Respiratory Spring

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

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

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

ANS: A Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

A nurse admits a client from the emergency department. Client data are listed below: History: 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Physical Assessment: Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only Laboratory Values: WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters 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.

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

A client in the emergency department has several broken ribs. What care measure will best promote comfort? a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets

ANS: A Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures.

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

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

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer prescribed intravenous pain medications. c. Explain that soreness is normal and will improve in a couple days. d. Assess the client's neck for redness and swelling

ANS: A Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can provide relief from a sore throat after radiation therapy. Intravenous pain medications may be used if local anesthetics are unsuccessful. The nurse should explain to the client that this is normal and assess the client's neck, but these options do not decrease the client's discomfort.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other manifestations 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.

ANS: A 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 should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

A student is practicing suctioning a tracheostomy in the skills laboratory. 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

ANS: A Suction should only be applied while withdrawing the catheter. The other actions are appropriate.

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.

ANS: A 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 and confusion 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.

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

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

An unlicensed assistive personnel (UAP) 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 takes priority? a. Assess the client's lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.

ANS: A The priority is to check the client's oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can 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 client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority? 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.

ANS: A This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should 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 hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

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

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

ANS: A, B, D, E 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 should be assessed. Hydration is not directly related to the ability to perform self-care.

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

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

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 anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

ANS: A, B, C, D The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

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 unlicensed assistive personnel (UAP). 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.

ANS: A, B, C, E 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.

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

ANS: A, B, D 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.

A nurse is caring for a client 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 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.

ANS: A, B, D, E 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 is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated 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 at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

ANS: A, C, D, E Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). The client with a fractured femur is at risk for a pulmonary embolism.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the client's lips b. Ensuring 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

ANS: A, D The UAP 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 the humidity is adequate and suctioning through the tracheostomy are nursing functions.

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.

ANS: A, D, E The client with a tracheostomy may be shy and hesitant to go out in public. The client should 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.

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

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

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.

ANS: B 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 should 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 student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the client's platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol

ANS: B Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.

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 should 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 (Coumadin).

ANS: B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate 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 nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring 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

ANS: B 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 should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

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

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

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique.

ANS: B 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 should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options.

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should 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."

ANS: B Many clients experience changes in taste after surgery. The nurse should identify foods that the client wants to eat to ensure the client maintains necessary nutrition. Although the nurse should collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the client's concerns.

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals 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.

ANS: B Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have 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 nurse should 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 client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.

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

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client'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."

ANS: B Priority teaching related to the use of a room humidifier focuses on infection control. Clients should be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil should not be added to a humidifier. The humidifier should be refilled with water as needed and should be used while awake and asleep.

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 informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

ANS: B 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 client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired 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.

ANS: B 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 Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

ANS: B The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. 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.

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

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

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 Feels frightened "Can't catch my breath" Laboratory Analysis: pH: 7.12 PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88% Physical Assessment: Pulse: 120 bpm 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.

ANS: B This client has manifestations 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 should 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 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 b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3

ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery

ANS: B Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chef's salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips

ANS: B Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chef's salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medication's mechanism of action.

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

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

A nurse 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-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

ANS: B, D, E 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 registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

ANS: B, E The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days ago and the client who is awaiting gastric tube placement are stable. The client who is 6 hours post-surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching; teaching cannot be delegated.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks 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."

ANS: C 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. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

A nurse cares for a client who is infected with Burkholderia cepacia. Which action should 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 isolated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.

ANS: C Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for these clients to be separated from one another. Strict isolation measures will not be necessary. Although the client should 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 Burkholderia cepacia infection.

A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this client's teaching? a. "Take an antibiotic each day." b. "Contact your provider to obtain genetic screening." c. "Eat a well-balanced, nutritious diet." d. "Plan to exercise for 30 minutes every day."

ANS: C 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 would not help the client manage CF better.

A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How should 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."

ANS: C Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.

ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

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.

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

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

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

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

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? 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.

ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should 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.

ANS: C The client will not be able to speak after surgery. The nurse should assist the client to choose a communication method that he or she would like to use after surgery. Assessing the client's airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this client's gait should not be impacted by a total laryngectomy and therefore is not a priority.

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? 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

ANS: C To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the client's neck, not in back. The other actions are appropriate.

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 all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube.

ANS: C 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 assess the patency of the tube and connections and perform suction.

When working with women who are taking hormonal birth control, what health promotion measures should 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.

ANS: C, D, E 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.

A nurse cares for a client who has a pleural chest tube. Which action should 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 at the level prescribed by the provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

ANS: D Padded clamps should be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse should never strip the tubing. Tubing junctions should be taped, not clamped. Wall suction should be set at the level indicated by the device's manufacturer, not the provider.

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

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

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should 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.

ANS: D A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should 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 client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

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

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

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

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. When the insertion site becomes red and warm to the touch b. When the tube drainage decreases and becomes sanguineous c. When the client experiences pain at the insertion site d. When the tube becomes disconnected from the drainage system

ANS: D Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the client's risk for a pneumothorax. Tube drainage should decrease and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the client's risk for a pneumothorax.

A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor 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."

ANS: D 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 nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? 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.

ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should 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 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 by the nurse is the priority? 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.

ANS: D This client has manifestations 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 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 provider immediately.

ANS: D This client may have a trachea-innominate 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 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.