A&C I Practice Respiratory Assessment #1

A nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client. Which of the following results indicates exposure to and a possible infection with tuberculosis (TB)?

15 mm induration A positive reaction to a tuberculin skin test is an induration (a hardened area) that is 10 mm or greater in diameter. The nurse should measure the area of induration, not any accompanying erythema or swelling.

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A room with air exhausts directly to the outdoor environment A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of anti-tubercular medications. Which of the following information should the nurse include in the teaching?

A typical course of treatment involves 6 to 9 months of consistent medication use. Pulmonary TB is a contagious bacterial infection caused by Mycobacterium tuberculosis. Active TB is usually treated with the simultaneous administration of a combination of medications to which the organisms are susceptible. Such therapy is continued until the disease is controlled. A 6- to 9-month regimen consisting of two, and often four, different medications is used. The client should not drink alcohol during this time.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Administer oxygen therapy The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation.

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?

Administer the abdominal thrust maneuver The nurse should immediately begin applying abdominal thrusts to a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange.

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

Auscultate lung fields The first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to auscultate lung fields to provide knowledge of which lung areas are most affected and would be the focus of the procedure.

A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. The nurse should recognize these findings are associated with which of the following diagnises?

Bronciolitis A client who has bronchiolitis often has sneezing, coughing, nasal congestion, intermittent fever, and in severe cases, apneic spells. Bronchiolitis is also most common in infants between 2 and 12 months of age.

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

Confusion Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.

A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. which of the following findings indicates that the treatment has been effective?

Decreased stridor Laryngotracheobronchitis, or croup, is a condition caused by an infection of the upper airway (larynx, trachea, and bronchus) and is characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The direct purpose of a cool mist tent is to humidify the inspired air, which decreases respiratory effort.

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

Frequent swallowing Children who exhibit frequent swallowing should be evaluated for hemorrhage.

A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this postoperative complication?

Frequent swallowing Frequent swallowing and throat clearing are signs of hemorrhage after a tonsillectomy.

A nurse is caring for a client who has active pulmonary TB. The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray.

Have the client wear a mask. When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Heparin A pulmonary embolism is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot of formation of new clots.

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis?

Night sweats Low grade fever Blood in sputum

A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?

Place the client in a private room with a special ventilation system. Clients who have active tuberculosis should be assigned to private rooms with negative-pressure airflow via HEPA filtration systems. In these rooms, the air is not returned to the inside ventilation system but is filtered and exhausted directly to the outside.

A nurse in an emergency department is assessing a 3 year old child who has a high fever, severe dyspnea, and is drooling. Whihc of the following actions is the nurse's priority?

Prepare for a nasotracheal intubation The client's manifestations suggest epiglottitis, which is a respiratory emergency. Airway obstruction is imminent, and that is the greatest risk to the client's safety at this time, so the priority action is to prepare for intubation to maintain airway patency.

A nurse is providing teaching to a parent of a child who has acute group A beta hemolytic streptococci. Which of the following information should the nurse include in the teaching?

Replace the child's toothbrush after 24 hr on antibiotics The child's toothbrush should be replaced after 24 hr on antibiotics to prevent the spread of infection or re-infection.

A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer?

Rifampin Isoniazid Pyrazinamide A client who has tuberculosis should take rifampin to kill slower growing micro-organisms. The nurse should instruct the client to avoid drinking alcohol, to expect body secretions to have a reddish-orange tinge, and to report a yellow tinge to the skin or whites of the eyes. A client who has tuberculosis should take isoniazid to kill actively growing mycobacteria. The nurse should instruct the client to take the medication on an empty stomach and to take a daily multiple vitamin. A client who has tuberculosis usually takes pyrazinamide for the first 12 months of therapy and can shorten the entire course of therapy to 6 months. The nurse should instruct the client to drink at least 240 mL (8 oz) of fluid when taking the medication and to protect himself from the sun with cotton clothing and sunscreen.

A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

Sputum culture for acid-fast bacillus Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis.

A nurse is teaching a client about the intradermal purified protein derivative (PPD). Which of the following information should the nurse include?

This test is performed if previous results are negative The nurse should assess whether the client has tested positive to a prior PPD test. For clients who have tested positive, chest x-ray is performed to determine exposure.

A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored?

Visual acuity A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of color discrimination, especially red and green. Baseline vision testing should be performed before use, and visual acuity monitored at regular intervals.

A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching?

We'll discard his toothbrush and buy another Children who have positive throat cultures for streptococcal infection should replace their toothbrush after they have been taking antibiotics for 24 hr. Using a contaminated toothbrush can re-introduce the bacteria and spread it to others if others handle the toothbrush.