the primary health care provider has approved switching to a nasal cannula during meals. If not, the nurse would consult with the primary health care provider about this issue. The primary health care provider would need to prescribe discontinuing oxygen if the client's oxygen saturation is normal. The oxygen would not be turned off. Lifting the mask to eat will alter the FiO2 delivered.
A nurse is assessing a client who has emphysema. which of the following findings should the nurse report to the provider? a. Rhonchi on inspiration b. Elevated temperature c. Barrel-shaped chest d. Diminished breath sounds
Answer: b. Elevated temperature The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.
A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure from the emergency department. What action does the nurse take first? a. Assessing that the ventilator settings are correct b. Ensuring that there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room
Answer: b. Ensuring that there is a bag-valve-mask in the room Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse would know and check the settings. Personal protective equipment is important, but ensuring client safety is the most important action. The client may or may not need suctioning on arrival.
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.
Answer: b. Measure and compare cuff pressures. Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse would measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.
A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? a. The client may have memory and cognitive issues postburn. b. Everything between the entry and exit wounds can be damaged. c. The respiratory system requires close monitoring for signs of swelling. d. Electrical burns increase the risk of developing future cancers.
Answer: b. Everything between the entry and exit wounds can be damaged. As the electricity enters the body, travels through various tissues, and exits, it damages all the tissue it flows through. There may be severe internal injury that is not yet apparent. The client may have cognitive issues postburn but this is not as important as vigilant monitoring for complications. Respiratory system swelling is associated with thermal burns and smoke inhalation. Exposure to radiation increases cancer risk.
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information - • Shortness of breath for 20 minutes • Reports feeling frightened • "Can't catch my breath" Laboratory Analysis - • pH: 7.32 • PaCO2: 28 mm Hg • PaO2: 78 mm Hg • SaO2: 88% Vital Signs - • Pulse: 120 beats/min • Respiratory rate: 34 breaths/min • Blood pressure 158/92 mm Hg • Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.
Answer: b. Facilitate a STAT pulmonary angiography. This client has signs and symptoms of pulmonary embolism (PE); however, many conditions can cause the client's presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse would facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.
A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse to determine the best course of action. What will the new nurse do? a. Contact the primary health care provider. b. Give the ordered diuretic as scheduled. c. Request an increase in the IV rate. d. Calculate the client's 24-hour fluid balance.
Answer: b. Give the ordered diuretic as scheduled. Research has shown that clients with ARDS may benefit from conservative fluid therapy along with diuretics to maintain fluid balance. The nurse will give the ordered diuretic as scheduled. There is no reason to contact the provider or request an increased IV rate. The nurse can calculate the 24-hour fluid balance, but this will not influence the administration of the medication.
A nurse is caring for a newly admitted client who has emphysema. the nurse should place the client in which of the following positions to promote effective breathing? a. Lateral position with a pillow at the back and over the chest to support the arm b. High-Fowler's position with the arms supported on the overbed table c. Semi-Fowler's position with pillows supporting both arms d. Supine position with the head of the bed elevated to 15°
Answer: b. High-Fowler's position with the arms supported on the overbed table The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin.
Answer: b. Increase the heparin rate. For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.
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 oral 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.
Answer: b. Inform the client that oral antibiotics will be needed for 60 days. This client has signs and symptoms 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.
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. Inquire as to recent travel outside the United States. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.
Answer: b. Inquire as to recent travel outside the United States. Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Preventing the spread of disease is vital. The nurse would ask the "clients" about recent overseas travel to assess the risk of a pandemic flu. Clients with possible pandemic flu need to be in Contact and Airborne Precautions the infectious organism is identified and routes of transmission known. There is no specific danger to pregnant caregivers. Droplet Precautions are not appropriate.
A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days
Answer: b. Intact skin behind the ears Oxygen tubing can cause pressure injuries, so clients using oxygen have a high risk of skin breakdown. Intact skin behind the ears indicates that goals for maintaining client safety with oxygen therapy are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem.
A nurse is caring for a client who's in respiratory distress. which of the following low-flow delivery devices should the nurse use to provide the client w/ highest level of oxygen? a. Nasal cannula b. Nonrebreather mask c. Simple face mask d. Partial rebreather mask
Answer: b. Nonrebreather mask The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures.
Answer: b. Notify the Rapid Response Team. Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of benzocaine spray. This condition can lead to death. The nurse would notify the Rapid Response Team to provide advanced care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat the client.
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.
Answer: b. Notify the Rapid Response Team. This client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.
A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most important? a. Take a full set of vital signs. b. Obtain pulse oximetry reading. c. Ask the patient about hemoptysis. d. Inspect the biopsy site.
Answer: b. Obtain pulse oximetry reading. Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry reading and perform other respiratory assessments. Temperature is not a priority. The nurse can ask about other symptoms while conducting the assessment. The nurse would assess the biopsy site and/or dressings, but this is not the first action.
A nurse on a medical unit is caring for a patient who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the patient reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? a. Tympanic temperature of 38 C (100.4 F) b. PaO2 50 mm Hg c. Rhonchi d. Hypopnea
Answer: b. PaO2 50 mm Hg The patient who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS. The client who has ARDS will have clear breath sounds because edema occurs in the interstitial spaces and not in the airway. The client who has ARDS will manifest hyperpnea.
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL (142 g/L) b. Platelet count: 82,000/L (82 ́ 10^9/L) c. Red blood cell count: 4.8/mm3 (4.8 ́ 10^12/L) d. White blood cell count: 8700/mm3 (8.7 ́ 109/L)
Answer: b. Platelet count: 82,000/L (82 ́ 109/L) This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.
A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.
Answer: b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. Often clients are discharged from the hospital on warfarin after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The other option is to lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.
A nurse in a provider's office is assessing a client who has COPD. which of the following findings is the priority for the nurse to report to the provider? a. Increased anterior-posterior chest diameter b. Productive cough with green sputum c. Clubbing of the fingers d. Pursed-lip breathing with exertion
Answer: b. Productive cough with green sputum When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.
A nurse is providing instructions about pursed-lip breathing for a patient who has COPD with emphysema. The nurse should explain that this breathing technique accomplishes which of the following? a. Increases oxygen intake b. Promotes carbon dioxide elimination c. Uses the intercostal muscles d. Strengthens the diaphragm
Answer: b. Promotes carbon dioxide elimination A patient who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the patient's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.
A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Swallow twice while bearing down. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.
Answer: b. Swallow twice while bearing down. The client post supraglottic laryngectomy has a high risk for aspiration. The nurse or speech-language pathologist teaches the client the supraglottic method of swallowing. This includes placing a small amount of food in the mouth, performing the Valsalva maneuver, then swallowing twice. The client sits upright. The client holds their breath while swallowing twice. Keeping the head still and straight will not decrease the risk of aspiration.
Which teaching point is most important for the client with a peritonsillar abscess? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Let us know if you want liquid medications. d. Wash hands frequently.
Answer: b. Take all antibiotics as directed. 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.
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client's decrease in self-esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.
Answer: b. The client has joined a book club that meets at the library. The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for disrupted self-esteem are being met. The other findings are all positive signs but do not relate to this client problem.
After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lies on his or her side with knees bent. b. The client places his or her hands on the abdomen. c. The client lies in a prone position with straight. d. The client places his or her hands above the head.
Answer: b. The client places his or her hands on the abdomen. To perform diaphragmatic breathing correctly, the client would place his or her hands on the abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.
A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? a. How to eliminate environmental triggers that precipitate attacks b. The client's perception of the disease process and what might have triggered past attacks c. The client's medication regimen d. Manifestations of respiratory infections
Answer: b. The client's perception of the disease process and what might have triggered past attacks The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client's current knowledge.
A nurse is teaching about daily chest physiotherapy with a client who has cystic fibrosis. The nurse should instruct the client that which of the following is the purpose of the treatments? a. To encourage deep breaths b. To mobilize secretions in the airways c. To dilate the bronchioles d. To stimulate the cough reflex
Answer: b. To mobilize secretions in the airways The purpose of chest physiotherapy is to loosen the patient's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity.
When working with women who are taking hormonal birth control, what health promotion measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.
Answer: c, d, e. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes. Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.
The emergency department nurse is participating in a bioterrorism drill in which several "clients" are suspected to have inhalation anthrax. Which "clients" would the nurse see as the priorities? (Select all that apply.) a. Widened mediastinum on chest x-ray b. Dry cough c. Stridor d. Oxygen saturation of 91% e. Diaphoresis f. Oral temperature of 99.9° F (37.7° C)
Answer: c, d, e. c. Stridor d. Oxygen saturation of 91% e. Diaphoresis Clients with fulminant anthrax may exhibit stridor, hypoxia, and diaphoresis. Although an oxygen saturation of 91% is not critical, it is abnormally low. These clients would be seen as the priority. A widened mediastinum and dry cough are usually seen in the prodromal phase when the temperature elevation is not as severe.
A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that going out with friends is no longer enjoyable. How would the nurse respond? a. "There are a variety of support groups for people who have COPD." b. "I will ask your primary health care provider to prescribe an antianxiety agent." c. "I'd like to hear about thoughts and feelings causing you to limit social activities." d. "Friends can be a good support system for clients with chronic disorders."
Answer: c. "I'd like to hear about thoughts and feelings causing you to limit social activities." Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. While friends can be good sources of support, the client specifically is discussing going out of the home.
A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best? (Select all that apply.) a. Administer prescribed salmeterol inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen and place client on an oximeter. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol inhaler. f. Assess the client's lung sounds after administering the inhaler.
Answer: c, e, f. c. Administer oxygen and place client on an oximeter. e. Administer prescribed albuterol inhaler. f. Assess the client's lung sounds after administering the inhaler. Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is becoming unstable, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would reassess the lung sounds after the rescue inhaler. The nurse would not do a peak flow reading at this time, nor would a code be called. The nurse could assess for tracheal deviation after administering oxygen and albuterol.
A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first? a. "Do you have a strong support system?" b. "What do you understand about your disease?" c. "Do you experience shortness of breath with basic activities?" d. "What medications are you prescribed to take each day?"
Answer: c. "Do you experience shortness of breath with basic activities?" Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse would ask the client if shortness of breath is interfering with basic activities. Although the nurse would need to know about the client's support systems, current knowledge, and medications, these questions do not address the client's appearance.
A nurse is teaching a client who has cystic fibrosis (CF). Which statement would the nurse include in this client's teaching? a. "Take an antibiotic each day." b. "You should get genetic screening." c. "Eat a well-balanced, nutritious diet." d. "Plan to exercise for 30 minutes every day."
Answer: c. "Eat a well-balanced, nutritious diet." Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening might be an option; however, the nurse would not just tell the client to do something like that.
A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. which of the following instructions should the nurse include? a. "Ringing in the ears is an adverse effect of this medication." b. "Have your skin test repeated in four months to show a positive result." c. "Expect your urine and other secretions to be orange while taking this medication." d. "Remember to take this medication with a sip of water just before your first bite of each meal."
Answer: c. "Expect your urine and other secretions to be orange while taking this medication." The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.
A nurse is providing discharge teaching to a client who has a temporary tracheostomy. which of the following statements by the client indicates an understanding of the teaching? a. "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma" b. "I should cut a 4 inch gauze dressing and place it around my tracheostomy tube to absorb drainage" c. "I should remove the old twill ties after the new ties are in place" d. "I should apply suction while inserting the catheter into my tracheostomy tube"
Answer: c. "I should remove the old twill ties after the new ties are in place" As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.
After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates that the client comprehends the teaching? a. "I will carry this medication with me at all times in case I need it." b. "I will take this medication when I start to experience an asthma attack." c. "I will take this medication every morning to help prevent an acute attack." d. "I will be weaned off this medication when I no longer need it."
Answer: c. "I will take this medication every morning to help prevent an acute attack." Long-acting beta^2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.
A nurse has educated a client on isoniazid. What statement by the client indicates that teaching has been effective? a. "I need to take extra vitamin C while on isoniazid." 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."
Answer: c. "I will take this medication on an empty stomach." Isoniazid 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.
After teaching a client who is prescribed salmeterol, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in my asthma." c. "I will use the drug when I have an asthma attack." d. "I will be careful not to let the drug escape out of my nose and mouth."
Answer: c. "I will use the drug when I have an asthma attack." Salmeterol is a long-acting beta^2 agonist designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it would not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client's part allows the drug to escape through the nose and mouth.
A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen, the client's lungs are clear. What explanation does the more senior nurse provide? a. "The client is too dehydrated for moist-sounding lungs." b. "The client hasn't started having any bronchospasm yet." c. "Lung edema is in the interstitial tissues, not the airways." d. "Clients with ARDS usually have clear lung sounds."
Answer: c. "Lung edema is in the interstitial tissues, not the airways. The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues, where it can't be auscultated, instead of in the airways. It is not related to the client being dehydrated or having bronchospasm. The statement about all clients with ARDS having clear lung sounds does not provide any information.
A nurse cares for a client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How would the nurse respond? a. "Since many of your family members are carriers, your children will also be carriers of the gene." b. "Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder." c. "Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." d. "Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder."
Answer: c. "Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse would encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.
A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client's teaching? a. "Make a list of reasons why smoking is a bad habit." b. "Rise slowly when getting out of bed in the morning." c. "Smoking while taking this medication will increase your risk of a stroke." d. " Stopping this medication suddenly increases your risk for a heart attack."
Answer: c. "Smoking while taking this medication will increase your risk of a stroke." Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The nurse would encourage the client to make a list of reasons for stopping the habit but would not phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy. Stopping suddenly does not increase the risk of heart attack.
A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."
Answer: c. "The blood clot interferes with perfusion in the lungs." A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Acute respiratory distress syndrome can occur, but this is not as likely soon after the client starts on oxygen plus there is no indication of how much oxygen the client is on. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
The nurse is caring for a client who has cystic fibrosis (CF). The client asks for information about gene therapy. What response by the nurse is best? a. "Unfortunately, gene therapy is only provided to children upon diagnosis." b. "Do you know that you will have to have genetic testing?" c. "There is a good treatment for the most common genetic defect in CF." d. "Gene therapy will only help improve your pulmonary symptoms."
Answer: c. "There is a good treatment for the most common genetic defect in CF." The drug ivacaftor/lumacaftor is effective as therapy for patients whose CF is caused by the F508del (also known as the Phe508del) mutation, the most common mutation involved in CF, even in patients who are homozygous for the mutation with both alleles being affected. The nurse would provide that information as the best response. Asking if the client understands he or she will have to undergo genetic testing is a correct statement, but is a yes/no question which is not therapeutic and might sound paternalistic. It also does not provide any information on the therapy itself. The drug is not limited to children and helps move chloride closer to the membrane surfaces so it would have an effect on any organ compromised by CF.
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 a computed tomography scan this week."
Answer: c. "Try warm, moist heat packs on your face." This client has rhinosinusitis. Comfort measures for this condition include humidification, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.
A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include? a. "If the test is positive, it means you have an active case of tuberculosis." b. "If the test is positive, you should have another tuberculin skin test in 3 weeks." c. "You must return to the clinic to have the test read in 2 or 3 days." d. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."
Answer: c. "You must return to the clinic to have the test read in 2 or 3 days." The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72hr indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72hr, another tuberculin skin test is necessary.
A nurse cares for a client who tests positive for alpha^1-antitrypsin (AAT) deficiency. The client asks, "What does this mean?" How would the nurse respond? a. "Your children will be at high risk for chronic obstructive pulmonary disease." b. "I will contact a genetic counselor to discuss your condition." c. "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." d. "This is a recessive gene and would have no impact on your health."
Answer: c. "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." Alpha^1-antitrypsin deficiency is an important risk factor for COPD. The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent COPD unless the client smokes or there is sufficient exposure to other inhalants. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partner's AAT levels. Contacting a genetic counselor may be helpful but does not address the client's current question.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant. b. A 42-year-old man with gastroesophageal reflux disease. c. A 55-year-old woman who is 50 lb (23 kg) overweight. d. A 73-year-old man with type 2 diabetes mellitus.
Answer: c. A 55-year-old woman who is 50lb (23 kg) overweight. The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea. Clients with sleep apnea may develop gastroesophageal reflux.
A nurse is caring for a client who's in acute respiratory failure and is receiving mechanical ventilation. which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? a. BP b. Cap refill c. ABGs d. HR
Answer: c. ABGs. When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.
A nurse cares for a client with arthritis who reports frequent asthma attacks. What action would the nurse take first? a. Review the client's pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the primary health care provider and request arterial blood gases.
Answer: c. Assess how frequently the client uses a bronchodilator. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a likely culprit given the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good time to review response to bronchodilators, but assessing triggers is more important. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next? a. Call the primary health care provider and request food and water for the client. b. Provide the client with ice chips instead of a drink of water. c. Assess the client's gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.
Answer: c. Assess the client's gag reflex before giving any food or water. The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.
A nurse cares for a client who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.
Answer: c. Assist the client to choose a communication method. The client will not be able to speak after surgery. The nurse would assist the client to choose a communication method that he or she would like to use after surgery. Assessing the patient's airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this patient's gait would not be impacted by a total laryngectomy and therefore is not a priority.
A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client reports being dizzy—nurse calls the Rapid Response Team. b. Client's heart rate is 55 beats/min—nurse withholds pain medication. c. Client has reduced breath sounds—nurse calls primary health care provider immediately. d. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.
Answer: c. Client has reduced breath sounds—nurse calls primary health care provider immediately. A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The primary health care provider needs to be notified immediately. Dizziness without other data would not lead the nurse to call the RRT. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.
A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? a. Client reports pain is controlled satisfactorily with analgesic regime. b. Client does not have foul odor to the breath or beefy red mucus membranes. c. Client is able to swallow own secretions without drooling. d. Client's vital signs are within normal parameters.
Answer: c. Client is able to swallow own secretions without drooling. The priority after a modUPPP is maintaining a patent airway. The client who has a patent airway can swallow his or her own secretions without drooling. Controlled pain is important, but not the priority. Foul breath odor and beefy red mucus membranes indicate possible infection, which probably would not occur this soon after surgery, but preventing infection does not take priority over airway. Vital signs "within normal parameters" are vague.
A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best? a. Teach the client about possible drowsiness. b. Instruct the client to drink plenty of water. c. Consult with the PHCP about the medication. d. Encourage the client to take the medication with food.
Answer: c. Consult with the PHCP about the medication. First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. The nurse would consult with the PHCP and request a different medication. Diphenhydramine does cause drowsiness, but the nurse would request a different medication. Drinking plenty of fluids is appropriate for the condition and is not related to the medication. Antihistamines can be taken without regard to food.
A patient is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the patient's chest. After notifying the provider, the nurse should document the finding as which of the following? a. Friction rub b. Crackles c. Crepitus d. Tactile fremitus
Answer: c. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the patient's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.
A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.
Answer: c. Ensure a patent airway. The priority for any chest trauma client is airway, breathing, and circulation. The nurse first ensures that the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.
A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer IV fluid boluses every 2 hours. c. Explain that xerostomia may be a permanent side effect. d. Assess the client's neck for redness and swelling.
Answer: c. Explain that xerostomia may be a permanent side effect. Xerostomia, or dry mouth, is a potential side effect of radiation, particularly if the salivary glands were in the radiation zone. Unfortunately, this may be long term or even permanent. Gargling with lidocaine would not help. Increasing fluids is somewhat helpful, but the client would be encouraged to drink. The client's neck may have redness and swelling, but this finding is not related to the reported dry mouth.
The nurse assesses the client using the device pictured below to deliver 50% O2: (image of venturi mask) The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min.
Answer: c. Immediately increase the flow rate. For the venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The client's flow rate is too low and the nurse would increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings.
A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," (image of reddened lesion on anterior forearm) The reddened area is firm. What action by the nurse is best? a. Assess the client for possible items to which he or she is allergic. b. Call the primary health care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.
Answer: c. Immediately place the client on Airborne Precautions. This "allergy test" is actually a positive tuberculosis test. The client would be placed on Airborne Precautions immediately. The other options do not take priority over preventing the spread of the disease.
A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best? a. Ensure that the client has adequate sedation. b. Find another qualified provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.
Answer: c. Interrupt the procedure to give oxygen. Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse would interrupt the intubation attempt and give the client oxygen. The nurse would also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another qualified provider to intubate the client is not appropriate at this time.
A nurse cares for a client who is infected with Burkholderia cepacia. What action would the nurse take first when admitting this client to a pulmonary care unit? a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client separated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.
Answer: c. Keep the client separated from other clients with cystic fibrosis. B. cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for infected clients to be separated from noninfected clients. Strict isolation measures will not be necessary. Although the client would wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with B. cepacia infection.
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure that all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube.
Answer: c. Listen to the client's lung sounds. When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and perform suction if needed, assess for pneumothorax, and finally check the equipment.
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he or she needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.
Answer: c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. Smoking assessments and cessation information can be an uncomfortable and sensitive topic among both clients and health care providers. The nurse would maintain a nonjudgmental attitude in order to foster trust with the client. Telling the client he or she needs to quit smoking is paternalistic and threatening. Assessing exposure to smoke includes more than tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a history, it is most important to get accurate information.
A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection would the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole-wheat bread d. Pasta salad, custard, orange juice
Answer: c. Omelet, soft whole-wheat bread Side effects of radiation therapy may include inflammation of the esophagus. Clients would be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.
A nurse is preparing to assist a provider to withdraw arterial blood from a patient's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? a. Hyperventilate the patient with 100% oxygen prior to obtaining the specimen. b. Apply ice to the site after obtaining the specimen. c. Perform an Allen's test prior to obtaining the specimen. d. Release pressure applied to the puncture site 1 minute after the needle is withdrawn.
Answer: c. Perform an Allen's test prior to obtaining the specimen. The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.
A nurse is caring for a client who's 1 hr postoperative following a thoracentesis. which of the following is the priority assessment finding? a. Pallor b. Insertion site pain c. Persistent cough c. Temperature 37.3° C (99.1° F)
Answer: c. Persistent cough When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.
Which respiratory side effect does the nurse teach the client who is now prescribed an angiotensin-converting enzyme (ACE) inhibitor to expect? a. Wheezing on Exertion b. Increased Secretions c. Persistent dry cough d. Orthopnea
Answer: c. Persistent dry cough
A nurse is creating a plan of care for a client who has COPD. which of the following interventions should the nurse include? a. Schedule respiratory treatments following meals. b. Have the client sit up in a chair for 2-hr periods three times per day. c. Provide a diet that is high in calories and protein. d. Combine activities to allow for longer rest periods between activities.
Answer: c. Provide a diet that is high in calories and protein. The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.
A client with acute respiratory failure is on a ventilator and is sedated. What care may the nurse delegate to the assistive personnel AP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.
Answer: c. Provide frequent oral care per protocol. The client on mechanical ventilation needs frequent oral care, which can be delegated to the AP. The other actions fall within the scope of practice of the nurse.
A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)? 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.
Answer: c. Provide oral care every 4 hours. Oral colonization by gram-negative bacteria is a risk factor for health care-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the AP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients are important to detect the onset of possible pneumonia but do not prevent it.
A nurse is caring for a client who has asthma and is receiving albuterol. for which of the following adverse effects should the nurse monitor the client? a. Hyperkalemia b. Dyspnea c. Tachycardia d. Candidiasis
Answer: c. Tachycardia The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.
A nurse is planning care for a patient following placement of a chest tube 1 hour ago. Which of the following actions should the nurse include in the plan of care? a. Clamp the chest tube if there is continuously bubbling in the water seal chamber b. Keep the chest tube drainage system at the level of the right atrium c. Tape all of the connections between the chest tube and the drainage system d. Empty the collection chamber and record the amount of drainage every 8 hours
Answer: c. Tape all of the connections between the chest tube and the drainage system The nurse should tape all of the connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.
Answer: c. Teach the client about factor V Leiden testing. Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder would be asked about family history and referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.
A nurse is assessing a client who has bacterial pneumonia. which of the following manifestations should the nurse expect? a. decreased fremitus b. SaO2 95% on room air c. temperature 38.8° C (101.8° F) d. bradypnea
Answer: c. Temperature 38.8° C (101.8° F) An elevated temperature is an expected finding for a client who has bacterial pneumonia.
A nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing
Answer: c. Tying a square knot at the back of the neck. To prevent pressure injuries and for client safety, when ties are used that must be knotted, the knot would be placed at the side of the client's neck, not in back. The other actions are appropriate.
A nurse is caring for a client who's receiving mechanical ventilation when the low-pressure alarm sounds. which of the following situations should the nurse recognize as a possible cause of the alarm? a. Excess secretions b. Kinks in the tubing c. Artificial airway cuff leak d. Biting on the endotracheal tube
Answer: c. artificial airway cuff leak An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound.
A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. which of the following client statements indicates an understanding of the teaching? a. "I will monitor my heart rate every day while taking this medication." b. "I will make sure I have this medication with me at all times." c. "I will need to carefully rinse my mouth after I take this medication." d. "I will take this medication every night even if I don't have symptoms."
Answer: d. "I will take this medication every night even if I don't have symptoms." Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.
A new nurse asks for an explanation of "refractory hypoxemia." What answer by the staff development nurse is best? a. "It is chronic hypoxemia that accompanies restrictive airway disease." b. "It is hypoxemia from lung damage due to mechanical ventilation." c. "It is hypoxemia that continues even after the client is weaned from oxygen." d. "It is hypoxemia that persists even with 100% oxygen administration."
Answer: d. "It is hypoxemia that persists even with 100% oxygen administration." Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.
A client is on mechanical ventilation and the client's spouse wonders why ranitidine is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation."
Answer: d. "It will prevent ulcers from the stress of mechanical ventilation." Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them and possible subsequent aspiration. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Ranitidine is a histamine-blocking agent.
The nurse is providing teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? a. "Apply warm compresses to the face." b. "Take aspirin 650 milligrams by mouth for mild pain." c. "Close your mouth when sneezing." d. "Lie on your back with your head elevated 30° when resting."
Answer: d. "Lie on your back with your head elevated 30° when resting." The nurse should instruct the client to rest in the semi-fowler's position to prevent aspiration of nasal secretions.
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?"
Answer: d. "What is your occupation?" 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.
A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who reports orthopnea in bed d. A 27-year-old client with a heart rate of 120 beats/min
Answer: d. A 27-year-old client with a heart rate of 120 beats/min Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. Orthopnea at night in bed is breathlessness when lying down but is not an acute finding at this moment.
A nurse is caring for 4 clients. which of the following clients is at greatest risk for a pulmonary embolism? a. A client who is 48hr postoperative following a total hip arthroplasty b. A client who is 8hr postoperative following an open surgical appendectomy c. A client who is 2hr postoperative following an open reduction external fixation of the right radius d. A client who is 4hr postoperative following a laparoscopic cholecystectomy
Answer: d. A client who is 48hr postoperative following a total hip arthroplasty The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or anti-embolic stockings and by administering anticoagulant medications.
A nurse is caring for a client who has pulmonary embolism. which of the following interventions is the nurse's priority? a. Provide a quiet environment b. Encourage use of incentive spirometer every 1-2 hrs c. Obtain blood sample for electrolyte study d. Administer heparin via continuous IV infusion
Answer: d. Administer heparin via continuous IV infusion. When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the client's anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.
Answer: d. Administer pain medication and encourage the client to take deep breaths. A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse would provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client's discomfort and need to take deep breaths to prevent complications.
A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency
Answer: d. Airway patency. A patent airway is the priority. The nurse first would make sure that the airway is patent and then would determine whether the client is in pain and whether bone displacement or blood loss has occurred.
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first? a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Assess the client's airway.
Answer: d. Assess the client's airway. If the packing slips out of place, it may obstruct the client's airway. The other options are good interventions, but ensuring that the airway is patent in the priority objective.
A nurse is providing preoperative teaching to a patient who is to undergo a pneumonectomy. The patient states "I am afraid it will hurt to cough after surgery." Which of the following statements by the nurse is appropriate? a. After the surgeon removes your lung you will not need to cough. b. I'll make sure you get a cough suppressant to keep you from straining the incision when you cough. c. Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain. d. I will show you how to splint your incision while you cough.
Answer: d. I will show you how to splint your incision while you cough. The patient who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show how to splint the incision to reduce pain while coughing.
A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): ABGs: pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3 = 28 mEq/L (28 mmol/L) Vitals: Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% What action would the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 88% to 92%.
Answer: d. Initiate oxygenation therapy to increase saturation to 88% to 92%. Oxygen would be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the client's hypoxia, which is the major issue. There is no indication the client needs an inhaler. Diaphragmatic breathing techniques would not be taught to a client in distress. These findings are not normal for all clients with COPD.
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? a. Decreased bowel sounds b. Oxygen saturation 92% c. CO2 24 mEq/L d. Intercostal retractions
Answer: d. Intercostal retractions The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.
A nurse cares for a client who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction as prescribed by the primary health care provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.
Answer: d. Keep padded clamps at the bedside for use if the drainage system is interrupted. Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not clamped. Wall suction would be set at the level indicated by the device's manufacturer, not the primary health care provider.
A nurse assesses a client's respiratory status. Which information is most important for the nurse to obtain? a. Average daily fluid intake. b. Neck circumference. c. Height and weight. d. Occupation and hobbies.
Answer: d. Occupation and hobbies. Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. This is part of the I-PREPARE assessment model for particulate matter exposure. Determining the client's neck circumference will not be an important part of a respiratory assessment.
A nurse in an ED is caring for a client who's experiencing acute respiratory failure. which of the following lab findings should the nurse expect? a. Arterial pH 7.50 b. PaCO2 25 mm Hg c. SaO2 92% d. PaO2 58 mm Hg
Answer: d. PaO2 58 mm Hg The nurse should expect the client to have lower partial pressures of oxygen.
A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action does the nurse take first? a. Administer oxygen and reassess. b. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.
Answer: d. Prepare to assist with intubation. The client has signs and symptoms of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.
A nurse is caring for a patient who is scheduled for a thoracentesis. In which of the following positions should the nurse place the client? a. Lying flat on the affected side b. Prone with the arms raised over the head c. Supine with the head of the bed elevated d. Sitting while leaning forward over the bedside table
Answer: d. Sitting while leaning forward over the bedside table When preparing a client for a thoracentesis, the nurse should have the client sit on the edged of the bed and lean forward over the bedside table because this position maximizes the space between the client's ribs (intercostal space) and allows for aspiration of accumulated fluid and air.
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the primary health care provider immediately.
Answer: d. Stay with the client and have someone else call the primary health care provider immediately. This client may have a tracheoinnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the primary health care provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.
A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes that the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir. 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.
Answer: d. Teach the client to sneeze in the upper sleeve. Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have symptoms 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 would be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following indicates that the nurse should suction the client's airway secretions? a. The client is unable to speak b. The client's airway secretions were last suctioned 2 hr ago c. The client coughs and expectorates a large mucous plug d. The nurse auscultates coarse crackles in the lung fields
Answer: d. The nurse auscultates coarse crackles in the lung fields. The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 L of oxygen. d. The trachea is shifted toward the opposite side of the neck.
Answer: d. The trachea is shifted toward the opposite side of the neck. A shift of central thoracic structures toward one side is a sign of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal. The nurse would report this finding immediately or call the Rapid Response Team.
A nurse working in an ED is caring for a client following an acute chest trauma. which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? d. Collapsed neck veins on the affected side b. Collapsed neck veins on the unaffected side c. Tracheal deviation to the affected side d. Tracheal deviation to the unaffected side
Answer: d. Tracheal deviation to the unaffected side The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.
Which information should the nurse teach the client diagnosed with acute sinusitis? 1. Instruct the client to complete all the ordered antibiotics. 2. Teach the client how to irrigate the nasal passages. 3. Have the client demonstrate how to blow the nose. 4. Give the client samples of a narcotic analgesic for the headache.
Answer:1. Instruct the client to complete all the ordered antibiotics. The client should be taught to take all antibiotics as ordered. Discontinuing antibiotics prior to the full dose results in the development of antibiotic-resistant bacteria. Sinus infections are difficult to treat and may become chronic and will then require several weeks of therapy or possibly surgery to control. If the sinuses are irrigated, it is done under anesthesia by a health-care provider. Blowing the nose will increase pressure in the sinus cavities and will cause the client increased pain The nurse is not licensed to prescribe medications so this is not in the nurse's scope of practice. Also, narcotic analgesic medications are controlled substances and require written documentation of being prescribed by the health-care provider; samples are not generally available. TEST-TAKING HINT: Note in this situation that an "all" is in the correct answer. There are very few cases in which absolute adjectives will describe the correct answer. The test taker must be aware that general rules will not always apply.
