Nclex 10000 respiratory
A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma?
Have an anti-inflammatory effect Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.
Which technique for administering the tuberculin skin test is correct?
Hold the needle and syringe almost parallel to the client's skin Explanation: The Mantoux test is administered via intradermal injection. The appropriate technique for an intradermal injection includes holding the needle and syringe almost parallel to the client's skin, keeping the skin slightly taut when the needle is inserted, and inserting the needle with the bevel side up. There is no need to aspirate, a technique that assesses for incorrect placement in a blood vessel, when giving an intradermal injection. The injection site is not massaged
A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine?
It's a centrally-acting antitussive and can cause dependence. Explanation: As a centrally-acting antitussive, codeine suppresses the cough reflex by directly affecting the sensitivity of the cough center in the medulla to incoming stimuli. Because codeine is an opioid, it can cause dependence.
Which nursing action would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?
Teach the client to splint the rib cage when coughing. Explanation: The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain
A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which of the following results are consistent with this disorder?
pH 7.28, PaO2 50 mm Hg Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35
A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that he should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is:
1.4 L. Explanation: Clients need to keep their secretions thin by drinking 2 to 3 L of clear liquids per day. In clients with heart failure, fluid intake shouldn't exceed 1.5 L daily.
A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?
Airborne and contact precautions Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles
A client is being discharged with a home oxygen delivery device. Which comments indicate that the client understands safety regarding home oxygen? Select all that apply.
"No one can smoke within 10 feet (3 meters) of the oxygen." • "I need to keep my oxygen away from electrical sources." • "I should keep my oxygen away from direct heat." he client demonstrates understanding about the safe use of oxygen therapy at home when he states that no one should smoke within 10 feet of oxygen and that he should keep the oxygen away from electrical sources and direct heat and sunlight. It isn't safe to place oxygen in a bag; the tank should have adequate airflow around the concentrator. It's best not to place the oxygen tank in direct sunlight, but it isn't necessary to keep it out of the sun at all times
A client with bacterial pneumonia is coughing up tenacious, purulent sputum. Which action would help liquefy these viscous secretions?
Breathe humidified air. Explanation: Humidified air helps to liquefy respiratory secretions, making them easier to raise and expectorate. Postural drainage may be helpful for respiratory hygiene but will not affect the nature of secretions. Vibration and percussion of the chest wall may be helpful for respiratory hygiene but will not affect the nature of secretions. Coughing and deep-breathing exercises may be helpful for respiratory hygiene but will not affect the nature of secretions.
Which performance improvement strategy helps prevent adverse reactions to blood products?
Confirming client identification with two qualified health professionals Explanation: The client must be correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs, instructing the client about the signs and symptoms of a blood reaction, and priming the blood administration tubing with normal saline solution are key steps in the blood administration procedure; however, they don't prevent adverse reactions.
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?
Monitor vital signs and oxygen saturation every 15 to 30 minutes. Explanation: Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in his respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don't take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if he does, the nurse can't predict the length of time it may be necessary.
What is the rationale that supports multidrug treatment for clients with tuberculosis?
Multiple drugs reduce development of resistant strains of the bacteria. Explanation: Use of a combination of antituberculosis drugs slows the rate at which organisms develop drug resistance. Combination therapy also appears to be more effective than single-drug therapy. Many drugs potentiate (or inhibit) the actions of other drugs; however, this is not the rationale for using multiple drugs to treat tuberculosis. Treatment with multiple drugs does not reduce adverse effects and may expose the client to more adverse effects. Combination therapy may allow some medications (e.g., antihypertensives) to be given in reduced dosages; however, reduced dosages are not prescribed for antibiotics and antituberculosis drugs.
As status asthmaticus worsens, the nurse would expect which acid-base imbalance?
Respiratory acidosis Explanation: As staticus asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.
The nurse teaches the client how to instill nose drops. Which technique is correct?
The client blows the nose gently before instilling drops. Explanation: The client should blow the nose before instilling nose drops. Instilling nose drops is a clean technique. The dropper should be cleaned after each administration, but it does not need to be changed. The client should assume a position that will allow the medication to reach the desired area; this is usually a supine position.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak. Explanation: Constant bubbling in the water-seal chamber indicates a system air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber
Two days after placement of a pleural chest tube, the tube is accidentally pulled out of the chest wall. The nurse should first:
apply an occlusive dressing such as petroleum jelly gauze. Explanation: If the chest tube is accidentally pulled out (a rare occurrence), a petroleum jelly gauze and sterile 4×4 inch dressing should be applied over the chest wall insertion site immediately. The dressing should be covered with adhesive tape and be occlusive, and the surgeon should be notified. The lungs can be auscultated and vital signs can be taken after the dressing is in place and the surgeon has been called. Placing the tube in sterile water will not reestablish a seal to prevent air entering the insertion site of the chest tube.
For a client with a sucking stab wound in the chest wall, the nurse should first:
cover the wound with a petroleum-impregnated dressing. Explanation: The first course of action for a client with a sucking chest wound is to stop air from entering the chest cavity. Air entry will cause the lung to collapse. Stopping air entry is best done in an emergency situation by applying an air-occlusive dressing over the wound. The nurse can next notify the health care provider. Starting oxygen therapy and preparing for endotracheal intubation may be necessary later, but neither has the same priority on admission as closing the wound.
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:
encourage coughing and deep breathing. Explanation: When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first?
impaired gas exchange Explanation: Emboli obstruct blood flow, leading to a decreased perfusion of the lung tissue. Because of the decreased perfusion, a ventilation-perfusion mismatch occurs, causing hypoxemia to develop. Arterial blood gas analysis typically will indicate hypoxemia and hypocapnia. A priority objective in the treatment of pulmonary emboli is maintaining adequate oxygenation. A productive cough and activity intolerance do not indicate impaired gas exchange. The client does not demonstrate an ineffective breathing pattern; rather, the problem of impaired gas exchange is caused by the inability of blood to flow through the lung tissue
The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis?
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance
A client with tuberculosis is taking Isoniazid (INH). To help prevent development of peripheral neuropathies, the nurse should instruct the client to:
supplement the diet with pyridoxine (vitamin B6). Explanation: INH competes for the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed. Following a low-cholesterol diet, getting extra rest, and avoiding excessive sun exposure will not prevent the development of peripheral neuropathies.
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when the client:
uses the sternocleidomastoid muscles. Explanation: Use of accessory muscles indicates worsening breathing conditions. Asking for an additional pillow, having a 91% pulse oximetry reading, and requesting the nurse to raise the head of the bed are not indications of a worsening condition.
A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 ml/hour. How long will this transfusion take to infuse?
4 hours Explanation: One unit of packed red blood cells is about 250 mL. If the blood is delivered at a rate of 60 mL/h, it will take about 4 hours to infuse the entire unit. The transfusion of a single unit of packed red blood cells should not exceed 4 hours to prevent the growth of bacteria and minimize the risk of septicemia
A home health nurse sees a client with end-stage chronic obstructive pulmonary disease (COPD). An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met?
Decreased oxygen requirements Explanation: A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements. Elevated white blood cell count may be indicative of infection.
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing Explanation: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.
A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)?
arterial oxygen level of 46 mm Hg (6.1 kPa) Explanation: Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg (6.1 kPa) to the HCP. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.
A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim:
cannot speak due to airway obstruction. Explanation: The Heimlich maneuver should be administered only to a victim who cannot make any sounds due to airway obstruction. If the victim can whisper words or cough, some air exchange is occurring and the emergency medical system should be called instead of attempting the Heimlich maneuver. Cyanosis may accompany or follow choking; however, the Heimlich maneuver should only be initiated when the victim cannot speak.
What type of diet should the nurse teach the parents to give an older infant with cystic fibrosis (CF)?
high-calorie diet Explanation: CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high-calorie, high-protein, high-carbohydrate, moderate-fat diet is indicated
A physician orders albuterol for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause:
nervousness. Explanation: Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Other adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting, and muscle cramps.
A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply.
• Assess for hemoptysis and frank bleeding. • Monitor the client's vital signs. • Withhold food and fluids until the client's gag reflex returns. Explanation: To prevent aspiration, the client should not receive food or fluids until the gag reflex returns. Although a small amount of blood in the sputum is expected if a biopsy was performed, frank bleeding indicates hemorrhage and should be reported to the physician immediately. Vital signs should be monitored after the procedure, because a vasovagal response may cause bradycardia, laryngospasm can affect respirations, and fever may develop within 24 hours of the procedure. To reduce the risk of aspiration, the client should be placed in a semi-Fowler's or side-lying position after the procedure until the gag reflex returns. The client does not lose the voice after a bronchoscopy, so voice should not be used as a gauge for resuming food and fluid intake.
A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?
Anxiety Correct Explanation: In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis. This client may have inadequate nutrition, making Imbalanced nutrition: More than body requirements an unlikely nursing diagnosis. Impaired swallowing may occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder. Unilateral neglect may be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.
A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease?
Azithromycin Explanation: Azithromycin is the drug of choice for treating legionnaires' disease. Rifampin is used to treat tuberculosis. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterial infection.
A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following?
Continuous bubbling in the water-seal chamber. Explanation: Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid in the water-seal chamber.
A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client?
Ineffective breathing pattern related to tissue trauma Correct Explanation: Although all of these nursing diagnoses are appropriate for this client, ineffective breathing pattern takes priority. According to Maslow's hierarchy of needs, air is essential to maintain life and is assigned the highest priority, along with the other physiologic needs, such as food, elimination, temperature control, sex, movement, rest, and comfort.
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
Extreme anxiety Explanation: Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
Impaired gas exchange Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange
A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn't want to be placed on a ventilator. What action should the nurse take?
Notify the physician immediately so he can determine client competency. Explanation: Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so he can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about his care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order.
A client is using an over-the-counter nasal spray containing pseudoephedrine to treat allergic rhinitis. Which instruction about this medication would be most appropriate for the nurse to provide for the client?
Overuse of pseudoephedrine can lead to increased nasal congestion. Explanation: Overuse of nasal spray containing pseudoephedrine can lead to rhinitis medicamentosa, which is a rebound effect causing increased swelling and congestion. Use of pseudoephedrine nasal spray does not cause infections or thrush. Pseudoephedrine is not addictive
The nurse is aware that frequent repositioning in bed will assist in the prevention of which of the following for a client?
Pneumonia Explanation: By frequently changing positions in bed, the client can prevent the development of pneumonia, urinary stasis, and deep vein thrombosis. These movements promote blood, oxygen, and fluid circulation throughout the body systems and prevent stasis. Postural hypotension can often be associated with medications and no information is given about this in the question. Arterial thrombosis is incorrect because decreased movement would more likely result in a venous thrombosis.
A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?
Runs of ventricular tachycardia Explanation: Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.
The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. The nurse should instruct the client that:
aspirin-containing medications should not be taken for 2 weeks before surgery. Explanation: Aspirin-containing medications should be discontinued for 2 weeks before surgery to decrease the risk of bleeding. Nasal packing is usually removed the day after surgery. Normal saline nose drops are not routinely administered preoperatively. The results of the surgery will not be obvious immediately after surgery because of edema and ecchymosis.
A client has a newly placed tracheostomy tube. The nurse should assess the client for which possible complication?
damage to the laryngeal nerve Explanation: Tracheostomy tubes are associated with several potential complications, including laryngeal nerve damage, bleeding, and infection. Tracheostomy tubes do not cause decreased cardiac output, pneumothorax, or acute respiratory distress syndrome
In which areas of the United States and Canada is the incidence of tuberculosis highest?
inner-city areas Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease. Farming areas have a low incidence of tuberculosis. Variations in water standards and industrial pollution are not correlated to tuberculosis incidence
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant Staphylococcus aureus (MRSA) (see figure). The nurse should
proceed to suction the client's tracheostomy. Explanation: The nurse is wearing protective personnel equipment appropriate for suctioning the client: goggles, gown, and respirator mask. It is not necessary to wear a PAPR face shield to suction a tracheostomy. A surgical mask does not provide maximum protection
Following a thoracotomy, the client has pain of 9 on a 10-point scale. Thirty minutes after administering the highest dose of the prescribed pain medication, the nurse should:
reassess the client. Explanation: It is essential that the nurse evaluate the effects of pain medication after the medication has had time to act; reassessment is necessary to determine the effectiveness of the pain management plan. Although it is prudent to check for discomfort related to positioning when assessing the client's pain, repositioning the client immediately after administering pain medication is not necessary. Verbally reassuring the client after administering pain medication may be useful to help instill confidence in the treatment plan; however, it is not as important as evaluating the effectiveness of the medication. Readjusting the pain medication dosage as needed according to the client's condition is essential, but the effectiveness of the medication must be evaluated first
The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority?
teaching the client about the disease and its treatment Explanation: Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. Offering the client emotional support, coordinating various agency services, and assessing the environment may be part of the care for the client with tuberculosis; however, these interventions are of less importance than education about the disease process and its treatment
A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client?
Impaired gas exchange Explanation: Impaired gas exchange requires collaboration between the nurse, physician, and respiratory therapist to help achieve the best respiratory outcome for the client. Medications, oxygen, nebulizer treatments, and arterial blood gas analyses all require a physician's order. The respiratory therapist administers the oxygen and nebulizer treatments. The nurse assesses the client's response to medications and respiratory treatments and provides feedback to the physician and respiratory therapist. Impaired skin integrity, Activity intolerance, and Imbalanced nutrition: Less than body requirements (when applied to the client with COPD) require independent nursing interventions without collaboration with other health team members. These interventions include skin care, pacing nursing care to promote rest and minimize fatigue, and providing small, frequent meals
A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report which adverse effect?
irregular heartbeat Explanation: Irregular heartbeats should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.
A client had a Mantoux test result of an 8-mm induration. The test is considered positive when the client:
is immunocompromised. Explanation: An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive, and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (e.g., prisons, long-term care facilities, hospitals, homeless shelters), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categories.
When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects:
while exhaling through pursed lips. Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias.
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds Explanation: For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.
The nurse has assisted the health care provider (HCP) at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should:
assess breath sounds. Explanation: The nurse should first assess for bilateral breath sounds since a complication of central line insertion is a pneumothorax, which would cause an increase in respiratory rate and drop in oxygen, causing irritability. The nurse should also assess blood pressure and heart rate for the complication of bleeding. A chest x-ray will be performed to determine correct placement and complications. A central line was most likely placed because peripheral IV access was not available or adequate for the client. Repositioning may be considered after assessments are done.
The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
• Apply antiembolic stockings. • Keep the client oriented. • Obtain vital signs. Explanation: It is appropriate for the nurse to delegate obtaining vital signs and applying antiembolic stockings to the UAP. The UAP can also help keep the client oriented to time, person, and place by talking with the client. The registered nurse is responsible for evaluating the quality and character of the client's vital signs, but the assistant may take the vital signs and report readings to the nurse. It is the registered nurse's responsibility to assess the client's need for oxygen therapy and apply as needed in accordance with the health care provider's prescriptions. It is also the registered nurse's responsibility to perform the nursing history and assess the client's breath sounds
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?
"Before you do the exercise, I'll give you pain medication if you need it." Explanation: The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.
A client on mechanical ventilation becomes very frustrated when he/she tries to communicate. Which intervention should the nurse perform to assist the client?
Ask the client to write or spell words with an alphabet board. Explanation: If the client uses an alternative method of communication, such as writing, using a picture board, or spelling words on an alphabet board, he'll feel more in control and be less frustrated. Assuring the client that everything will be all right offers false reassurance, and telling him not to be upset minimizes the client's feelings. Neither of these methods helps the client to communicate. Family members are also likely to encounter difficulty interpreting the wishes of a client with an endotracheal tube or tracheostomy tube. Making them responsible for interpreting the client's gestures may frustrate them. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met
A physician orders prednisone to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:
acute adrenocortical insufficiency. Explanation: Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.
In preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment. Which statement by the mother indicates successful teaching?
"I need to wash my hands more often." Explanation: Handwashing is the best way to prevent respiratory illnesses and the spread of disease. Bronchiolitis, a viral infection primarily affecting the bronchioles, causes swelling and mucus accumulation of the lumina and subsequent hyperinflation of the lung with air trapping. It is transmitted primarily by direct contact with respiratory secretions as a result of eye-to-hand or nose-to-hand contact or from contaminated fomites. Therefore, handwashing minimizes the risk for transmission. Taking the child's temperature is not appropriate in most cases. As long as the child is getting better, taking the temperature will not be helpful. The mother's statement that she hopes she does not get a cold from her child does not indicate understanding of what to do after discharge. For most parents, listening to the child's chest would not be helpful because the parents would not know what they were listening for. Rather, watching for an increased respiratory rate, fever, or evidence of poor eating or drinking would be more helpful in alerting the parent to potential illness.
When evaluating the effectiveness of airway suctioning, the nurse should use which criterion?
breath sounds clear on auscultation Explanation: Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning. Auscultation should also be done to determine whether or not the client needs suctioning. Assessing for labored respirations is not as accurate in evaluating the effectiveness of tracheobronchial suctioning. A client may have labored breathing that is not affected by the presence or absence of tracheobronchial secretions. Percussion of the chest is useful for detecting masses or dense consolidation of lung tissue. It is not an accurate method for assessing the effectiveness of suctioning. Suctioning clears mucus but does not decrease its production.
