Respitory disorders

The nurse is teaching the client about deep-breathing techniques. Which statement from the client indicates the need for additional education? 1. "I should place my hands lightly over my lower ribs and upper abdomen." 2. "I will use my incentive spirometer every hour while I am awake." 3. "I should get into a comfortable position before doing my breathing exercises." 4. "I should take four deep breaths and then cough deeply from the lungs."

Correct response: "I should get into a comfortable position before doing my breathing exercises." Explanation: The client should sit in an upright position when doing breathing exercises to allow for full chest expansion of both lungs and all fields and bases. Using an incentive spirometer every hour while awake is appropriate and allows the client visual feedback. Placing his hands lightly over the lower ribs and upper abdomen allows the client to see muscles of inspiration and expiration and is appropriate. Coughing deeply from the lungs after four deep breaths allows the client to effectively cough up secretions.

A client with emphysema is at a greater risk for developing what acid-base imbalance? 1. metabolic alkalosis 2. chronic respiratory acidosis 3. chronic metabolic acidosis 4. respiratory alkalosis

Correct response: chronic respiratory acidosis Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.

A client diagnosed with tuberculosis is taking the prescribed chemotherapy of isoniazid, rifampin, and pyrazinamide. Although side effects are rare, the nurse should assess the client for which side effect of this drug combination? 1. hepatotoxicity 2. optic neuritis 3. ototoxicity 4. nephrotoxicity

Correct response: hepatotoxicity Explanation: The major side effect of these three drugs is liver toxicity. While the client is taking these drugs, the nurse should carefully monitor the client's liver function tests.Ototoxicity and nephrotoxicity are side effects of other drugs used to treat TB, such as streptomycin, kanamycin, and capreomycin.Optic neuritis can be a rare side effect of isoniazid.

For a client with chronic obstructive pulmonary disease who has trouble raising respiratory secretions, which intervention would help reduce the tenacity of secretions? 1. Help the client maintain an adequate fluid intake. 2. Keep the client in a semi-sitting position as much as possible. 3. Ensure that the client's oxygen therapy is continuous. 4. Take a diet history to determine if the client's diet is low in salt.

Correct response: Help the client maintain an adequate fluid intake. Explanation: A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions.A low-salt diet, continuous oxygen therapy, and maintaining a semi-sitting position do not help reduce the viscosity of mucus.

A competent client requiring long-term mechanical ventilation privately tells a nurse that they want the ventilator withdrawn. Which response by the nurse is best? 1. "Tell me more about how you are feeling." 2. "I'll let your healthcare provider know your feelings." 3. "How does your family feel about this?" 4. "Now that I'm here, tell me all about it."

Correct response: "Tell me more about how you are feeling." Explanation: Asking the client how they are feeling uses an open-ended question that encourages the client to express their feelings. Asking the client to consider their family is judgmental and is an inappropriate statement. Ventilation can be withdrawn according to the client's wishes. The nurse stating, "Now that I'm here" is unprofessional and would be inappropriate. Contacting the healthcare provider would be premature as the nurse needs more information.

A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for: 1. Vertigo. 2. Difficulty swallowing. 3. Impaired vision. 4. Facial paralysis.

Correct response: Vertigo. Explanation: The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve (ototoxicity). Symptoms of ototoxicity include vertigo, tinnitus, hearing loss, and ataxia. Facial paralysis would result from damage to the facial nerve (VII). Impaired vision would result from damage to the optic (II), oculomotor (III), or the trochlear (IV) nerves. Difficulty swallowing would result from damage to the glossopharyngeal (IX) or the vagus (X) nerve.

A health care provider (HCP) has just inserted nasal packing for a client with epistaxis. The client is taking ramipril for hypertension. What should the nurse instruct the client to do? 1. Omit the next dose of ramipril. 2. Remove the packing if there is difficulty swallowing. 3. Use 81 mg of aspirin daily for relief of discomfort. 4. Avoid rigorous aerobic exercise.

Correct response: Avoid rigorous aerobic exercise. Explanation: Epistaxis, or nosebleed, is a common, sudden emergency. Commonly, no apparent explanation for the bleeding is known. With significant blood loss, systemic symptoms, such as vertigo, increased pulse, shortness of breath, decreased blood pressure, and pallor, will occur. Because aerobic exercise may increase blood pressure and increased blood pressure can cause epistaxis, the client with hypertension should avoid it. Aspirin inhibits platelet aggregation, reducing the ability of the blood to clot. The client should continue to take his antihypertension medication, ramipril. Posterior nasal packing should be left in place for 1 to 3 days.

The nurse is developing a care plan for a client with tuberculosis. Which measures would be implemented for staff prior to entering the room? 1. Wear a mask at all times when entering the room. 2. Wear a mask, gown, and gloves when providing care. 3. Prevent visitors from visiting to reduce the possibility of transmission. 4. Wear a gown and gloves when in contact with the client.

Correct response: Wear a mask at all times when entering the room. Explanation: A special mask that prevents the passage of airborne droplets is needed to intercept airborne droplet transmission. This choice represents the use of transmission-based precautions specifically to prevent the spread of tuberculosis. Gowns and gloves are not required; visitors are welcomed providing they wear a mask during their visit to protect themselves.

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; Pco2 48 mm Hg (6.4 kPa); Po2 58 mm Hg (7.7 kPa); HCO3 26 mEq/L (26 mmol/L). Which prescription should the nurse implement first? 1. chest X-ray 2. sputum culture 3. ipratropium inhaler 4. albuterol nebulizer

Correct response: albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest X-ray and sputum sample can be obtained once the client is stable.

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? 1. decreased activity tolerance 2. increased white blood cell count 3. increased sputum production 4. decreased oxygen requirements

Correct response: 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.

The nursing student is explaining sputum for cytology procedure to a client. Which statements require the nurse to intervene? Select all that apply. 1. "You will need to cough and deep breathe to try and mobilize your sputum." 2. "If you cannot expectorate sputum, we can suction it easily." 3. "If you just put saliva in the container it will be fine." 4. "You can try to expectorate the sputum after dinner tonight." 5. "Just cough into the tissue, then transfer the specimen to this container."

Correct response: "If you cannot expectorate sputum, we can suction it easily." "You can try to expectorate the sputum after dinner tonight." "If you just put saliva in the container it will be fine." "Just cough into the tissue, then transfer the specimen to this container." Explanation: Instruct the client to rinse the mouth with water to reduce specimen contamination, take three slow, deep breaths and then to cough deeply from a maximal inspiration. Have the client repeat the procedure as necessary until the client has produced sputum. When the client has mobilized the sputum, instruct the client to expectorate directly into a sterile specimen container without touching the inside or rim of the container. Have the client continue producing and expectorating sputum until the amount totals at least 5 mL, if possible. Assess the sputum specimen to ensure that it's actually sputum and not saliva because saliva produces inaccurate test results. Sputum appears thick and opaque, while saliva appears thin, clear, and watery. When a client can't produce an adequate sputum specimen, additional treatments may need to be performed to help mobilize secretions. These treatments include nebulizer use, hydration, deep-breathing exercises, chest percussion, and postural drainage.

A nurse is completing discharge instructions for a client who has severe chronic obstructive pulmonary disease. Which information on activity tolerance should the nurse include in the plan of care? Select all that apply. 1. "Walk 15 to 20 minutes daily at least 3 times a week." 2. "Limit exercise to activities of daily living." 3. "Sit down if you can when you are cooking, eating, dressing, and bathing." 4. "Eat six small meals each day." 5. "Walk until it is a little hard to breathe."

Correct response: "Walk until it is a little hard to breathe." "Eat six small meals each day." "Walk 15 to 20 minutes daily at least 3 times a week." "Sit down if you can when you are cooking, eating, dressing, and bathing." Explanation: Encourage the client to walk 15-20 minutes a day at least three times a week with gradual increases to build up strength. Clients should be instructed to walk until it is a little hard to breathe. Eat smaller meals more often, such as six small meals a day, to make it easier to breathe when the abdomen is not full. Conserve energy by sitting down while cooking, eating, dressing, and bathing.

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: 1. 15 to 60 seconds. 2. 1 to 2.5 minutes. 3. 5 to 20 minutes. 4. 30 to 40 minutes.

Correct response: 5 to 20 minutes. Explanation: Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 seconds to 2.5 minutes wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

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? 1. Unilateral neglect 2. Anxiety 3. Impaired swallowing 4. Imbalanced nutrition: More than body requirements

Correct response: Anxiety 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 homeless client comes to the clinic coughing up blood and is diagnosed with active tuberculosis (TB). Which interventions by the nurse will be most effective in ensuring adherence with the pharmacological treatment regimen? 1. Arrange for the client to come to a community center each day to receive a meal and medication. 2. Arrange for the client to pick up the medication in unit dose packaging at a local pharmacy. 3. Provide the client with written instructions about the importance of adherence to the treatment plan. 4. Recommend having the client admitted to the hospital until the medication regimen is completed.

Correct response: Arrange for the client to come to a community center each day to receive a meal and medication. Explanation: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for tuberculosis. Providing the client with a daily meal will help ensure the client will come to receive the medication. The client should be provided with a mask to wear to the community center to prevent transmission of TB to others. It is not cost-effective to keep the client hospitalized; the TB medication regimen may last one or more years. A homeless client probably will not have the financial resources to pick up the medication at a pharmacy, so a prescription and/or written instructions will not be an effective way to ensure adherence.

A firefighter is admitted with superficial skin wounds and a sprained back following an intense fire. No respiratory concerns are verbalized. Nearly 24 hours after admission, the firefighter reports dyspnea, a harsh cough, and hoarseness. Which nursing interventions would the nurse add to the plan of care? Select all that apply. 1. Assess for increased pulse rate. 2. Monitor for fever. 3. Prepare the chest for chest tube insertion. 4. Monitor for increased anxiety levels. 5. Auscultate the lungs for adventitious breath sounds.

Correct response: Auscultate the lungs for adventitious breath sounds. Assess for increased pulse rate. Monitor for increased anxiety levels. Explanation: More than half of all clients with pulmonary involvement following inhalation injury do not immediately demonstrate pulmonary signs. Any client with possible inhalation injury must be observed for at least 24 hours for possible respiratory complications. Maintaining increased oxygen saturation levels is essential, especially following a carbon monoxide inhalation injury, to prevent the development of carboxyhemoglobin, which competes with oxygen for available hemoglobin. The client does not typically develop a fever with inhalation injury, but may progress to acute respiratory syndrome with bilateral lung infiltrates, cardiac involvement with tachycardia, and increasing anxiety due to oxygen starvation. A chest tube is not indicated.

A client with newly diagnosed chronic obstructive disease is to be discharged home with oxygen per nasal prongs. Which teaching points should the nurse include in this client's discharge plan? Select all that apply. 1. Apply petroleum jelly on lips and nose to prevent dryness and irritation. 2. Avoid areas where people are smoking cigarettes or cigars. 3. Request a large, pressurized oxygen tank for use during car travel. 4. Avoid use of a microwave oven when using oxygen. 5. Increase oxygen flow at night during hours of sleep. 6. Place gauze between the ears and oxygen tubing to prevent skin irritation.

Correct response: Avoid areas where people are smoking cigarettes or cigars. Place gauze between the ears and oxygen tubing to prevent skin irritation. Explanation: Close proximity to smoking, fire, and small electrical appliances can be a fire hazard and should be avoided. The use of gauze is helpful in preventing skin irritation from the constant pressure and friction of the oxygen tubing. Typically, oxygen needs are lower at rest and during sleep. Increasing oxygen flow should be done at the discretion of the prescribing healthcare provider and not the client. Water soluble lubricants are considered safer than petroleum-based lubricants. Small liquid oxygen tanks are easier to transport during travel than pressurized tanks. Use of microwave ovens for cooking is considered safe for those using supplemental oxygen.

A health care provider (HCP) has just inserted nasal packing for a client with epistaxis. The client is taking ramipril for hypertension. What should the nurse instruct the client to do? 1. Remove the packing if there is difficulty swallowing. 2. Avoid rigorous aerobic exercise. 3. Use 81 mg of aspirin daily for relief of discomfort. 4. Omit the next dose of ramipril.

Correct response: Avoid rigorous aerobic exercise. Explanation: Epistaxis, or nosebleed, is a common, sudden emergency. Commonly, no apparent explanation for the bleeding is known. With significant blood loss, systemic symptoms, such as vertigo, increased pulse, shortness of breath, decreased blood pressure, and pallor, will occur. Because aerobic exercise may increase blood pressure and increased blood pressure can cause epistaxis, the client with hypertension should avoid it. Aspirin inhibits platelet aggregation, reducing the ability of the blood to clot. The client should continue to take his antihypertension medication, ramipril. Posterior nasal packing should be left in place for 1 to 3 days.

The unlicensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the medical record obtained by the UAP. What should the nurse do? Select all that apply. Assure the client is maintaining complete bed rest. 1. Notify the health care provider (HCP). 2. Check the urine output. 3. Administer acetaminophen as prescribed. 4. Ask the client to drink more fluids.

Correct response: Check the urine output. Ask the client to drink more fluids. Notify the health care provider (HCP). Administer acetaminophen as prescribed. Explanation: A client with pneumonia experiencing diaphoresis is at risk for dehydration and increased temperature and heart rate. The fluid status, intake, and urine output should be monitored closely. The client is febrile, causing an increase in heart rate. Fluid volume deficit may also increase the heart rate. The underlying cause of the tachycardia can be treated with acetaminophen and increased intake of fluids. Bed rest limits lung expansion, and sitting up and deep breathing should be encouraged in a client with pneumonia. The blood pressure is stable enough to allow the client to get out of bed to the chair, with assistance to ensure safety. The nurse should notify the HCP because this client is exhibiting signs of possible sepsis.

A client in severe respiratory distress is admitted to the hospital. When assessing the client, what should the nurse do? 1. Conduct a comprehensive physical examination. 2. Delay assessment until client's respiratory distress is resolved. 3. Complete a focused assessment on the respiratory system. 4. Obtain a brief health history.

Correct response: Complete a focused assessment on the respiratory system. Explanation: During an episode of acute respiratory distress, it is important that the nurse focus the assessment on the client's respiratory system and distress to quickly address the client's problem. Conducting a complete health history and a comprehensive physical examination can be deferred until the client's condition is stabilized. It is not appropriate to delay all assessments until the respiratory distress is resolved because the nurse must have data to guide treatment.

A client in severe respiratory distress is admitted to the hospital. When assessing the client, what should the nurse do? 1. Obtain a brief health history. 2. Complete a focused assessment on the respiratory system. 3. Delay assessment until client's respiratory distress is resolved. 4. Conduct a comprehensive physical examination.

Correct response: Complete a focused assessment on the respiratory system. Explanation: During an episode of acute respiratory distress, it is important that the nurse focus the assessment on the client's respiratory system and distress to quickly address the client's problem. Conducting a complete health history and a comprehensive physical examination can be deferred until the client's condition is stabilized. It is not appropriate to delay all assessments until the respiratory distress is resolved because the nurse must have data to guide treatment.

An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, the client asks the nurse how long they must be separated from their family. Which nursing diagnosis is most appropriate for this client? 1. Social isolation 2. Anxiety 3. Impaired social interaction 4. Deficient knowledge (disease process and treatment regimen)

Correct response: Deficient knowledge (disease process and treatment regimen) Explanation: This client is exhibiting Deficient knowledge about the disease process and treatment regimen; treatment of tuberculosis no longer requires isolation, provided the client complies with the ordered medication regimen. Although the client is upset, the question reflects sadness at the prospect of being separated from their family rather than anxiety about the disease. Because the client has just been diagnosed and hasn't had a chance to demonstrate compliance, a nursing diagnosis of Social isolation isn't appropriate. A diagnosis of Impaired social interaction usually has a psychiatric or neurologic basis, not a respiratory one, such as pulmonary tuberculosis.

A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse? 1. Further assess the client for reinflation of the lung. 2. Increase the suction level of the chest tube. 3. Clamp the chest tube and document the response. 4. Connect the client to a new chest tube system.

Correct response: Further assess the client for reinflation of the lung. Explanation: A lack of bubbling in the water chamber and normal lung sounds are an indication that lung reinflation has occurred. The nurse can further assess the client in relation to pulse oximetry, respiratory rate, and other signs that indicate improvement and can be relayed to the physician for possible removal of the chest tube.

A client is in the emergency department with sneezing and coughing. The client is in the triage area, waiting to be seen by a health care provider. To prevent spread of infection to others in the area and to the health care staff, what should the nurse do? 1. Give the client a surgical mask to wear. 2. Place the client in an isolation room. 3. Ask the others in the area to move away from the client. 4. Ask the client to wash the hands before being examined.

Correct response: Give the client a surgical mask to wear. Explanation: In order to prevent infections in hospitals, the nurse institutes measures to contain respiratory secretions in symptomatic clients. The nurse gives the client a mask to wear, and tissues; the nurse instructs the client to dispose of used tissues in a no-touch receptacle. It is not necessary to place the client in isolation. It is not appropriate to ask others to move away from the client, but the nurse can ask the client to keep 3 feet away from others in the waiting room, if there is room. The nurse instructs the client to perform hand hygiene after blowing his nose or touching his nose or face, but doing so is not a prerequisite for being examined by the HCP. The nurse and HCP also use hand hygiene practices when caring for this client.

Which instruction should the nurse include in the discharge teaching plan for a client with asthma? Select all that apply. 1. Avoid smoke filled rooms. 2. Eliminate stressors in the work and home environment. 3. Monitor peak flow numbers after meals and at bedtime. 4. Use melatonin to ensure uninterrupted sleep at night. 5. Incorporate physical exercise as tolerated into the daily routine.

Correct response: Incorporate physical exercise as tolerated into the daily routine. Avoid smoke filled rooms. Explanation: Physical exercise is beneficial and should be incorporated as tolerated into the client's schedule. The client should also avoid areas with smoke, as smoke is a trigger for an asthma attack. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Peak flow does not need to be monitored after each meal. Stressors in the client's life should be modified but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that a drug such as melatonin or sedatives be routinely taken to induce sleep.

A client who underwent surgery 12 hours ago has difficulty breathing. The client has petechiae over their chest and complains of acute chest pain. What action should the nurse take first? 1. Administer analgesics as ordered. 2. Perform nasopharyngeal suctioning. 3. Initiate oxygen therapy. 4. Administer a heparin bolus and begin an infusion at 500 units/hour.

Correct response: Initiate oxygen therapy. Explanation: The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? 1. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. 2. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. 3. Obtain a sputum specimen for enzyme immunoassay testing. 4. Institute isolation precautions.

Correct response: Institute isolation precautions. Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

A nurse is instructing a client on how to use an incentive spirometer. The nurse should instruct the client to use the spirometer using steps. Place the steps in order from first to last. All options must be used. 2Instruct the client to client exhale fully. 1Instruct the client to inhale on the mouthpiece and hold the breath for 3 seconds. 3Instruct the client to passively exhale. 4Instruct the client to take a deep breath and cough

Correct response: Instruct the client to client exhale fully. Instruct the client to inhale on the mouthpiece and hold the breath for 3 seconds. Instruct the client to passively exhale. Instruct the client to take a deep breath and cough. Explanation: The nurse should instruct the client to first exhale fully. The client should then place the mouthpiece of the spirometer in the mouth and inhale and hold the breath for 3 seconds. The client should then exhale passively. Finally, the client should take a deep breath and cough.

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? 1. It's a centrally-acting antitussive and doesn't cause dependence. 2. It's a peripherally-acting antitussive and can cause dependence. 3. It's a peripherally-acting antitussive and doesn't cause dependence. 4. It's a centrally-acting antitussive and can cause dependence.

Correct response: 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.

The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, what should the nurse do? 1. Notify the health care provider (HCP) of the amount of chest tube drainage. 2. Add water to maintain the water seal. 3. Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity. 4. Lower the drainage system to maintain gravity flow.

Correct response: Lower the drainage system to maintain gravity flow. Explanation: To promote chest tube drainage, the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the HCP. The nurse should chart the amount and color of drainage every 4 to 8 hours. The chest tube does not need to be clamped; the tubing connection is intact. There is sufficient water to maintain a water seal.

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? 1. Decrease chest pain. 2. Reduce the client's anxiety. 3. Maintain adequate oxygenation. 4. Maintain adequate circulating volume.

Correct response: Maintain adequate oxygenation. Explanation: Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? 1. Reduce the client's anxiety. 2. Maintain adequate circulating volume. 3. Decrease chest pain. 4. Maintain adequate oxygenation.

Correct response: Maintain adequate oxygenation. Explanation: Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.

A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin. Which instruction should the nurse give the client about potential adverse effects of rifampin? Select all that apply. 1. Have eye examinations every 6 months. 2. Decrease protein intake in the diet. 3. Maintain follow-up monitoring of liver enzymes. 4. Avoid alcohol intake. 5. The urine may have an orange color.

Correct response: Maintain follow-up monitoring of liver enzymes. Avoid alcohol intake. The urine may have an orange color. Explanation: A potential adverse effect of rifampin is hepatotoxicity. Clients should be instructed to avoid alcohol intake while taking rifampin and keep follow-up appointments for periodic monitoring of liver enzyme levels to detect liver toxicity. Rifampin causes the urine to turn an orange color, and the client should understand that this is normal. It is not necessary to restrict protein intake in the diet or have the eyes examined due to rifampin therapy.

A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which intervention should the nurse include in the plan of care? 1. Initiate small feedings of soft foods. 2. Irrigate drainage tubes as needed. 3. Maintain the head of the bed at 30 to 40 degrees. 4. Teach the client how to use esophageal speech.

Correct response: Maintain the head of the bed at 30 to 40 degrees. Explanation: Immediately after surgery, the client should be maintained in a position with the head of the bed elevated 30 to 40 degrees (semi-Fowler's position) to decrease tissue edema, facilitate breathing, and decrease pain related to edema formation. Immediately postoperatively, the client should be provided alternative means of communicating, such as a communication board. As healing progresses and edema subsides, a speech therapist should work with the client to explore various voice restoration options, such as the use of a voice prosthesis, electrolarynx, artificial larynx, or esophageal speech. Food is not initiated in the immediate postoperative phase; enteral feedings are usually used to meet nutritional needs until edema subsides. Irrigation of the drainage tubes is an inappropriate action.

A client with newly diagnosed asthma has a cough and wheeze after being outside all day. The client calls the health care provider in an attempt to get help using the peak flow meter. What is the appropriate order for using the peak flow meter that the nurse should convey to the client? All options must be used. 1. Place mouthpiece in mouth and close lips around the mouth piece. 2. Record the number achieved on the indicator. 3. Take a deep breath and fill the lungs completely. 4. Move the indicator to the bottom of the numbered scale. 5. Blow out hard and fast with a single blow. 6. Stand up.

Correct response: Move the indicator to the bottom of the numbered scale. Stand up. Take a deep breath and fill the lungs completely. Place mouthpiece in mouth and close lips around the mouth piece. Blow out hard and fast with a single blow. Record the number achieved on the indicator. Explanation: Peak flow meters measure the highest airflow during a forced expiration. Daily peak flow monitoring is recommended for certain clients. Peak flow monitoring helps measure asthma severity and, when added to symptom monitoring, indicates the current degree of asthma control. The Expert Panel Report 3 (2007) recommends that peak flow monitoring be considered an adjunct to asthma management for clients with moderate to severe persistent asthma. Peak flow monitoring plans may enhance communication between the client and health care providers and may increase the client's awareness of disease status and control.

A client has been admitted with a chronic cough, progressive weight loss, and a positive tuberculin skin test. Which isolation precautions are appropriate for the nurse to follow? Select all that apply. 1. Place a mask on the client when transporting to radiology. 2. Discourage visitors from spending time with the client to reduce transmission. 3. Wear a disposable mask when in the client's room. 4. Dispose of tissues in the wastebasket outside the room. 5. Wear a gown and gloves while providing care.

Correct response: Place a mask on the client when transporting to radiology. Wear a disposable mask when in the client's room. Explanation: The client has had a positive tuberculin skin test. Because tuberculosis is airborne and spread by droplet infection, isolation precautions need to be initiated. The nurse will need to wear a mask to prevent transmission of this droplet-transmitted infection. Gown and gloves are not required when the infection is a droplet-transmitted infection. Tissues would need to be disposed of in an isolation bag. When isolation precautions are implemented, it is important that the client not experience social isolation as well, so family are encouraged to abide by isolation precautions and visit.

A client has been admitted with a chronic cough, progressive weight loss, and a positive tuberculin skin test. Which isolation precautions are appropriate for the nurse to follow? Select all that apply. 1. Wear a disposable mask when in the client's room. 2. Place a mask on the client when transporting to radiology. 3. Dispose of tissues in the wastebasket outside the room. 4. Wear a gown and gloves while providing care. 5. Discourage visitors from spending time with the client to reduce transmission.

Correct response: Place a mask on the client when transporting to radiology. Wear a disposable mask when in the client's room. Explanation: The client has had a positive tuberculin skin test. Because tuberculosis is airborne and spread by droplet infection, isolation precautions need to be initiated. The nurse will need to wear a mask to prevent transmission of this droplet-transmitted infection. Gown and gloves are not required when the infection is a droplet-transmitted infection. Tissues would need to be disposed of in an isolation bag. When isolation precautions are implemented, it is important that the client not experience social isolation as well, so family are encouraged to abide by isolation precautions and visit.

A client is admitted to the postsurgical unit after wiring of a fractured jaw. When the nurse completes an assessment, noisy, shallow breathing is noted and the oxygen saturation level is now 90%. What is the appropriate action by the nurse? 1. Position in Fowler's position to assist in breathing and give oxygen as ordered. 2. Insert an airway, suction, and position in the supine position. 3. Encourage deep breathing, position in the prone position, and give oxygen as ordered. 4. Position in Sims position with head to the side, administer oxygen as ordered, and suction if needed.

Correct response: Position in Sims position with head to the side, administer oxygen as ordered, and suction if needed. Explanation: Sims position is indicated for clients in the initial postoperative period. Sims position helps ensure patency of the airway by allowing secretions and blood to pool in the cheek and drain out the side of the mouth. If secretions are accumulating too quickly, suctioning may be required. Oxygen is given to improve oxygen saturation levels. If positioned in Fowlers, there will be more likelihood of swallowing the bloody secretions and becoming nauseated. The client's jaw is wired, so the airway cannot be inserted. If positioned supine, the client could aspirate. If positioned prone, there is more compression on the chest cage that could contribute to more shallow breathing.

The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate? 1. Position in Fowler's position and administer oxygen. 2. Position in a semi-prone position and encourage deep breathing. 3. Position in high Fowler's position and administer an albuterol sulfate inhaler. 4. Position in orthopneic position and encourage the client to calm down.

Correct response: Position in high Fowler's position and administer an albuterol sulfate inhaler. Explanation: Following an asthma attack, it is important to ensure optimal positioning (Fowler's) and adequate oxygen levels. The client is still experiencing wheezing, so coughing to remove secretions is important. A bronchodilator would also help by enlarging the size of the bronchioles. Asking the client to calm down is incorrect because it does not explore concerns. Semi-prone positioning would not assist with breathing.

The registered nurse (RN) is assisting the licensed practical nurse (LPN) in performing a purified protein derivative (PPD) test on a nursing home resident. Which statements about this test are correct? Select all that apply. 1. A PPD test is done to test for allergies. 2. The preferred injection site is the ventral surface of the forearm. 3. No wheal should appear at the site following injection. 4. Always aspirate before injecting the PPD solution. 5. The PPD test is an intradermal test. 6. Hold the syringe at a 45° angle to the skin.

Correct response: The PPD test is an intradermal test. The preferred injection site is the ventral surface of the forearm. Explanation: The PPD test is used to determine whether a person has been exposed/infected with the Tuberculosis bacillus. PPD tests should be injected intradermally in the ventral forearm, unless contraindicated, without aspiration prior to injecting. The syringe would be held at a 10° to 15° angle from the site so the needle enters the dermis as nearly parallel to the skin as possible. A small wheal would appear; this indicates that the medication has been injected into the dermis.

A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? 1. The client is developing subcutaneous emphysema. 2. The chest tube system is functioning properly. 3. An obstruction is present in the chest tube. 4. There is a leak in the chest tube system.

Correct response: The chest tube system is functioning properly. Explanation: Fluctuation of fluid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.

A client has been placed on isoniazid (INH) as prophylactic treatment against tuberculosis. The nurse should give the client which instruction about taking isoniazid? 1. The client should take the drug with antacids to decrease gastric distress. 2. The client should limit tyramine-rich foods in the diet. 3. The client can double the dosage if a dose is missed. 4. The client should increase fluid intake to 3,000 mL/day.

Correct response: The client should limit tyramine-rich foods in the diet. Explanation: When taking isoniazid, the client should limit tyramine-rich foods in the diet because these foods and the drug could interact to cause hypertension. Foods such as cheese, dairy products, alcohol (red wine and beer), bananas, raisins, caffeine, and chocolate should be limited.Antacids can inhibit the absorption of INH and should not be taken with the drug.The client does not need to increase fluids to 3,000 mL/day.The client should not double the dose because INH is potentially toxic to the liver.

Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease? 1. Assess the client's fatigue level. 2. Evaluate the client's hemoglobin level daily. 3. Use a pulse oximeter to determine oxygen saturation.

Correct response: Use a pulse oximeter to determine oxygen saturation. Explanation: A pulse oximeter, which measures oxygen saturation, is the most effective noninvasive way to determine a client's need for oxygen therapy.Although the client may feel the need for oxygen during periods of dyspnea, this is not a reliable way of determining the client's need.Fatigue may be due to other factors besides oxygenation levels.Evaluating the client's hemoglobin level can provide an indication that the client may have less oxygen-carrying capacity but is not a reliable indicator of oxygen need.

A nurse is assessing a client using a tracheostomy tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which action should the nurse take? 1. Teach the client pursed lip breathing. 2. Call respiratory therapy for a breathing treatment. 3. Encourage the use of the incentive spirometer. 4. Use a sterile suction kit to suction the client.

Correct response: Use a sterile suction kit to suction the client. Explanation: The priority for this client is suctioning to remove secretions in the upper airway if the client is unable to cough adequately. The other interventions will not effectively assist the client to maintain a patent airway.

The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply. 1. Keep the client in strict isolation. 2. Have all people in contact with the client outside of the client's room wear a mask. 3. Wash hands after direct contact with the client or contaminated articles. 4. Keep the client's door open to allow fresh air into the room and to prevent social isolation. 5. Wear gloves when handling tissues containing sputum. 6. Wear a face mask at all times.

Correct response: Wear gloves when handling tissues containing sputum. Wear a face mask at all times. Wash hands after direct contact with the client or contaminated articles. Explanation: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in the client's room; masks must be discarded before leaving the client's room. Handwashing is required after direct contact with the client or contaminated articles. Strict isolation is not required if the client adheres to special respiratory precautions. The client, not the people in contact with the client, must wear a mask when leaving the room for tests. The client should be in a negative-pressure, private room, and the door should remain closed at all times to prevent the spread of infection.

A nurse has received report on four clients. Which client would the nurse visit first? 1. a client with chronic obstructive pulmonary disease (COPD) whose last report of oxygen saturation was 91% 2. a client with tuberculosis who raised 50 mL of sanguineous sputum over the past 2 hours 3. a client with congestive heart failure (CHF) who has gained 2 pounds overnight 4. a client with C. difficile who continues to have loose, fouling smelling stools

Correct response: a client with tuberculosis who raised 50 mL of sanguineous sputum over the past 2 hours Explanation: Sanguineous or bloody sputum (hemoptysis) is a sign of possible hemorrhage and may indicate vessel damage in the lungs; the nurse should assess this client first. The nurse should next evaluate the client with CHF and weight gain for additional signs of heart failure. Loose stools are expected for a client with C. difficile, and the nurse can delegate care to an unlicensed assistive personnel and follow up with this client later to determine the character and frequency of the stools. The client with COPD and an O2 saturation of 91% is within acceptable levels at this time, and the nurse can assess this client last.

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; Pco2 48 mm Hg (6.4 kPa); Po2 58 mm Hg (7.7 kPa); HCO3 26 mEq/L (26 mmol/L). Which prescription should the nurse implement first? 1. sputum culture 2. ipratropium inhaler 3. chest X-ray 4. albuterol nebulizer

Correct response: albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest X-ray and sputum sample can be obtained once the client is stable.

The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client's oxygen therapy can be best determined by which indicator of oxygenation? 1. client's respiratory rate. 2. arterial blood gas (ABG) values. 3. absence of cyanosis. 4. client's level of consciousness.

Correct response: arterial blood gas (ABG) values. Explanation: The client's ABG levels are the most sensitive indicator of the effectiveness of the client's oxygen therapy. Cyanosis is a late sign of decreased oxygenation and is not a reliable indicator. The client's respiratory rate and level of consciousness may be altered because of other problems not related to the client's oxygenation.

When instructing clients with allergic rhinitis about the use of nasal decongestants, it is important for the nurse to emphasize that: 1. the condition requires treatment only during the spring. 2. the condition is self-limited and should not return. 3. the condition will not benefit from environmental changes. 4. continuous use for more than 3 days can result in worsening of symptoms.

Correct response: continuous use for more than 3 days can result in worsening of symptoms. Explanation: The continuous use of nasal decongestants can result in a rebound effect when the agents are discontinued. This leads to a worsening of symptoms due to reflex vasodilation. Environmental changes can affect allergic rhinitis. The client should be instructed on identifying and avoiding exposure to allergens. Allergic rhinitis can occur during any season. It is not self-limited and may require prolonged management.

A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? 1. nothing, until signs of active disease arise 2. daily oral doses of isoniazid and rifampin for 6 months to 2 years 3. daily doses of isoniazid, 300 mg for 6 months to 1 year i4. solation until 24 hours after antitubercular therapy begins

Correct response: daily doses of isoniazid, 300 mg for 6 months to 1 year Explanation: All clients exposed to persons with tuberculosis should receive prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium. Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with active tuberculosis. Isolation for 2 to 4 weeks is warranted for a client with active tuberculosis.

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? 1. myasthenia gravis 2. type 1 diabetes mellitus 3. opioid overdose 4. extreme anxiety

Correct response: 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 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 client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the 1. sphenoidal and ethmoidal sinuses. 2. frontal sinuses only. 3. sphenoidal sinuses only. 4. frontal and maxillary sinuses.

Correct response: frontal and maxillary sinuses. Explanation: After detecting tenderness of the paranasal sinuses, the nurse should transilluminate both the frontal and maxillary sinuses; lack of illumination may indicate sinus congestion and pus accumulation. The sphenoidal and ethmoidal sinuses can't be transilluminated because of their location.

The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcome? Steroids will: 1. prevent development of respiratory infections. 2. promote bronchodilation. 3. act as an expectorant. 4. have an anti-inflammatory effect.

Correct response: have an anti-inflammatory effect. Explanation: 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.

A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about? 1. urinary output of 190 milliliters and dark amber urine in 6 hours 2. reports of pain and an occasional premature ventricular contraction (PVC) 3. dressing saturated with a moderate amount of bloody drainage, and blood pressure of 130/70 mm Hg 4. heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24

Correct response: heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 Explanation: The nurse should check for bleeding, monitor the vital signs, and promote urine output after airway patency has been established. Heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 indicates the early signs and symptoms of shock and the nurse should be most concerned about these.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? 1. hypoxia 2. delirium 3. semiconsciousness 4. hyperventilation

Correct response: hypoxia Explanation: As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on the nurse's knowledge of palliative care? 1. decreasing administration of pain medications 2. decreasing the use of bronchodilators 3. increasing the need for antianxiety agents 4. reducing oxygen requirements

Correct response: increasing the need for antianxiety agents Explanation: The nurse should anticipate that the physician will increase antianxiety agents during treatment to maintain comfort throughout the dying process. Bronchodilators, pain medications, and home oxygen therapy help promote client comfort. Therefore, they should be continued as part of palliative care

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? 1. acute pain related to tissue trauma 2. risk for vascular trauma related to pulmonary emboli 3. impaired circulation related to blood clot 4. ineffective breathing pattern related to tissue trauma

Correct response: ineffective breathing pattern related to tissue trauma 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.

A nurse is teaching a client about theophylline toxicity. Which are signs and symptoms of theophylline toxicity? Select all that apply. 1. nausea and lethargy 2. pruritis and abdominal pain 3. dizziness and headache 4. itching and jaundice 5. bradycardia and constipation

Correct response: itching and jaundice nausea and lethargy pruritis and abdominal pain Explanation: The client should be instructed to discontinue use if experiencing signs and symptoms of liver dysfunction, right upper quadrant pain, pruritis, lethargy, jaundice, and nausea. Bradycardia, constipation, dizziness, and headache are not associated with theophylline use.

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? 1. respiratory acidosis 2. respiratory alkalosis 3. metabolic acidosis 4. metabolic alkalosis

Correct response: metabolic acidosis Explanation: This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.

The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of arterial blood gas values does the nurse expect for this client?

Correct response: pH 7.25, PaCO2 48, HCO3 24 Explanation: The nurse would expect a client with ARDS to exhibit respiratory acidosis. The results of pH 7.25, PaCO2 48, HCO3 24 indicate respiratory acidosis. Results of pH 7.29, PaCO2 36, HCO3 19 indicate metabolic acidosis and results of pH 7.30, PaCO2 28, HCO3 16 indicate metabolic acidosis with partial compensation, which would be expected in a client with a metabolic problem such as diabetic ketoacidosis. Results of pH 7.35, PaCO2 46, HCO3 30 indicate fully compensated respiratory acidosis, which would be expected for client with a chronic respiratory problem.

A client who has just had a triple-lumen catheter placed in their right subclavian vein complains of chest pain and shortness of breath. The client's blood pressure is decreased from baseline and, on auscultation of the chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? 1. myocardial infarction (MI) 2. pneumothorax 3. pulmonary embolism 4. heart failure

Correct response: pneumothorax Explanation: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? 1. incentive spirometry 2. endotracheal suctioning 3. use of a cooling blanket 4. encouragement of coughing

Correct response: pneumothorax Explanation: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately following the insertion of the catheter and notes a sudden onset of chest pain and shortness of breath. Which complication should the nurse be prepared to treat? 1. sepsis 2. pneumothorax 3. bronchopneumonia 4. clotted catheter

Correct response: pneumothorax Explanation: Pneumothorax can occur from inadvertent puncture of the pleura, causing sudden chest pain and shortness of breath. Bronchopneumonia would not occur as a result of catheter contamination. Bronchopneumonia is an infection in the lung tissue. The central line is inserted in the venous system, namely the subclavian vein in this situation. The other answers are incorrect because they are not complications from central line insertions. The nurse must assess the client carefully for these complications to ensure that the parenteral nutrition is being administered safely.

An expected outcome of theophylline ethylenediamine when administered to a client with chronic obstructive pulmonary disease is: 1. strengthen myocardial contractions. 2. reduce bronchial secretions. 3. decrease alveolar elasticity. 4. relax bronchial smooth muscle.

Correct response: relax bronchial smooth muscle. Explanation: Theophylline ethylenediamine is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease.Theophylline ethylenediamine does not reduce bronchial secretions or decrease alveolar elasticity.Theophylline ethylenediamine does increase strength of myocardial contractility, but this is not the action for which it is used.

Which outcome criteria would the nurse develop for a child with cystic fibrosis who has ineffective airway clearance related to increased pulmonary secretions and inability to expectorate? 1. ability to engage in age-related activities 2. ability to tolerate usual diet without vomiting 3. absence of chills and fever 4. respiratory rate and rhythm within expected range

Correct response: respiratory rate and rhythm within expected range Explanation: After treatment, the client outcome would be that respiratory status would be within normal limits, as evidenced by a respiratory rate and rhythm within expected range. Absence of chills and fever, although related to an underlying problem causing the respiratory problem (e.g., the infection), do not specifically relate to the respiratory problem of ineffective airway clearance. The child's ability to engage in age-related activities may provide some evidence of improved respiratory status. However, this outcome criterion is more directly related to activity intolerance. Although the child's ability to tolerate his or her usual diet may indirectly relate to respiratory function, this outcome is more specifically related to an imbalanced nutrition that may or may not be related to the child's respiratory status.

A client has a newly positive Mantoux skin test but does not have active tuberculosis. The nurse should instruct the client to: 1. have a blood test for tuberculosis in 3 months. 2. take isoniazid as prescribed. 3. have a repeat Mantoux skin test in 6 months. 4. inform the health care provider if the skin test reverts to negative.

Correct response: take isoniazid as prescribed. Explanation: Clients with newly positive skin tests are aggressively treated with isoniazid for about 9 months.The client with a newly positive Mantoux test requires prophylactic drug treatment; a blood test will not reveal tuberculosis at this time.Repeat skin testing should not be performed as it will always be positive.Skin tests do not convert to negative once a positive response has been obtained.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? 1. 3 to 5 days 2. 1 to 3 weeks 3. 2 to 4 months 4. 6 to 12 months

Correct response: 6 to 12 months Explanation: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? 1. Check for an apical pulse. 2. Ventilate the client with a handheld mechanical ventilator. 3. Increase the oxygen percentage. 4. Suction the client's artificial airway.

Correct response: Suction the client's artificial airway. Explanation: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a diagnosis of pneumothorax? 1. Bradypnea and elevated blood pressure. 2. Tracheal deviation toward the affected side. 3. Sudden, sharp pain on the affected side. 4. Presence of crackles and wheezes.

Correct response: Sudden, sharp pain on the affected side. Explanation: Signs and symptoms of a pneumothorax include sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness. Tracheal deviation away from the affected side indicates a tension pneumothorax, which is a medical emergency.

A client's arterial blood gas analysis reveals an excess of carbon dioxide. The nurse should recognize that this is consistent with which condition? 1. metabolic acidosis 2. respiratory acidosis 3. metabolic alkalosis 4. respiratory alkalosis

Correct response: respiratory acidosis Explanation: An increased level of dissolved carbon dioxide (PaCO2) indicates respiratory acidosis. Metabolic acidosis and alkalosis are not correct because this is a respiratory issue, not a metabolic one. Respiratory alkalosis would have a PaCO2 deficit, not an increase.

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn, yielding the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory alkalosis 4. respiratory acidosis

Correct response: respiratory acidosis Explanation: The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, respiratory acidosis exists and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

The nurse is planning to assist the health care provider with a thoracentesis for a client who has a pleural effusion. Which position for the client would be appropriate for this procedure? 1. lying supine with the arms extended 2. side-lying with the knees drawn up to the abdomen 3. sitting upright and leaning on an overbed table 4. lying prone with the head supported by the arms

Correct response: sitting upright and leaning on an overbed table Explanation: The client should be seated upright with the arms raised and crossed in front and supported by the overbed table. The client's head should rest on the arms. This position allows for outward expansion of the chest wall and promotes collection of the pleural fluid at the base of the thorax.

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)? 1. oxygen saturation of 96% on room air 2. respirations of 12 breaths/min 3. lack of adventitious lung sounds 4. arterial oxygen level of 46 mm Hg (6.1 kPa)

Correct Responce: 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.

The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, what should the nurse do? 1. Lower the drainage system to maintain gravity flow. 2. Add water to maintain the water seal. 3. Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity. 4. Notify the health care provider (HCP) of the amount of chest tube drainage.

Correct response: Lower the drainage system to maintain gravity flow. Explanation: To promote chest tube drainage, the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the HCP. The nurse should chart the amount and color of drainage every 4 to 8 hours. The chest tube does not need to be clamped; the tubing connection is intact. There is sufficient water to maintain a water seal.

Before administering morphine to a client with pain of 8 on a pain scale, the nurse should assess which vital signs? Select all that apply. 1. level of consciousness 2. blood pressure 3. temperature 4. pulse 5. respiration rate

Correct response: respiration rate level of consciousness Explanation: Morphine can cause respiratory depression, leading to respiratory arrest. Morphine can also decrease levels of consciousness. The nurse should assess the client's respiratory rate before administration and throughout the course of analgesic treatment. The nurse should also assess the client's level of consciousness. Morphine does not affect the blood pressure, pulse rate, or body temperature.

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? 1. tidal volume 2. functional residual capacity 3. vital capacity 4. maximal voluntary ventilation

Correct response: tidal volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

The nurse is reviewing the history and physical and health care provider prescriptions on the medical record of a newly admitted client. What should the nurse do first? 1. Reassess vital signs. 2. Collect a sputum sample. 3. Apply oxygen at 2 L per nasal cannula. I4. nitiate airborne precautions.

Initiate airborne precautions. Explanation: There is a high risk and potential for tuberculosis, and airborne precautions should be implemented immediately to prevent the spread of infection. After initiating precautions the nurse can start the oxygen, check the vital signs, and collect the sputum specimen.

The nurse is educating a client about allergy management at home. What client statements indicate further teaching is required? Select all that apply. 1. "Rugs can be used on my floors, as long as I vacuum them daily." 2. "Wearing a mask is necessary when it is windy outside." 3. "Cleaning my hardwood floors is important to do every day." 4. "I will dust my venetian blinds every day." 5. "I will buy a high-efficiency particulate air purifier for my home."

Correct response: "I will dust my venetian blinds every day." "Rugs can be used on my floors, as long as I vacuum them daily." Explanation: Venetian blinds and rugs should not be used because they collect dust. Buying a high-efficiency particulate air purifier and washing hardwood floors daily will help minimize dust and help with allergy symptoms. Wearing a mask when it is windy outside will help reduce exposure to pollens and molds.

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? 1. "If the test area turns red that means I have tuberculosis." 2. "I will avoid contact with my family until I am done with the test." 3. "I will come back in 1 week to have the test read." 4. "Because I had a previous reaction to the test, this time I need to get a chest X-ray."

Correct response: "Because I had a previous reaction to the test, this time I need to get a chest X-ray." Explanation: A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period.

A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect? 1. crackles auscultated halfway up lungs, previously in bases 2. trace peripheral edema, previously +2 3. PaO2 80 mm Hg 4. blood pressure 140/80 mm Hg

Correct response: trace peripheral edema, previously +2 Explanation: The therapeutic effect of furosemide is to mobilize excess fluid. The client's peripheral edema should decrease, indicated by changing from +2 to trace. As furosemide decreases fluid in the lungs, the client's crackles should decrease, not continue to progress. If furosemide is attaining a therapeutic effect, the blood pressure should decrease into normal range and the oxygen level should increase to above 90%.

The nurse is conducting a health history with a client with active tuberculosis. The nurse should ask the client about: 1. mental status changes. 2. dyspnea on exertion. 3. weight loss. 4. increased appetite.

Correct response: weight loss. Explanation: Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats.Increased appetite is not a symptom of tuberculosis; dyspnea on exertion and change in mental status are not common symptoms of tuberculosis.

The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply. 1. Keep the client's door open to allow fresh air into the room and to prevent social isolation. 2. Have all people in contact with the client outside of the client's room wear a mask. 3. Wear a face mask at all times. 4. Wash hands after direct contact with the client or contaminated articles. 5. Wear gloves when handling tissues containing sputum. 6. Keep the client in strict isolation.

Wear gloves when handling tissues containing sputum. Wear a face mask at all times. Wash hands after direct contact with the client or contaminated articles. Explanation: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in the client's room; masks must be discarded before leaving the client's room. Handwashing is required after direct contact with the client or contaminated articles. Strict isolation is not required if the client adheres to special respiratory precautions. The client, not the people in contact with the client, must wear a mask when leaving the room for tests. The client should be in a negative-pressure, private room, and the door should remain closed at all times to prevent the spread of infection.

The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? 1. assessing the client's environment for sanitation 2. teaching the client about the disease and its treatment 3. coordinating various agency services 4. offering the client emotional support

Correct response: 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.

Which is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? 1. minimizing chest pain 2. increasing carbon dioxide levels in the blood 3. treating infectious agents 4. maintaining functional ability

Correct response: maintaining functional ability Explanation: A priority goal for the client with COPD is to manage the signs and symptoms of the disease process so as to maintain the client's functional ability. Chest pain is not a typical symptom of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.

The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statements indicate that the client has understood the nurse's instructions? Select all that apply. 1. "I should always cover my mouth and nose when sneezing." 2 . "I should use paper tissues to cough in and dispose of them promptly." 3. "It is important that I isolate myself from family when possible." 4. "I will need to dispose of my old clothing when I return home."

Correct response: "I should always cover my mouth and nose when sneezing." "I should use paper tissues to cough in and dispose of them promptly." Explanation: When teaching the client how to avoid the transmission of tubercle bacilli, it is important for the client to understand that the organism is transmitted by droplet infection. Therefore, covering the mouth and nose when sneezing, using paper tissues to cough in with prompt disposal, indicate that the client has understood the nurse's instructions about preventing the spread of airborne droplets. It is not essential to discard clothing, nor does the client need to be isolated from family members.

A client asks a nurse a question about the tuberculin skin test for tuberculosis. The nurse should base their response on the fact that the 1. area of redness is measured in 3 days and determines whether tuberculosis is present. 2. presence of a wheal at the injection site in 2 days indicates active tuberculosis. 3. skin test doesn't differentiate between active and dormant tuberculosis infection. 4. test stimulates a reddened response in some clients and requires a second test in 3 months.

Correct response: skin test doesn't differentiate between active and dormant tuberculosis infection. Explanation: The tuberculin skin test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the tuberculin skin test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

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: 1. uses the sternocleidomastoid muscles. 2. wants the head of the bed raised to a 90-degree level. 3. asks for an additional pillow. 4. has a pulse oximetry reading of 91%.

Correct response: 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.