mis2
The nurse instructs a patient on the use of a metered-dose inhaler for asthma medications. To demonstrate understanding of the instructions, in which order should the patient self-administer this medication?
1 Shake the canister vigorously for 3 to 5 seconds. 2 Exhale slowly and completely. 3 Press and hold the canister down while inhaling deeply and slowly for 3 to 5 seconds. 4 Hold the breath for 10 seconds, release the pressure on the container, remove from the mouth, and exhale. 5 Rinse the mouth. Rationale: The canister is shaken before the medication is administered. The patient exhales before administering the medication. The canister is pressed and held down while the patient inhales. This step takes 3 to 5 seconds. The breath is held for 10 seconds after the medication is administered. Then the pressure on the canister is released and the canister is removed from the mouth. The patient can then exhale. The mouth is rinsed after the medication is inhaled.
A patient who has been feeling more anxious since the recent and unexpected death of his wife is experiencing an acute asthma attack. Rank the following events in the most likely order of occurrence.
1 The patient is allergic to aspirin but unknowingly ingested a product with aspirin among its ingredients. 2 Inflammatory mediators are released and inflammatory cells are activated. 3 The patient states, "I feel like my throat is closing off and I can't breathe very well." 4 The patient's respiratory rate is 32 breaths per minute and his oxygen saturation level falls from 94% to 89%. 5 The patient is taken to the hospital via an ambulance and treated with medication. Rationale: Aspirin-containing products are a common pharmacologic trigger for acute asthma attacks. When a trigger is present, an acute or early response develops in the hyperreactive airways predisposed to bronchospasm. Sensitized mast cells in the bronchial mucosa release inflammatory mediators such as histamine, prostaglandins, and leukotrienes. These events lead to bronchoconstriction, airway edema, and impaired mucociliary clearance. Airway narrowing limits airflow and increases the work of breathing; trapped air mixes with inhaled air, impairing gas exchange. Hospitalization may be required to prevent the complications of an asthma attack, which include acute respiratory failure, dehydration, respiratory infection, atelectasis, pneumothorax, and cor pulmonale.
A patient has been admitted to the hospital with an acute exacerbation of emphysema. The physician prescribes 60 mg of methylprednisolone per intravenous push. The medication is available from the pharmacy as 40 mg per 1 mL. How many mL of the medication should the nurse administer?
1.5 Rationale: Using the equation Dosage Available/Dosage Prescribed, 60 mg/40 mg × 1 mL = 6/4 × 1 = 1.5 mL. The nurse will need to administer 1.5 mL of methylprednisolone.
A patient who is unable to swim fell into a swimming pool and is diagnosed with pulmonary edema. The physician prescribes furosemide 40 mg slow intravenous push. The medication available is a vial containing 100 mg/10 mL. How many mL of the medication should the nurse administer?
4 Rationale: The nurse can use the equation Dosage Required/Dosage Available × mL, or 40 mg/100 mg × 10 mL = 4/10 × 10 = 0.4 × 10 = 4 mL. The nurse will administer 4 mL of the medication.
The nurse is reviewing the information from a patient who is 22 weeks pregnant. For which physician order should the nurse request clarification before implementing it?
Administer heparin: initial dose 10,000 units, then set at 1,200 units per hour via intravenous line. Administer oxygen at 3 liters per minute, keep oxygen saturation level above 95%. Administer urokinase. This is the correct answer. Assess arterial blood gases. Rationale: Most patients receive a thrombolytic to help treat a pulmonary embolus, but thrombolytics are contraindicated for the pregnant patient. The nurse would anticipate administering oxygen. The patient's arterial blood gases should be assessed. The patient should be started on heparin. Heparin therapy is initiated with an intravenous bolus of 5,000 to 10,000 units, followed by continuous infusion at the rate of 1,000 to 1,500 units per hour.
A patient is being mechanically ventilated with SIMV at a rate of 25 breaths per minute. Why should the nurse question this order?
SIMV is always used in combination with PEEP. The patient is not receiving enough sedation. The patient would be more comfortable with a different mode. The rate could be too high for this mode. This is the correct answer. Rationale: SIMV is usually set so that the patient can breathe over the set rate to exercise the respiratory muscles. A rate of 25 breaths per minute would not allow this and could also establish auto PEEP. The patient would not necessarily be more comfortable with a different mode; SIMV is the most commonly used mode in an ICU setting. Too much sedation is contraindicated in SIMV, to allow the patient to initiate breaths on his or her own. PEEP can be used with any of the modes.
The nurse is preparing discharge instructions for a patient recovering from acute respiratory distress syndrome (ARDS). What should be included in this teaching?
Select all that apply. Avoid large crowds. Practice lifestyle modifications to reduce oxygen demands. This is the correct answer. Restrict fluids to prevent congestive heart failure (CHF). Avoid smoking and exposure to air pollution. This is the correct answer. Get the influenza immunization annually. This is the correct answer. Rationale: Pollution and cigarette smoke can further damage already traumatized lung tissue and should be avoided. Lifestyle modifications to conserve energy and reduce oxygen demands are necessary, as lung tissues are still recovering from the damage of the disease process. Exertional dyspnea will continue to increase if additional demands are made on the pulmonary and cardiovascular system. Immunizations for pneumonia and flu are encouraged to minimize additional insults to lung tissue, as the entire physical status of lung tissue will require up to 6 months to recover. Fluids are needed to rehydrate lung tissue and to enhance renal function by diluting wastes from tissue repair. CHF from right-sided failure is possible, but not usually in the recovery phase (after discharge from the hospital). These patients are not immunocompromised and can attend large-crowd events, such as church services, without risk.
The nurse assists in the extubation of a patient recovering from injuries caused by a motor vehicle crash. Which observations indicate that the patient is able to independently maintain an airway?
Select all that apply. The patient has a hoarse voice. This is the correct answer. The patient swallows small sips of water. This is the correct answer. The patient is coughing. This is the correct answer. The patient's oxygen saturation 75%. The patient has inspiratory stridor. Rationale: When the patient is able to maintain effective respirations and ventilatory support is no longer required, the endotracheal tube is removed (extubation). Cough and swallow reflexes must be intact to prevent aspiration. A hoarse voice is common after extubation. Inspiratory stridor within the first 24 hours indicates laryngeal edema, which may necessitate reintubation. An oxygen saturation of 75% indicates that the patient is not receiving adequate oxygen. Reintubation may be necessary.
The nurse realizes that the medication tiotropium bromide (Spiriva) is contraindicated for a patient with chronic obstructive pulmonary disease (COPD). What information in the patient's medical history led to this clinical decision?
Select all that apply. The patient is being treated for glaucoma. This is the correct answer. The patient limits the intake of dietary fats for weight loss. The patient uses a topical steroid for psoriasis. The patient is taking medication for prostatic hypertrophy. This is the correct answer. The patient attends physical therapy three times a week. Rationale: Contraindications to tiotropium bromide (Spiriva) include glaucoma and prostatic hypertrophy. This medication is not contraindicated in with a topical steroid, physical therapy, or a low-fat diet.
The nurse instructs a patient with chronic obstructive pulmonary disease (COPD) on the huff cough technique. Which observations indicate that teaching has been effective?
Select all that apply. The patient leans forward. This is the correct answer. The patient inhales through the nose with the mouth closed. The patient coughs twice. The patient makes a huff sound when exhaling. This is the correct answer. The patient places one hand on the abdomen and the other on the chest. Rationale: For huff coughing, the patient should be instructed to inhale deeply while leaning forward and to exhale sharply with a "huff" sound, to help keep airways open while mobilizing secretions. Coughing twice is part of the controlled coughing technique. Inhaling through the nose with the mouth closed is part of the pursed-lip technique. Placing one hand on the abdomen and the other on the chest is part of the diaphragmatic breathing technique.
The nurse is caring for a patient experiencing atelectasis of the right lower lung lobe. What interventions should the nurse include in this patient's plan of care?
Select all that apply. administering antibiotics as prescribed encouraging increased oral fluids This is the correct answer. applying oxygen as prescribed coaching to deep-breathe and cough This is the correct answer. positioning on the left side This is the correct answer Rationale: Nursing care to prevent and treat atelectasis is directed toward airway clearance. The patient with atelectasis should be positioned on the unaffected side to promote gravity drainage of the affected segment. Frequent position changes, ambulation, coughing, and deep breathing should be encouraged. Unless contraindicated, fluid intake should be encouraged to help liquefy secretions. Oxygen and antibiotics are not indicated in the treatment of atelectasis.
After an assessment the nurse is concerned that a patient is experiencing cor pulmonale associated with right-heart failure. What findings led the nurse to make this clinical decision?
Select all that apply. ankle edema This is the correct answer. nasal drainage distended neck veins This is the correct answer. cyanotic nail beds This is the correct answer. ruddy cheeks This is the correct answer. Rationale: The manifestations of cor pulmonale are those of the underlying pulmonary disorder and right-sided heart failure. With right-sided heart failure, peripheral edema and distended neck veins are seen. The skin is both ruddy and cyanotic because of increased numbers of RBCs and hypoxemia. Nasal drainage is not a manifestation of cor pulmonale associated with right-heart failure.
A patient is diagnosed with subacute hypersensitivity pneumonitis. What should the nurse expect to assess in this patient?
Select all that apply. chronic cough This is the correct answer. shortness of breath This is the correct answer. loss of appetite This is the correct answer. chills and fever weight loss This is the correct answer. Rationale: The subacute syndrome of hypersensitivity pneumonitis is characterized by an insidious onset of chronic cough, progressive dyspnea, anorexia, and weight loss. Chills and fever are associated with acute hypersensitivity pneumonitis.
A chest CT scan confirms that a patient has bronchiectasis. On which problems should the nurse focus when determining the care this patient will need?
Select all that apply. inability to provide self-care This is the correct answer. ineffective breathing pattern This is the correct answer. airway clearance This is the correct answer. insufficient nutritional intake This is the correct answer. changes in fluid balance Rationale: Nursing care of the patient with bronchiectasis is similar to that for patients with other obstructive lung diseases. Airway clearance is a primary problem, as is ineffective breathing pattern. Other problems include impaired nutrition and inability to provide self-care. Fluid balance is not a potential problem for the patient with bronchiectasis.
The nurse is caring for a patient intubated for acute respiratory distress syndrome (ARDS). Which medications should the nurse expect to be prescribed for this patient?
Select all that apply. nitrous oxide This is the correct answer. surfactant This is the correct answer. cardiac glycosides anticoagulants antibiotics Rationale: Although there is no definitive drug therapy for ARDS, a number of medications may be used. Inhaled nitric oxide reduces intrapulmonary shunting and improves oxygenation by dilating blood vessels in better-ventilated areas of the lungs. Surfactant therapy may be prescribed. Surfactant reduces the surface tension within the alveoli, helps maintain open alveoli, reduces the work of breathing, improves compliance and gas exchange, and prevents atelectasis. Antibiotics, anticoagulants, and cardiac glycosides are not indicated in the treatment of ARDS.
The nurse is reviewing the results of laboratory and diagnostic tests conducted on a patient experiencing respiratory dysfunction. Which results confirm the nurse's suspicion that the patient has cystic fibrosis?
Select all that apply. patchy infiltrates on chest x-ray mediastinal shift on chest CT scan chloride concentration of sweat 85 mEq/L This is the correct answer. reduced total lung capacity from pulmonary function test This is the correct answer. oxygen saturation 82% on room air This is the correct answer. Rationale: Cl- concentration in sweat is analyzed to confirm the diagnosis of cystic fibrosis. In CF, the Cl- concentration is > 70 mEq/L. ABGs and oxygen saturation levels show hypoxemia. Pulmonary function studies reveal reduced total lung capacity. Patchy infiltrates on chest x-ray would be associated with pneumonia. Mediastinal shift on chest CT scan is consistent with a tension pneumothorax.
A patient who is intubated is having difficulty being weaned from the ventilator. What actions should the nurse take to successfully wean this patient?
Select all that apply. placing in high-Fowler's position This is the correct answer. administering a sedative before weaning limiting activities during weaning This is the correct answer. coaching on coughing during weaning weaning in the morning This is the correct answer. Rationale: Interventions to facilitate the weaning process include weaning in the morning when the patient is well-rested and alert. Weaning may be discontinued overnight to provide rest. The work of breathing increases during the weaning process and adequate rest is important. The patient should be placed in Fowler's or high-Fowler's position to facilitate lung expansion and reduce the work of breathing. Procedures and activities should be limited during weaning periods. Reducing energy expenditures and cardiac work facilitates the weaning process. The patient is intubated. Coughing will not be effective or encouraged at this time. Administering drugs that may depress respirations during the weaning process should be avoided, except as ordered at night to facilitate rest when ventilator support is provided. Sedatives or analgesics that depress respirations can impair the weaning process.
A patient is admitted with pulmonary edema. What is important for the nurse to assess first when completing the patient's history?
Select all that apply. pulmonary history This is the correct answer. pulmonary and renal history cardiac history This is the correct answer. recent drug use and past vaccination record renal and cardiac history Rationale: Attempting to determine a cause for pulmonary edema will assist the healthcare team in providing appropriate care. Cardiogenic and noncardiogenic pulmonary edemas require different approaches to treatment. The renal history will be addressed but is not a priority assessment. Recent drug use and the past vaccination record are important but not a first area to assess for the patient.
A patient being mechanically ventilated is diagnosed with barotrauma. Which assessment findings would lead the nurse to determine that the patient is experiencing subcutaneous emphysema?
Select all that apply. reduced breath sounds sudden reduction of heart sounds crackling sound upon palpation of the skin of the upper chest This is the correct answer. blood-tinged sputum swollen neck and face This is the correct answer. Rationale: Subcutaneous emphysema, or air in the subcutaneous tissue, causes tissue swelling of the chest, neck, and face. A "crackling" or air-bubble-popping sensation is felt on palpation of subcutaneous emphysema. Subcutaneous emphysema does not cause blood-tinged sputum or affect breath or heart sounds.
A patient recovering from a lung transplant will have denervation of the lung tissue. What should the nurse include when planning this patient's care?
Select all that apply. scheduling deep breathing and coughing every 2 hours This is the correct answer. positioning for chest vibration and percussion twice per shift This is the correct answer. administering mucolytics every 2 hours ensuring oxygen delivery is below 2 liters performing postural drainage twice a shift This is the correct answer. Rationale: Denervation of the transplanted lung eliminates the usual cough stimuli. Regularly scheduled coughing and deep breathing and the use of vibration, percussion, and postural drainage are important to prevent accumulation of secretions. Mucolytics and oxygen will not help with denervation of the lung tissue
A patient has a nasal endotracheal tube. For which complications should the nurse assess this patient?
Select all that apply. tracheoesophageal fistula This is the correct answer. sinusitis This is the correct answer. obstruction of the tube This is the correct answer. pressure necrosis of nares This is the correct answer. wound infection Rationale: The patient with a nasal endotracheal tube can develop a tracheoesophageal fistula and/or pressure necrosis of the nares from the pressure exerted against the tissues by the tube, as well as sinusitis if sinus drainage is blocked. The tube can be displaced or obstructed. Wound infection can occur with a tracheostomy.
During an assessment the nurse suspects that a patient has chronic bronchitis. On what assessment findings is the nurse basing this clinical decision?
Select all that apply. wheezes and rhonchi lung sounds This is the correct answer. diminished breath sounds barrel chest persistent productive cough This is the correct answer. smoking 1 ppd This is the correct answer. Rationale: Smoking, persistent and productive coughing, and the adventitious breath sounds of wheezing and rhonchi are associated with chronic bronchitis. Barrel chest and diminished breath sounds are associated with emphysema.
The nurse is caring for a patient who is receiving neuromuscular blocking agents and is mechanically ventilated. When planning care for this patient, the nurse should recall that the alarms are not bypassed or turned off for what reason?
The patient might have arrhythmias. The patient may have reduced intrapleural pressure. The patient cannot breathe. This is the correct answer. The patient will experience oxygen toxicity. Rationale: A patient on a ventilator and a neuromuscular blocker cannot breathe, as he or she is paralyzed. If the alarms are turned off or bypassed, the patient may die if there is a malfunction. The patient will not experience oxygen toxicity but may have increased intrapleural pressure, which can rupture the alveoli. The patient may experience arrhythmias, but that would occur with hypoxia.
The chest x-ray of a patient who was recently intubated shows the endotracheal tube located in the right bronchus. What does the nurse recognize related to this finding?
The tube needs to be inserted further. The tube is correctly placed. The tube needs to be withdrawn slightly. This is the correct answer. The tube is incorrectly attached to the ventilator. Rationale: The right bronchus is easy to intubate due to the anatomy of the lung. If the tube is in the right bronchus, it will need to be withdrawn slightly so that both lungs can be ventilated. The tube is not correctly placed or incorrectly attached to the ventilator and does not need to be inserted further.
The nurse is providing medications to a patient with asthma. What does the nurse recognize about the use of corticosteroid inhalers for this patient?
They should be provided after the bronchodilator. This is the correct answer. They are used to activate muscarinic receptors. They are used only for acute asthma attacks. They are used often with methylxanthines. Rationale: Corticosteroids are given after the bronchodilator, as the bronchodilator opens the airways. Corticosteroids require weeks to begin to have an effect on breathing and therefore cannot be used for acute attacks. Corticosteroids are usually not combined with methylxanthines but may be combined with adrenergic stimulants. The anticholinergics affect the muscarinic receptors.
The nurse is reviewing a patient's arterial blood gas results. Which condition should the nurse suspect is developing in this patient? Laboratory Value Patient Results PaCO2 40 mmHg pH 7.3 HCO3 18 mEq/L
chronic obstructive pulmonary disease, hypercapnia hypercapnia with respiratory acidosis hypoxemic respiratory failure, metabolic acidosis This is the correct answer. alkalytic response from sympathomimetics Rationale: Arterial blood gases are used to evaluate alveolar ventilation and gas exchange. With hypoxemic respiratory failure, the PaCO2 may be normal, 35 to 45 mmHg, or even low due to tachypnea. A pH of less than 35 and low bicarbonate levels indicate metabolic acidosis, typical of hypoxemic respiratory failure. Hypercapnia from COPD would be respiratory acidosis. Sympathomimetics do not produce alkalosis. The values do not indicate respiratory acidosis from hypercapnia, as the PaCO2 is within normal limits.
A patient diagnosed with sepsis suddenly develops dyspnea, crackles, agitation, and confusion. The nurse recognizes these are symptoms of which health problem?
constrictive pericarditis left-sided heart failure right-sided heart failure noncardiogenic pulmonary edema This is the correct answer. Rationale: Sepsis is a condition associated with acute respiratory distress syndrome (ARDS). Manifestations of ARDS include dyspnea, crackles, agitation, and confusion, which are associated with noncardiogenic pulmonary edema. Right-sided heart failure, left-sided heart failure, and constrictive pericarditis are considered cardiogenic causes for pulmonary edema.
A patient being mechanically ventilated is exhibiting hypoxia, with a pulse oximeter reading of 88%. After ensuring the integrity of the ventilator tubing and assessing the patient, the nurse auscultates adventitious lung sounds. Which action should the nurse take next?
contacting the physician suctioning the patient This is the correct answer. silencing the alarm turning the patient to one side Rationale: When the tubing integrity is intact and the pulse oximeter reading falls to 88% with adventitious breath sounds, the patient needs to be suctioned. The physician will not need to be contacted unless the nursing actions are unsuccessful at resolving the hypoxia. Turning the patient on the side has no purpose. Silencing the alarm will not resolve the issue.
A patient being mechanically ventilated requires increasing PEEP for worsening ARDS. The order for PEEP is now at 20 cm of H2O. The nurse will need to contact the physician immediately if the patient develops which finding?
diminished peripheral pulses lung sounds greater on one side than the other This is the correct answer. lung sounds with crackles high-pressure alarm Rationale: A potential complication from increasing PEEP is a pneumothorax. The nurse needs to be alert to diminishing or absent lung sounds on one side of the chest. Crackles and diminished peripheral pulses would not be related to a pneumothorax. A low-pressure alarm would be more likely to sound if the patient developed a pneumothorax
The nurse is caring for a patient who is intubated and being mechanically ventilated. Which of the physician's orders should the nurse question for this patient?
endotracheal suctioning every hour This is the correct answer. endotracheal suctioning as needed intake and output every 4 hours NPO status while patient is ventilated Rationale: Suctioning should always be based on patient need and not routinely ordered. The patient will be NPO, and intake and output will be measured every 4 hours.
A patient being mechanically ventilated suddenly develops cardiac dysrhythmias from increasingly higher PEEP. What underlying issue should the nurse suspect in this patient?
increased cardiac output and electrolyte disturbance decreased cardiac output and renal failure decreased cardiac output and acidosis This is the correct answer. increased cardiac output and alkalosis Rationale: Increasingly higher PEEP with decreased cardiac output and acidosis may predispose the patient to cardiac arrhythmias. Increased cardiac output does not occur with PEEP. Renal failure and electrolyte disturbances are not the likely causes for the cardiac dysrhythmias.
A patient being mechanically ventilated has the following ventilator settings: SIMV 16, PEEP 20 cm of H2O, FiO2 45%, tidal volume .450 liters. What concern should the nurse have for this patient?
oxygen toxicity barotrauma This is the correct answer. volutrauma sinusitis Rationale: This patient is at risk for barotrauma due to the high PEEP levels. The tidal volume is within a standard setting. Sinusitis is a potential complication of ventilated patients, but this patient should not have a higher risk for this. The oxygen setting at 45% will not cause oxygen toxicity in this patient.
A patient with dyspnea and chest pain has the following diagnostic study results. The nurse suspects the patient has which condition?
pulmonary embolism and respiratory alkalosis This is the correct answer. chronic obstructive pulmonary disease with respiratory acidosis coronary artery disease and metabolic acidosis acute asthma attack with metabolic alkalosis Rationale: An elevated plasma D-dimer result indicates pulmonary embolism. Arterial blood gases usually show hypoxemia (PO2 < 80 mmHg) and often respiratory alkalosis (pH > 45, PaCO2 < 38 mmHg) due to tachypnea and hyperventilation. The patient does not have metabolic acidosis; the elevated pH indicates alkalosis. The patient does not have respiratory acidosis. An acute asthma attack would produce respiratory alkalosis.
A patient who is intubated is exhibiting rhonchi and has a pulse oximeter of 92%, soft abdomen, heart rate of 88 bpm, and blood pressure of 98/54 mmHg. Which would be the nurse's first priority?
suction the patient This is the correct answer. increase the oxygen start dopamine contact the physician Rationale: The presence of rhonchi suggests the patient needs to be suctioned. The other assessment data do not require contacting the physician or increasing the oxygen. The relative hypotension can be caused by the ventilation and does not require dopamine for blood pressure support.
A patient is admitted to the hospital with weight loss, fatigue, and an enlarged liver, and several diagnostic tests are performed. After reviewing the patient's chart, the nurse educates the patient about the health problem. Which patient statement indicates that further teaching is required?
"It sounds like my risk of dying from this is really high." This is the correct answer. "I should take my steroids with a meal." "This disease could just disappear all by itself." "Okay, I am finally going to stop smoking." Rationale: This patient has developed sarcoidosis. Sarcoidosis has a low mortality rate but a relatively high rate of serious disability. It often resolves spontaneously, so treatment is indicated only when symptoms are severe or disabling. Patients should avoid respiratory irritants and stop smoking. The patient should take corticosteroids with food or milk to minimize gastric irritation.
The family of a mechanically ventilated patient receiving a chest tube asks why the tube is necessary. How should the nurse respond?
"The chest tube helps to decompress the lung and prevents further complications." This is the correct answer. "The chest tube is an elective procedure that many physicians like to perform." "Placement of the chest tube requires surgery." "The chest tube helps the patient breathe more easily when on a ventilator." Rationale: The chest tube is indicated for a pneumothorax that can be spontaneous or brought on by increasingly higher PEEP. The insertion of a chest tube is not an elective procedure and is most often performed at the bedside, not in surgery. A chest tube does not directly assist a patient with breathing more easily on a ventilator, but it does allow the lung to expand more fully, which helps with the patient's overall oxygenation.
A patient being mechanically ventilated develops hypotension after the respiratory therapist implements the most recent physician orders. The nurse suspects that which ventilator mode might be the cause?
pressure-control mode assist-control mode SIMV mode PEEP This is the correct answer. Rationale: When PEEP is applied, intrathoracic pressure increases further; this can significantly decrease venous return, ventricular filling, stroke volume, and cardiac output. Manifestations of decreased cardiac output include hypotension. Increasing PEEP levels can cause declining blood pressure. Hypotension is not commonly caused by the adjustment of other modes on the ventilator.