Week 5 Guide

The teaching plan for the use of a dry powder inhaler for the treatment of asthma should include the warning to rinse the mouth after inhaling the powder. What does this prevent? a. Discoloration of tooth enamel b. Halitosis c. Irritation of oral membranes d. Candidiasis

Candidiasis Rationale: Inhalant powders can cause candidiasis (yeast) infection of the mouth.

The school nurse suspects a first grade student has sinusitis. Which symptoms might lead the nurse to this suspicion? (Select all that apply.) a. Child reports tooth pain. b. Severe wheezing is auscultated on inspiration. c. Child reports, I have had a cold for 2 weeks. d. Nurse observes periorbital swelling. e. Halitosis is present.

Child reports tooth pain. Child reports, I have had a cold for 2 weeks. Nurse observes periorbital swelling. Halitosis is present.

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action? Bronchodilator—stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. Corticosteroid—relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. Cromone—disrupts the production of pathways of inflammatory mediators.

Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? Client reports being dizzy—nurse calls the Rapid Response Team. Client's heart rate is 55 beats/min—nurse withholds pain medication. Client has reduced breath sounds—nurse calls primary health care provider immediately. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.

Client has reduced breath sounds—nurse calls primary health care provider immediately. Rationale: a potential serious complication after biopsy is pneumothorax which is indicated by decreased or absent breath sounds

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.) Cognition Dexterity Hydration Range of motion Vision Upper arm range of motion

Cognition Dexterity Range of motion Vision Upper arm range of motion

26. A toddler must maintain bed rest for the diagnosis of pneumonia. What actions will the nurse implement? (Select all that apply.) a. Maintain strict bed rest. b. Consider age. c. Assess developmental level. d. Implement light play activities e. Provide hypnotic medication as ordered.

Consider age. Assess developmental level. Implement light play activities

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the chest tube is dislodged. Which action by the nurse is best? Assess for drainage from the site. Cover the insertion site with sterile gauze. Contact the primary health care provider. Reinsert the tube using sterile technique.

Cover the insertion site with sterile gauze. Rationale: 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.

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.) Create a communication system. Don't go out in public alone. Find hobbies to enjoy at home. Try loose-fitting shirts with collars. Wear fashionable scarves. (highlighted)

Create a communication system. Try loose-fitting shirts with collars. Wear fashionable scarves.

Which is the most appropriate nursing action when planning care for a child with cystic fibrosis? a. Provide chest physiotherapy before meals every day. b. Assess weight monthly. c. Administer pancrease with protein food at mealtime. d. Ensure high-protein, high-calorie diet.

Ensure high-protein, high-calorie diet.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? Administer prescribed anxiolytic medication Ensure that informed consent is on the chart Reinforce any teaching done previously Start the preoperative antibiotic infusion

Ensure that informed consent is on the chart

A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this client's evaluation? (Select all that apply.) Examination of mucous membranes and nail beds Measurement of rate, depth, and rhythm of respirations Auscultation of bowel sounds for abnormal sounds Check peripheral veins for distention while at rest Determine the client's need and use of oxygen Ability to perform activities of daily living

Examination of mucous membranes and nail beds Measurement of rate, depth, and rhythm of respirations Determine the client's need and use of oxygen Ability to perform activities of daily living

6. What classic sign would the nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, expect to find? a. Fine crackles b. Coarse rhonchi c. Expiratory wheezing d. Decreased breath sounds at lung bases

Expiratory wheezing Ratioanle: The child experiencing an acute asthma attack wheezes as air moves in and out of tyhse. Tnahrerowed airwa expiratory wheeze is most pronounced.

A nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms would the nurse be aware of? (Select all that apply.) Gynecomastia in male patients Frequent shaking and sweating relieved by eating Positive Chvostek and Trousseau signs "Moon" face and "buffalo" hump Expectorating purulent sputum General edema

Gynecomastia in male patients Frequent shaking and sweating relieved by eating "Moon" face and "buffalo" hump General edema Rationale: Lung cancer often is associated with paraneoplastic syndromes. Symptoms of these include gynecomastia from ectopic follicle-stimulating hormone release, hypoglycemia from ectopic insulin production (shaking and sweating relieved by eating), and Cushing syndrome (moon facies and buffalo hump) from ectopic adrenocorticotropic hormone. General edema can be caused by antidiuretic hormone.

The nurse assesses the client using the device pictured below to deliver 50% O2: (Venturi Mask) The nurse finds that the mask fits snugly, the skin under the straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? Assess the client's oxygen saturation. Document these findings in the chart. Immediately increase the flow rate. Turn the flow rate down to 2 L/min.

Immediately increase the flow rate. Rationale: For the venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The client's flow rate is too low and the nurse would increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings.

A nurse assesses a client's respiratory status. Which information is most important for the nurse to obtain? Average daily fluid intake. Neck circumference. Height and weight Occupation and hobbies.

Occupation and hobbies. Rationale: Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection would the nurse provide for this client? Spaghetti with meat sauce, ice cream Chicken soup, grilled cheese sandwich Omelet, soft whole-wheat bread Pasta salad, custard, orange juice

Omelet, soft whole-wheat bread Rationale: Side effects of radiation therapy may include inflammation of the esophagus. Clients would be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

What will the nurse tell parents of a child with a positive throat culture for group A hemolytic streptococcus that the treatment is most likely to be? a. Acetaminophen and plenty of fluids b. Oral penicillin for 10 days c. Penicillin until his sore throat is gone d. Streptococcus immunization

Oral penicillin for 10 days Rationale: When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished.

What will the nurse teach the child with cystic fibrosis to take in order to facilitate digestion and absorption of nutrients? a. Pancreatic enzymes b. Water-soluble minerals c. Fat-soluble vitamins d. Salt supplements

Pancreatic enzymes Rationale: An oral pancreatic enzyme is given to the child with every meal and with snacks to replace the pancreatic enzymes that the childs body cannot produce.

The nurse is preparing to teach a community group about warning signs of lung cancer. What information does the nurse include? (Select all that apply.) Over 10-pack-year history of smoking Persistent coughing Rusty or blood-tinged sputum Dyspnea Hoarseness Fatigue

Persistent coughing Rusty or blood-tinged sputum Dyspnea Hoarseness

The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). What significant information would the nurse include? a. Wrapping the infant snugly for rest periods b. Positioning the infant prone for sleep c. Sitting the infant up in an infant seat d. Placing infants on their backs or sides for sleep

Placing infants on their backs or sides for sleep Rationale: The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying position on a firm mattress to prevent SIDS.

7. What is the best intervention for the nurse caring for a child experiencing an acute asthma attack? a. Offer plenty of fluids, particularly carbonated beverages. b. Place the child in a humidified cool mist tent with oxygen .c. Administer sedatives as ordered to decrease anxiety. d. Position the child with arms resting on the overbed table.

Position the child with arms resting on the overbed table. Rationale: This position is comfortable and allows maximum use of the accessory muscles for breathing. Sedatives would mask symptoms of increasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea.

The first child of a couple is being treated for bronchopulmonary dysplasia (BPD). They ask how to prevent this from happening with the child they are currently expecting. What will the nurse explain as the best way to prevent BPD? a. Maternal intake of folic acid b. Exercise c. Prevention of preterm birth d. Provision of oxygen therapy to the newborn

Prevention of preterm birth

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this client's teaching? (Select all that apply.) "Avoid drinking fluids just before and during meals." "Rest before meals if you have dyspnea." "Have about six small meals a day." "Eat high-fiber foods to promote gastric emptying." "Use pursed-lip breathing during meals." "Choose soft, high-calorie, high-protein foods."

"Avoid drinking fluids just before and during meals." "Rest before meals if you have dyspnea." "Have about six small meals a day." "Use pursed-lip breathing during meals." "Choose soft, high-calorie, high-protein foods."

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first? "Do you have a strong support system?" "What do you understand about your disease?" "Do you experience shortness of breath with basic activities?" "What medications are you prescribed to take each day?"

"Do you experience shortness of breath with basic activities?" Rationale: Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse would ask the client if shortness of breath is interfering with basic activities. Although the nurse would need to know about the client's support systems, current knowledge, and medications, these questions do not address the client's appearance.

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding? "Are you taking any medications or herbal supplements?" "Do you have any chronic breathing problems?" "How often do you perform aerobic exercise?" "What is your occupation and what are your hobbies?" (highlighted)

"Do you have any chronic breathing problems?"

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the client's activity tolerance? (Select all that apply.) "What color is your sputum?" "Do you have any difficulty sleeping?" "How long does it take to perform your morning routine?" "Do you walk upstairs every day?" "Have you lost any weight lately?" "How does your activity compare to this time last year?"

"Do you have any difficulty sleeping?" "How long does it take to perform your morning routine?" "Have you lost any weight lately?" "How does your activity compare to this time last year?"

8. A nurse is teaching a client who has cystic fibrosis (CF). Which statement would the nurse include in this client's teaching? "Take an antibiotic each day." "You should get genetic screening." "Eat a well-balanced, nutritious diet." "Plan to exercise for 30 minutes every day." (highlighted)

"Eat a well-balanced, nutritious diet." Rationale: Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening might be an option; however, the nurse would not just tell the client to do something like that.

A nurse teaches a client who is interested in smoke cessation. Which statements would the nurse include in this client's teaching? Select all that apply "Find an activity that you enjoy and will keep you hands busy" "Keep snacks like potato chips on hand to nibble on" "Identify a consequence for yourself in case you backslide" "Drink at least eight glasses of water each day." "Make a list of reasons you want to stop smoking." "Set a quit date and stick to it."

"Find an activity that you enjoy and will keep you hands busy" "Drink at least eight glasses of water each day." "Make a list of reasons you want to stop smoking." "Set a quit date and stick to it."

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements would the nurse include in communications with the respiratory therapist prior to the tests? Select all that apply "I held the clients morning bronchodilator medication" "The client is ready to go down to radiology for this examination" "Physical therapy states the client can run on a treadmill" "The client is alert and can follow your commands"

"I held the clients morning bronchodilator medication" "Physical therapy states the client can run on a treadmill" "The client is alert and can follow your commands"

A clinic nurse is reviewing care measures with a client who has asthma, Step 3. What statement by the client indicates the need to review the information? "I still will use my rapid-acting inhaler for an asthma attack." "I will always use the spacer with my dry powder inhaler." "If I am stable for 3 months, I might be able to reduce my drugs." "My inhaled corticosteroid must be taken regularly to work well."

"I will always use the spacer with my dry powder inhaler." Rationale: Dry powder inhalers are not used with a spacer. The other statements are accurate.

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates that the client comprehends the teaching? "I will carry this medication with me at all times in case I need it." "I will take this medication when I start to experience an asthma attack." "I will take this medication every morning to help prevent an acute attack." "I will be weaned off this medication when I no longer need it." (highlighted !)

"I will take this medication every morning to help prevent an acute attack." Rationale: Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. Long-acting beta2 ( SALMUTEROL )

After teaching a client who is prescribed salmeterol, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? "I will be certain to shake the inhaler well before I use it." "It may take a while before I notice a change in my asthma." "I will use the drug when I have an asthma attack." "I will be careful not to let the drug escape out of my nose and mouth."

"I will use the drug when I have an asthma attack." Rationale: Salmeterol is a long-acting beta2 agonist designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it would not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client's part allows the drug to escape through the nose and mouth.

7. A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that going out with friends is no longer enjoyable. How would the nurse respond? "There are a variety of support groups for people who have COPD." "I will ask your primary health care provider to prescribe an antianxiety agent." "I'd like to hear about thoughts and feelings causing you to limit social activities." "Friends can be a good support system for clients with chronic disorders."

"I'd like to hear about thoughts and feelings causing you to limit social activities."

A nurse cares for a client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How would the nurse respond? "Since many of your family members are carriers, your children will also be carriers of the gene." "Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder." "Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." "Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder."

"Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse would encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client's teaching? "Make a list of reasons why smoking is a bad habit" "Rise slowly when getting out of bed in the morning" "Smoking while taking this medication will increase your risk of a stroke" "Stopping this medication suddenly increases your risk for heart attack"

"Smoking while taking this medication will increase your risk of a stroke"

The nurse is caring for a client who has cystic fibrosis (CF). The client asks for information about gene therapy. What response by the nurse is best? "Unfortunately, gene therapy is only provided to children upon diagnosis." "Do you know that you will have to have genetic testing?" "There is a good treatment for the most common genetic defect in CF." "Gene therapy will only help improve your pulmonary symptoms."

"There is a good treatment for the most common genetic defect in CF."

A nurse is teaching a client how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? (Select all that apply.) "Open your mouth and breathe deeply." "Use your abdominal muscles to squeeze air out of your lungs." "Breath out slowly without puffing your cheeks." "Focus on inhaling and holding your breath as long as you can." "Exhale at least twice the amount of time it took to breathe in." "Lie on your back with your knees bent."

"Use your abdominal muscles to squeeze air out of your lungs." "Breath out slowly without puffing your cheeks." "Exhale at least twice the amount of time it took to breathe in."

While obtaining a client's health history, the client states, "I am allergic to avocados, molds, and grass." Which responses by the nurse are best? (Select all that apply.) "What happens when you are exposed to those things? "How do you treat these allergies?" "When was the last time you ate foods containing avocados?" "I will document this in your record so all so everyone knows." "Have you ever been in the hospital after an allergic response?" "How do manage to avoid grass and mold?"

"What happens when you are exposed to those things? "How do you treat these allergies?" "I will document this in your record so all so everyone knows." "Have you ever been in the hospital after an allergic response?"

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, "What does this mean?" How would the nurse respond? "Your children will be at high risk for chronic obstructive pulmonary disease." "I will contact a genetic counselor to discuss your condition." "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." "This is a recessive gene and would have no impact on your health." (highlighted)

"Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." Rationale: Alpha1-antitrypsin deficiency is an important risk factor for COPD. The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent COPD unless the client smokes or there is sufficient exposure to other inhalants

A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first? A 66-year-old client with a barrel chest and clubbed fingernails A 48-year-old client with an oxygen saturation level of 92% at rest A 35-year-old client who reports orthopnea in bed A 27-year-old client with a heart rate of 120 beats/min (highlighted)

A 27-year-old client with a heart rate of 120 beats/min Rationale: Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available.

A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%

21% Rationale: 21%= RA

The nurse is caring for a 3-year-old who suffered a smoke inhalation injury. How long is this patient at the highest risk for pulmonary edema after exposure? a. 2 hours b. 4 hours c. 18 hours d. 72 hours

72 hours Rationale: Pulmonary edema appears in a child with smoke inhalation injury 6 to 72 hours after exposure.

17. A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client would the nurse assess first? A 46 year old with a 30-pack-year history of smoking A 52 year old in a tripod position using accessory muscles to breathe A 68 year old who has dependent edema and clubbed fingers A 74 year old with a chronic cough and thick, tenacious secretions (highlighted)

A 52 year old in a tripod position using accessory muscles to breathe Rationale: The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how effectively the client is breathing and provide interventions to minimize respiratory distress. The other clients are not in acute distress.

What is the best choice for fluid replacement that the nurse can offer a child who has just had a tonsillectomy? a. A popsicle b. Chocolate milk c. Orange juice d. Cola drink

A popsicle Rationale: Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as irritating as natural juices. A popsicle is usually well-tolerated.

nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care? Assistance with activities of daily living Physical therapy activities every day Oxygen therapy at 2 L per nasal cannula Complete bedrest with frequent repositioning

Assistance with activities of daily living

The nurse reports which assessments that suggest a meconium ileus in a newborn? (Select all that apply.) a. Abdominal distention b. Vomiting c. Hiccoughing d. Jaundice e. Absence of stool

Abdominal distention Vomiting Absence of stool

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) Absorptive atelectasis Combustion Dried mucous membranes Alveolar recruitment Toxicity

Absorptive atelectasis Combustion Dried mucous membranes Toxicity

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best? (Select all that apply.) Administer prescribed salmeterol inhaler. Assess the client for a tracheal deviation. Administer oxygen and place client on an oximeter. Perform peak expiratory flow readings. Administer prescribed albuterol inhaler. Assess the client's lung sounds after administering the inhaler. (highlighted)

Administer oxygen and place client on an oximeter. Administer prescribed albuterol inhaler. Assess the client's lung sounds after administering the inhaler.

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take? Ambulate the client in the hallway to promote deep breathing. Auscultate the client's anterior and posterior lung fields. Encourage the client to take shallow breaths to help with the pain. Administer pain medication and encourage the client to take deep breaths.

Administer pain medication and encourage the client to take deep breaths. Rationale: A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse would provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client's discomfort and need to take deep breaths to prevent complications.

A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)? Apply water-soluble ointment to nares and lips. Periodically turn the oxygen down or off. Replaces the oxygen tubing with a different type. Turn the client every 2 hours or as needed.

Apply water-soluble ointment to nares and lips. Rationale: Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client's lips and nares. The AP would not adjust the oxygen flow rate or replace the tubing. Turning the client is not related to comfort measures for oxygen.

A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed? Applying suction while inserting the catheter Preoxygenating the client prior to suctioning Suctioning for a total of three times if needed Suctioning for only 10 to 15 seconds each time (highlighted)

Applying suction while inserting the catheter

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to assistive personnel (AP)? (Select all that apply.) Applying water-soluble lip balm to the client's lips Ensuring that the humidification provided is adequate Performing oral care with alcohol-based mouthwash Reminding the client to cough and deep breathe often Suctioning excess secretions through the tracheostomy Holding the new tracheostomy tube while the RN changes the ties

Applying water-soluble lip balm to the client's lips Reminding the client to cough and deep breathe often

2. A nurse cares for a client with arthritis who reports frequent asthma attacks. What action would the nurse take first? Review the client's pulmonary function test results. Ask about medications the client is currently taking. Assess how frequently the client uses a bronchodilator. Consult the primary health care provider and request arterial blood gases.

Ask about medications the client is currently taking. Rationale: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a likely culprit given the client's history.

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) Ask the client to drink 2 L of fluids daily. Add humidity to the prescribed oxygen. Suction the client every 2 to 3 hours. Use a vibrating chest physiotherapy device. Encourage diaphragmatic breathing. Administer the ordered mucolytic agent. (highlighted)

Ask the client to drink 2 L of fluids daily. Add humidity to the prescribed oxygen. Use a vibrating chest physiotherapy device. Administer the ordered mucolytic agent.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next? Call the primary health and request food and water for the client Provide the client with ice chips instead of a drink of water Assess the client's gag reflex before giving any food or water Let the client have a small sip to see whether he or she can swallow

Assess the client's gag reflex before giving any food or water Rationale: The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

A 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. (highlighted)

Assess the client's oxygen saturation. Rationale: This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy.

An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best? Assess the clients lung sounds Assign a different AP to the client Report the AP to the manager Request thicker liquids for meals (highlighted)

Assess the clients lung sounds

What should the nurse explain to the parent of a child with exercise-induced asthma about when to inhale Cromolyn? a. Before exercise to prevent attacks b. At the initial onset of the attack c. During the attack to relieve symptoms d. As often as 4 times a day

Before exercise to prevent attacks

The nurse would observe a child for frequent swallowing after a tonsillectomy and adenoidectomy (T&A). What might this indicate? a. Bleeding from the surgical site b. Pain at the incision area c. Sore throat from postnasal drip d. Potential vomiting

Bleeding from the surgical site Rationale: Hemorrhage is the most common postoperative complication. Blood trickling down the back of the childs throat could cause frequent swallowing.

The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in either of their families has CF. What is the nurses best response based on the understanding of CF? a. Only one parent carries the CF gene. b. Both parents are carriers of the CF gene. c. The inheritance pattern is multifactorial. d. The result is probably a genetic mutation.

Both parents are carriers of the CF gene.

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? Assess the client's oxygen saturation and, if normal, turn off the oxygen. Determine if the client can switch to a nasal cannula during the meal. Have the client lift the mask off the face when taking bites of food. Turn the oxygen off while the client eats the meal and then restart it.

Determine if the client can switch to a nasal cannula during the meal. Rationale: Oxygen is a drug that needs to be delivered constantly. The nurse would determine if the primary health care provider has approved switching to a nasal cannula during meals.

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first? Document the findings. Administer oxygen therapy. Position the client in high-Fowler position. Administer prescribed albuterol.

Document the findings. Rationale: Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse would document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal.

The asthmatic child who has been taking theophylline complains of stomachache and tachycardia and is sweating profusely. What does the nurse recognize as the cause of these symptoms? a. Severe asthma attack b. Allergic response to theophylline c. Onset of bronchitis d. Drug toxicity

Drug toxicity Rationale: The symptoms described are the signs of theophylline toxicity.

A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action would the nurse take? Encourage oral rinsing after fluticasone administration. Obtain an oral specimen for culture and sensitivity. Start the client on a broad-spectrum antibiotic. Document the finding as a known side effect. (highlighted)

Encourage oral rinsing after fluticasone administration. Rationale: The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infenction

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process would the nurse correlate with this client's history and clinical signs and symptoms? Increased pulmonary pressure creating a higher workload on the right side of the heart Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles Increased number and size of mucous glands producing large amounts of thick mucus Left ventricular hypertrophy creating a decrease in cardiac output (highlighted)

Increased pulmonary pressure creating a higher workload on the right side of the heart Rationale: Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure

An infant is hospitalized with RSV bronchiolitis. What is the priority nursing diagnosis? a. Fatigue related to increased work of breathing b. Ineffective breathing pattern related to airway inflammation and increased secretions c. Risk for fluid volume deficit related to tachypnea and decreased oral intake d. Fear and/or anxiety related to dyspnea and hospitalization

Ineffective breathing pattern related to airway inflammation and increased secretions Rationale: An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.

What would the nurse teaching an asthmatic child the technique of pursed-lip breathing include? (Select all that apply.) a. Inhale deeply through nose with mouth closed. b. Make exhalation twice as long as inhalation. c. Use medicated inhaler prior to performing breathing exercise. d. Exhale through mouth as if whistling. e. Exhale forcefully.

Inhale deeply through nose with mouth closed. Make exhalation twice as long as inhalation. Exhale through mouth as if whistling.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met? 100% of meals being eaten by the client Intact skin behind the ears The client understanding the need for oxygen Unchanged weight for the past 3 days

Intact skin behind the ears Rationale: Oxygen tubing can cause high risk for skin breakdown

A nurse is assessing a client's history of particular matter exposure. What questions are consistent with the I PREPARE tool? (Select all that apply.) Investigate all history of known exposures. Determine if breathing problems are worse at work. Ask the client what type of heating is in the home. Gather details about the geographic location of the client's home. Have client list all previous jobs and work experiences. Assess what hobbies the client and family enjoy.

Investigate all history of known exposures. Determine if breathing problems are worse at work. Ask the client what type of heating is in the home. Gather details about the geographic location of the client's home. Have client list all previous jobs and work experiences. Assess what hobbies the client and family enjoy.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary artery hypertension. What actions would the nurse take to ensure the client's safety while on this medication? (Select all that apply.) Keep an intravenous line dedicated strictly to the infusion. Teach the client that this medication increases pulmonary pressures. Ensure that there is always a backup drug cassette available. Start a large-bore peripheral intravenous line. Use strict aseptic technique when using the drug delivery system.

Keep an intravenous line dedicated strictly to the infusion. Ensure that there is always a backup drug cassette available. Use strict aseptic technique when using the drug delivery system.

A nurse cares for a client who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment? Strip the tubing to minimize clot formation and ensure patency. Secure tubing junctions with clamps to prevent accidental disconnections. Connect the chest tube to wall suction as prescribed by the primary health care provider. Keep padded clamps at the bedside for use if the drainage system is interrupted.

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

11. A nurse cares for a client who is infected with Burkholderia cepacia. What action would the nurse take first when admitting this client to a pulmonary care unit? Instruct the client to wash his or her hands after contact with other people. Implement Droplet Precautions and don a surgical mask. Keep the client separated from other clients with cystic fibrosis. Obtain blood, sputum, and urine culture specimens.

Keep the client separated from other clients with cystic fibrosis. Rationale: B. cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for infected clients to be separated from noninfected clients

5. When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would the nurse immediately report? a. Respiration rate decrease from 40 to 32 breaths/min b. Heart rate decrease from 110 to 100 beats/min c. Quiet chest from previous assessment of wheezing d. Oxygen saturation of 90%

Quiet chest from previous assessment of wheezing Rationale: A quiet chest after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest. All other options are within normal range for infants undergoing oxygen administration.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? Tell the client that he or she needs to quit smoking to stop further cancer development. Encourage the client to be completely honest about both tobacco and marijuana use. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. Avoid giving the client false hope regarding cancer treatment and prognosis.

Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

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? Elevate the head of the client's bed. Measure and compare cuff pressures. Place the client on NPO status. Request that the client have a swallow study.

Measure and compare cuff pressures. Rationale: 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 describes the allergic salute as a cluster of what signs related to chronic allergy? (Select all that apply.) a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes d. Productive cough e. Reddened conjunctiva

Mouth breathing Transverse nasal crease Dark circles under the eyes Reddened conjunctiva

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.) Bradycardia New-onset cough Purulent sputum Tachypnea Pain with respirations Rapid, shallow respirations

New-onset cough Tachypnea Pain with respirations

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next? Administer the albuterol treatment Notify the rapid response team Assess the client's peripheral pulses Obtain blood and sputum cultures

Notify the Rapid Response Team Rationale: Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of benzocaine spray. This condition can lead to death.

A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response team, what action by the nurse takes is most important? Take a full set of vitals Obtain a pulse oximetry reading Ask the patient about hemoptysis Inspect the biopsy site

Obtain a pulse oximetry reading Rationale: Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy

How would the nurse advise a mother to clear the nostrils when her infant has a cold? a. Clear the nasal passages after the infant has a feeding. b. Use over-the-counter nose drops to clear passages. c. Remove nasal secretions with a bulb syringe. d. Instill saline nose drops after clearing away secretions.

Remove nasal secretions with a bulb syringe. Rationale: The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the secretions with a bulb syringe.

The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding would indicate the child is experiencing increased respiratory obstruction? a. Restlessness b. Tachycardia c. Brassy cough d. Expiratory wheezing

Restlessness Rationale: Restlessness is a primary sign of increased respiratory obstruction.

The nurse is caring for a 4-year-old child diagnosed with H. influenzae type B. Which signs and symptoms exhibited by the child would alert the nurse to suspect epiglottitis? (Select all that apply.) a. Harsh cough b. Restlessness c. Edematous epiglottis d. Child insists on lying down e. Drooling

Restlessness Edematous epiglottis Drooling

The nurse offers a variety of fluids to a 5-year-old asthmatic child to compensate for the fluid loss through dyspnea. Which fluids are most appropriate? a. Room temperature water b. Carbonated beverages c. Iced fruit juice d. Cold milk

Room temperature water Rationale: Room temperature fluids are the best. Carbonated and iced beverages increase spasm. Milk stimulates mucus production.

The nurse would suggest the parents of an asthmatic child to encourage participation in which sport(s)? SWIMMING, GYMNASTICS, BASEBALL

SWIMMING, GYMNASTICS, BASEBALL Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics. Swimming, gymnastics, and baseball fit this criterion. DISTANCE RUNNING- WOULD NOT BE APPROPRIATE

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? Call the operating room to inform them of a pending emergency case. No action is needed at this time; this is a normal finding in some clients. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. Stay with the client and have someone else call the primary health care provider immediately. (highlighted)

Stay with the client and have someone else call the primary health care provider immediately.

What will the nurse discourage when providing education to parents of a child with asthma? (Select all that apply.) a. Stuffed toys b. Pet ownership c. Gymnastics d. Basketball e. Cotton blankets

Stuffed toys Basketball

2. Which initial intervention will the nurse suggest to the parents of a child experiencing laryngeal spasm? a. Take the child outside in the cool air. b. Bring the child directly to the emergency department. c. Take the child to the bathroom and turn on a hot shower. d. Have the child drink plenty of fluids. (will for sure be on test)

Take the child to the bathroom and turn on a hot shower. Rationale: The child experiencing laryngeal spasm should be placed in a high-humidity environment, such as the bathroom with a hot shower running. The humidity liquefies secretions and reduces spasm.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) The client does not allow smoking in the house. Electrical cords are in good working order. Flammable liquids are stored in the garage. Household light bulbs are the fluorescent type. The client does not have pets inside the home. No alcohol-based hand sanitizers are present.

The client does not allow smoking in the house. Electrical cords are in good working order. Flammable liquids are stored in the garage.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client's decrease in self-esteem are being met? The client demonstrates good understanding of stoma care care. The client has joined a book club that meets at the library. Family members take turns assisting with stoma care. Skin around the stoma is intact without signs of infection.

The client has joined a book club that meets at the library.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching? The client lies on his or her side with knees bent. The client places his or her hands on the abdomen. The client lies in a prone position with straight. The client places his or her hands above the head.

The client places his or her hands on the abdomen. Rationale: To perform diaphragmatic breathing correctly, the client would place his or her hands on the abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

A client, who has become increasingly dyspneic over a year, has been diagnosed with pulmonary fibrosis. What information would the nurse plan to include in teaching this client? (Select all that apply.) The need to avoid large crowds and people who are ill Safety measures to take if home oxygen is needed Information about appropriate use of the drug nintedanib Genetic therapy to stop the progression of the disease Measures to avoid fatigue during the day The possibility of receiving a lung transplant if infection-free for a year

The need to avoid large crowds and people who are ill Safety measures to take if home oxygen is needed Information about appropriate use of the drug nintedanib Measures to avoid fatigue during the day

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? The client rates pain as a 5/10 at the site of the procedure A small amount of drainage from the site is noted Pulse oximetry is 93% on 2L of oxygen The trachea is shifted toward the opposite side of the neck

The trachea is shifted toward the opposite side of the neck Rationale: A shift of central thoracic structures toward one side is a sign of a tension pneumothorax which is a medical emergency

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) Production of pink sputum Tracheal deviation Pain at insertion site Sudden onset of shortness of breath Drainage greater than 70 mL/hr Disconnection at Y site

Tracheal deviation Sudden onset of shortness of breath Drainage greater than 70 mL/hr Disconnection at Y site

A nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse? Holding the device securely when changing ties Suctioning the client first is the secretions are present Trying a square knot at the back of the neck Using half-strength peroxide for cleansing

Trying a square knot at the back of the neck Rationale: To prevent pressure injuries and for client safety, when ties are used that must be knotted, the knot would be placed at the side of the client's neck, not in back. The other actions are appropriate.

A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.) Provide a clear liquid breakfast. Verify that the informed consent was obtained. Document the client's allergies. Review laboratory results. Hold the client's bronchodilator. Monitor the client for at least 24 hours afterwards.

Verify that the informed consent was obtained. Document the client's allergies. Review laboratory results. Monitor the client for at least 24 hours afterwards.

A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or symptoms would the nurse identify as adverse effects of this medication? (Select all that apply.) Visual hallucinations Tachycardia Decreased cravings Manic behavior Increased thirst Orangish urine

Visual hallucinations Manic behavior Rationale: Varenicline has a black box warning stating that the drug can cause manic behavior and hallucinations.

Which statement indicates that the childs parents understand how to perform respiratory therapy? a. We do her postural drainage before the aerosol therapy. b. We give her respiratory treatments when she is coughing a lot. c. We give the aerosol followed by postural drainage before meals. d. She needs respiratory therapy every day when she has an infection.

We give the aerosol followed by postural drainage before meals. Rationale: Postural drainage for the child with CF is done following nebulization. Therapy is best scheduled before meals or at least 1 hour after eating to prevent vomiting.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): What action would the nurse take first? Administer a short-acting beta2 agonist inhaler. Document the findings as normal for a client with COPD. Teach the client diaphragmatic breathing techniques. Initiate oxygenation therapy to increase saturation to 88%-92%

pH: 7.32 PaCO2: 62 HCO3:28 HR: 110 RR: 12 BP:145/65 02: 76% Rationale: Oxygen would be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the client's hypoxia, which is the major issue. There is no indication the client needs an inhaler. Diaphragmatic breathing techniques would not be taught to a client in distress. These findings are not normal for all clients with COPD.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? Measure oxygen saturation before and after a 12-minute walk. Verify that the client understands all possible complications. Explain the procedure in detail to the client and the family. Validate that informed consent has been given by the client.

validate that informed consent has been given by the client. Rationale: A thoracentesis is an invasive procedure with many potentially serious complications