Ch 27: Assessment of the Respiratory System, Respiratory Practice Questions

The nurse is caring for a client with lung cancer who states, "I don't want any pain medication because I am afraid I'll become addicted." How should the nurse respond? Select one: a. "I will ask the provider to change your medication to a drug that is less potent." b. "Would you like me to give you acetaminophen (Tylenol) instead?" c. "It is unlikely you will become addicted when taking medicine for pain." d. "Would you like me to use music therapy to distract you from your pain?"

Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medication. The correct answer is: "It is unlikely you will become addicted when taking medicine for pain."

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? Select one: a. "I will use my portable oxygen when grilling burgers in the backyard." b. "I plan to wear my oxygen when I exercise and feel short of breath." c. "I plan to use cotton balls to cushion the oxygen tubing on my ears." d. "I will only smoke while I am wearing my oxygen via nasal cannula."

Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling and smoking increases the risk for fire. The correct answer is: "I plan to use cotton balls to cushion the oxygen tubing on my ears."

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

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

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

Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention. The correct answers are: Tracheal deviation, Sudden onset of shortness of breath, Drainage greater than 70 mL/hr, Disconnection at Y site

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? Select one: a. "We are testing for any possible source of infection in the client." b. "Chest x-rays are always ordered when we suspect pneumonia." c. "The x-ray can be done and read before laboratory work is reported." d. "Older people often have vague symptoms, so an x-ray is essential."

It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive manifestations are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has manifestations of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder. The correct answer is: "Older people often have vague symptoms, so an x-ray is essential."

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

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

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

Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has approved switching to a nasal cannula during meals. If not, the nurse should consult with the provider about this issue. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered. The correct answer is: Determine if the client can switch to a nasal cannula during the meal.

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.) Select one or more: a. The client does not have pets inside the home. b. The client does not allow smoking in the house. c. Household light bulbs are the fluorescent type. d. Flammable liquids are stored in the garage. e. Electrical cords are in good working order.

Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety. The correct answers are: The client does not allow smoking in the house., Electrical cords are in good working order., Flammable liquids are stored in the garage.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3- = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? Select one: a. Teach the client diaphragmatic breathing techniques. b. Document the findings as normal for a client with COPD. c. Initiate oxygenation therapy to increase saturation to 92%. d. Administer a short-acting beta2 agonist inhaler.

Oxygen should 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 priority.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching? Select one: a. "Add peppermint oil to the humidifier to relax the airway." b. "Keep the humidifier filled with water at all times." c. "Make sure you clean the humidifier to prevent infection." d. "Use the humidifier when you sleep, even during daytime naps."

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

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? Select one: a. Tell the client that he needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Avoid giving the client false hope regarding cancer treatment and prognosis. d. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs per day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Quitting smoking may not stop further cancer development. This statement would be giving the client false hope, which should be avoided, but is not as important as maintaining a nonjudgmental attitude. The correct answer is: Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

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

Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history. The correct answer is: Increased pulmonary pressure creating a higher workload on the right side of the heart

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? Select one: a. Administer prescribed intravenous pain medication. b. Assist the client to choose a communication method. c. Ambulate the client in the hallway to assess gait. d. Assess airway patency, breathing, and circulation.

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

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? Select one: a. Document the finding as a known side effect. b. Start the client on a broad-spectrum antibiotic. c. Encourage oral rinsing after fluticasone administration. d. Obtain an oral specimen for culture and sensitivity.

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 infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity will not provide information necessary to care for this client. The correct answer is: Encourage oral rinsing after fluticasone administration.

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) Select one or more: a. Change the nasal packing. b. Administer a nasal steroid to decrease edema. c. Ask the client to open his or her mouth. d. Watch the client for frequent swallowing. e. Observe for clear drainage. f. Assess for signs of bleeding.

The nurse should observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse should assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse should also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which should be changed by the surgeon the first time. The correct answers are: Observe for clear drainage., Assess for signs of bleeding., Watch the client for frequent swallowing., Ask the client to open his or her mouth.

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? Select one: a. Request thicker liquids for meals. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Assess the client's lung sounds.

The priority is to check the client's oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority. The correct answer is: Assess the client's lung sounds.

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

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

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? Select one: a. Assess the client's oxygen saturation. b. Oxygenate the client with a bag-valve-mask. c. Palpate the skin of the upper chest. d. Notify the Rapid Response Team.

This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the client's oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client. The correct answer is: Assess the client's oxygen saturation.

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? Select one: a. The client lays in a prone position with his or her legs straight. b. The client places his or her hands on his or her abdomen. c. The client places his or her hands above his or her head. d. The client lays on his or her side with his or her knees bent.

To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her 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. The correct answer is: The client places his or her hands on his or her abdomen.

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

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

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"

ANS: A Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information.

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

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

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

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

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

ANS: A A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? A) When the bronchial tree is obstructed B) When adventitious sounds are present C) In conjunction with whispered pectoriloquy D) In conditions of consolidation, such as pneumonia

ANS: A Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. A) side-to-side B) top-to-bottom C) posterior-to-anterior D) interspace-by-interspace

ANS: A Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are incorrect.

When assessing a patient's lungs, the nurse recalls that the left lung: A) consists of two lobes. B) is divided by the horizontal fissure. C) consists primarily of an upper lobe on the posterior chest. D) is shorter than the right lung because of the underlying stomach.

ANS: A The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobe.

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: A) the spinous process of C7. B) usually not palpable in most individuals. C) opposite the interior border of the scapula. D) located next to the manubrium of the sternum.

ANS: A The spinous process of C7 is the vertebra prominens. It is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.

A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

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

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

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

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

ANS: A, C, D, E Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.

A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Impaired judgment e. Increased thirst

ANS: A, D Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse should assess for changes in behavior and thought processes, including impaired judgment and visual hallucinations. Tachycardia and increased thirst are not adverse effects of this medication. Decreased cravings is a therapeutic response to this medication.

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

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

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

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

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."

ANS: B It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive manifestations are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has manifestations of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.

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

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

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

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first? a. Encourage the client to increase fluid intake. b. Assess the client's level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.

ANS: B Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to: A) assure the mother that these are normal symptoms of a cold. B) recognize that these are serious signs and contact the physician. C) ask the mother if the infant has had trouble with feedings. D) perform a complete cardiac assessment because these are probably signs of early heart failure.

ANS: B The infant is an obligatory nose breather until the age of 3 months. Normally there is no flaring of the nostrils and no sternal or intercostal retraction. Marked retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and assessment of the infant's feeding is not a priority at this time.

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: A) bronchitis. B) a pneumothorax. C) acute pneumonia. D) an asthmatic attack.

ANS: B With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are seen. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. See Table 18-8 for descriptions of the other conditions.

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

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

A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor-Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

ANS: C First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. Fexofenadine is a second-generation antihistamine.

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

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

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

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

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: What action by the nurse takes priority? a. Assess the client for possible items to which he or she is allergic. b. Call the primary care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.

ANS: C This "allergy test" is actually a positive tuberculosis test. The client should be placed on Airborne Precautions immediately. The other options do not take priority over preventing the spread of the disease.TB

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. "Ice packs may help with the facial pain." b. "Limit fluids to dry out your sinuses." c. "Try warm, moist heat packs on your face." d. "We will schedule you for a computed tomography scan this week."

ANS: C This client has rhinosinusitis. Comfort measures for this condition include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are: A) musical in quality. B) usually pathological. C) expected near the major airways. D) similar to bronchial sounds except that they are shorter in duration.

ANS: C Bronchovesicular sounds are heard over major bronchi where fewer alveoli are located: posteriorly, between the scapulae, especially on the right; anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

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

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

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

ANS: D Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have manifestations of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client should be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

A nurse is caring for a patient who is on mechanical ventilation. What actions will promote comfort in this patient? (Select all that apply.) A. Allow visitors at the patient's bedside. B. Ensure that the patient can communicate if awake. C. Keep the television tuned to a favorite channel. D. Provide back and hand massages when turning. E. Turn the patient every 2 hours or more.

A, B, D, E

A nurse is planning discharge teaching on tracheostomy care for an older patient. What factors does the nurse need to assess before teaching this particular patient? (Select all that apply.) A. Cognition B. Dexterity C. Hydration D. Range of motion E. Vision

A, B, D, E

A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the patient's face is puffy and the eyelids are swollen. What action by the nurse takes priority? A. Assess the patient's oxygen saturation. B. Notify the Rapid Response Team. C. Oxygenate the patient with a bag-valve-mask. D. Palpate the skin of the upper chest.

A

A patient has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the patient will need as the priority? A. Alteplase B. Enoxaparin C. Unfractionated heparin D. Warfarin sodium

A

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

A

A patient is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)? A. Apply water-soluble ointment to nares and lips. B. Periodically turn the oxygen down or off. C. Remove the tubing from the patient's nose. D. Turn the patient every 2 hours or as needed.

A

An unlicensed assistive personnel (UAP) was feeding a patient with a tracheostomy. Later that evening, the UAP reports that the patient had a coughing spell during the meal. What action by the nurse takes priority? A. Assess the patient's lung sounds. B. Assign a different UAP to the patient. C. Report the UAP to the manager. D. Request thicker liquids for meals.

A

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

A, B, E

The nurse caring for mechanically ventilated patients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) A. Chest wall stiffness B. Decreased muscle strength C. Inability to cooperate D. Less lung elasticity E. Poor vision and hearing

A, B, D

A patient is on intravenous heparin to treat a pulmonary embolism. The patient's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? A. Decrease the heparin rate. B. Increase the heparin rate. C. No change to the heparin rate. D. Stop heparin; start warfarin.

B

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

B

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

B

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

B

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

B, D, E, F

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

C

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

Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better. The correct answer is: "Eat a well-balanced, nutritious diet."

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? A. Applying suction while inserting the catheter B. Preoxygenating the patient prior to suctioning C. Suctioning for a total of three times if needed D. Suctioning for only 10 to 15 seconds each time

A

The nurse instructs a patient on the steps needed to obtain a peak expiratory flow rate. In which order would these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." A. 4, 2, 1, 3, 5, 6, 7 B. 3, 4, 1, 2, 5, 7, 6 C. 2, 1, 3, 4, 5, 6, 7 D. 1, 3, 2, 5, 6, 7, 4

A

A nurse assesses a 66-year-old client who is attempting to quit smoking. The client states, "I started smoking at age 16, and smoked one pack each day until 10 years ago. Then I decreased to a half of a pack per day." How many pack-years should the nurse document for this client? (Record your answer using a whole number.) ___ pack-years

ANS: 45 pack-years 66 (current age) - 16 (year started smoking) = 50 years of smoking. (40 years x 1 pack per day) + (10 years x 0.5 pack per day) = 45 pack-years.

A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.

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

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: A) dullness. B) tympany. C) resonance. D) hyperresonance.

ANS: A A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: A) asthma. B) atelectasis. C) lobar pneumonia. D) heart failure.

ANS: A Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma. See Table 18-8 for descriptions of the other conditions.

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

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

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation? A) Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema B) Rasping cough, thick mucoid sputum, wheezing, bronchitis C) Productive cough, dyspnea, weight loss, anorexia, tuberculosis D) Fever, dry nonproductive cough, diminished breath sounds

ANS: A Heart failure often presents with increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea are seen with tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia. See Table 18-8.

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? A) Between the scapulae B) Third intercostal space, MCL C) Fifth intercostal space, MAL D) Over the lower lobes, posterior side

ANS: A Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.

The primary muscles of respiration include the: A) diaphragm and intercostals. B) sternomastoids and scaleni. C) trapezius and rectus abdominis. D) external obliques and pectoralis major.

ANS: A The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles (sternomastoids, scalene, trapezii). Forced expiration involves the abdominal muscles.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? A) Wheezes B) Bronchial sounds C) Bronchophony D) Whispered pectoriloquy

ANS: A Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. B) As the patient says "ninety-nine" repeatedly, the examiner hears the words "ninety-nine" clearly. C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. E) As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.

ANS: A, C, D As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. e. Administer acetaminophen (Tylenol) twice daily.

ANS: A, C, D Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.

While obtaining a client's health history, the client states, "I am allergic to avocados." Which responses by the nurse are best? (Select all that apply.) a. "What response do you have when you eat avocados?" b. "I will remove any avocados that are on your lunch tray." c. "When was the last time you ate foods containing avocados?" d. "I will document this in your record so all of your providers will know." e. "Have you ever been treated for this allergic reaction?"

ANS: A, D, E Nurses should assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse should also document the allergies in a prominent place in the client's medical record. The nurse should collaborate with food services to ensure no avocados are placed on the client's meal trays. Asking about the last time the client ate avocados does not provide any pertinent information for the client's plan of care.

A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Find an activity that you enjoy and will keep your hands busy." b. "Keep snacks like potato chips on hand to nibble on." c. "Identify a punishment for yourself in case you backslide." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking."

ANS: A, D, E The nurse should teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least 8 glasses of water each day, and to make a list of reasons for quitting smoking. The nurse should also encourage the client not to be upset if he or she backslides and has a cigarette.

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."

ANS: A, D, E To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.

The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Cohort the "clients" in the same area of the unit. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.

ANS: B Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Clients can be cohorted together in the same set of rooms on one part of the unit to use distancing to help prevent the spread of the disease. The other actions are not appropriate.

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate: A) pneumonia. B) postnasal drip or sinusitis. C) exposure to irritants at work. D) chronic bronchial irritation from smoking.

ANS: B A cough that occurs mainly at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day.

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: A) tactile fremitus. B) crepitus. C) friction rub. D) adventitious sounds.

ANS: B Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

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. Which action should the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures.

ANS: B Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.

Which statement about the apices of the lungs is true? The apices of the lungs: A) are at the level of the second rib anteriorly. B) extend 3 to 4 cm above the inner third of the clavicles. C) are located at the sixth rib anteriorly and the eighth rib laterally. D) rest on the diaphragm at the fifth intercostal space in the midclavicular line.

ANS: B The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is: A) increased thoracic expansion. B) decreased mobility of the thorax. C) a decreased anteroposterior diameter. D) bronchovesicular breath sounds throughout the lungs.

ANS: B The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.

During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the: A) costal angle. B) sternal angle. C) xiphoid process. D) suprasternal notch.

ANS: B The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? A) An obese patient B) When part of the lung is obstructed or collapsed C) When bulging of the intercostal spaces is present D) When accessory muscles are used to augment respiratory effort

ANS: B Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain or atelectasis.

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client states he is dizzy. - Nurse applies oxygen and pulse oximetry. b. Client's heart rate is 55 beats/min. - Nurse withholds pain medication. c. Client has reduced breath sounds. - Nurse calls physician immediately. d. Client's respiratory rate is 18 breaths/min. - Nurse decreases oxygen flow rate.

ANS: C A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? A) Crepitus palpated at the costochondral junctions B) No diaphragmatic excursion as a result of a child's decreased inspiratory volume C) The presence of bronchovesicular breath sounds in the peripheral lung fields D) An irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

ANS: C Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are a normal finding. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults, so breath sounds are louder and harsher.

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply? A) "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." B) "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." C) "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." D) "This is normal as the fetus grows because of the increased oxygen demand on the mother's body and results in an increased respiratory rate."

ANS: C During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, even though structurally nothing is wrong. Estrogen increases relax the chest cage ligaments, causing an increase in transverse diameter. The growing fetus does increase the oxygen demand on the mother's body, but this is met easily by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? A) Absent or decreased breath sounds B) Productive cough with thin, frothy sputum C) Chest pain that is worse on deep inspiration, dyspnea D) Diffuse infiltrates with areas of dullness upon percussion

ANS: C Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, PaO2 less than 80, diaphoresis, hypotension, crackles, and wheezes.

The nurse knows that auscultation of fine crackles would most likely be noticed in: A) a healthy 5-year-old child. B) a pregnant woman. C) the immediate newborn period. D) association with a pneumothorax.

ANS: C Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus: A) is caused by moisture in the alveoli." B) indicates that there is air in the subcutaneous tissues." C) is caused by sounds generated from the larynx." D) reflects the blood flow through the pulmonary arteries."

ANS: C Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: A) adventitious sounds and limited chest expansion. B) increased tactile fremitus and dull percussion tones. C) muffled voice sounds and symmetrical tactile fremitus. D) absent voice sounds and hyperresonant percussion tones.

ANS: C Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? A) Airway obstruction B) Emphysema C) Pulmonary consolidation D) Asthma

ANS: C Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: A) bronchitis. B) pneumonia. C) tuberculosis. D) pulmonary edema.

ANS: C Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers.

The nurse is auscultating the chest in an adult. Which technique is correct? A) Instruct the patient to take deep, rapid breaths. B) Instruct the patient to breathe in and out through his or her nose. C) Use the diaphragm of the stethoscope held firmly against the chest. D) Use the bell of the stethoscope held lightly against the chest to avoid friction.

ANS: C The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? A) Obtain a detailed history of the patient's allergies and history of asthma. B) Tell the patient to sleep on his or her right side to facilitate ease of respirations. C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. D) Assure the patient that this is normal and will probably resolve within the next week.

ANS: C The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

The nurse notes hyperresonant percussion tones when percussing the thorax of an infant. The nurse's best action would be to: A) notify the physician. B) suspect a pneumothorax. C) consider this a normal finding. D) monitor the infant's respiratory rate and rhythm.

ANS: C The percussion note of hyperresonance occurs normally in the infant and young child, owing to the relatively thin chest wall. Anything less than hyperresonance would have the same clinical significance as would dullness in the adult.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: A) seen in patients with kyphosis. B) indicative of pectus excavatum. C) a normal finding in a healthy adult. D) an expected finding in a patient with a barrel chest.

ANS: C The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: A) sounds normally auscultated over the trachea. B) bronchial breath sounds and are normal in that location. C) vesicular breath sounds and are normal in that location. D) bronchovesicular breath sounds and are normal in that location.

ANS: C Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.

A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention? a. Hollow sounds are heard over the trachea. - The nurse increases the oxygen flow rate. b. Crackles are heard in bases. - The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. - The nurse has the client breathe deeply.

ANS: C Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention.

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

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

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

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

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: A) shallow breathing. B) normal lung tissue. C) decreased adipose tissue. D) increased density of lung tissue.

ANS: D A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor. Resonance is the expected finding in normal lung tissue.

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

ANS: D A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician or nurse practitioner, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these? A) Unequal chest expansion B) Increased tactile fremitus C) Atrophied neck and trapezius muscles D) An anteroposterior-to-transverse diameter ratio of 1:1

ANS: D An anteroposterior-to-transverse diameter of 1:1 or "barrel chest" is seen in individuals with chronic obstructive pulmonary disease because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.

The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult? A) Severe dyspnea is experienced on exertion resulting from changes in the lungs. B) Respiratory muscle strength increases to compensate for a decreased vital capacity. C) There is a decrease in small airway closure, leading to problems with atelectasis. D) The lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

ANS: D In the aging adult the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. There is a decreased vital capacity and a loss of intraalveolar septa, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.

When inspecting the anterior chest of an adult, the nurse should include which assessment? A) Diaphragmatic excursion B) Symmetric chest expansion C) The presence of breath sounds D) The shape and configuration of the chest wall

ANS: D Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness, skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.

A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain? a. Average daily fluid intake b. Neck circumference c. Height and weight d. Occupation and hobbies

ANS: D Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment.

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate? A) Croup B) Tuberculosis C) Viral infection D) Pulmonary edema

ANS: D Sputum alone is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema (or it may be a side effect of sympathomimetic medications). Croup is associated with a "barking" cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.

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

B

A student nurse is preparing to administer enoxaparin to a patient. What action by the student requires immediate intervention by the supervising nurse? A. Assessing the patient's platelet count B. Choosing an 18-gauge, 2-inch (5 cm) needle C. Not aspirating prior to injection D. Swabbing the injection site with alcohol

B

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

B

While assessing a patient who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action by the nurse is best? A. Assess for drainage from the site. B. Cover the insertion site with sterile gauze. C. Contact the provider and obtain a suture kit. D. Reinsert the tube using sterile technique.

B

A nurse assesses a patient who has a chest tube. For which manifestations would the nurse immediately intervene? (Select all that apply.) A. Production of pink sputum B. Tracheal deviation C. Sudden onset of shortness of breath D. Pain at insertion site E. Drainage of 75 mL/hr

B, C

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

B, C, E

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

B, C, E

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

Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for these clients to be separated from one another. Strict isolation measures will not be necessary. Although the client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with Burkholderia cepacia infection. The correct answer is: Keep the client isolated from other clients with cystic fibrosis.

A nurse cares for a patient who is infected with Burkholderia cepacia. What action would the nurse take first when admitting this patient to a pulmonary care unit? A. Instruct the patient to wash his or her hands after contact with other people. B. Implement droplet precautions and don a surgical mask. C. Keep the patient isolated from other patients with cystic fibrosis. D. Obtain blood, sputum, and urine culture specimens.

C

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

C

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

C

A nurse cares for a patient with chronic obstructive pulmonary disease (COPD). The patient states that he no longer enjoys going out with his friends. How would the nurse respond? A. "There are a variety of support groups for people who have COPD." B. "I will ask your provider to prescribe you with an antianxiety agent." C. "Share any thoughts and feelings that cause you to limit social activities." D. "Friends can be a good support system for patients with chronic disorders."

C

A patient is admitted with a pulmonary embolism (PE). The patient is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? A. Encourage the patient to walk 5 minutes each hour. B. Refer the patient to smoking cessation classes. C. Teach the patient about factor V Leiden testing. D. Tell the patient that sometimes no cause for disease is found.

C

A patient is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? A. Assess the patient for sedation needs. B. Get family permission for restraints. C. Provide frequent oral care per protocol. D. Use nonverbal pain assessment tools.

C

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

C

A nurse assesses a patient with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions would the nurse take? (Select all that apply.) A. Administer prescribed salmeterol (Serevent) inhaler. B. Assess the patient for a tracheal deviation. C. Administer oxygen to keep saturations greater than 94%. D. Perform peak expiratory flow readings. E. Administer prescribed albuterol (Proventil) inhaler.

C, E

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

D

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

D

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.) Select one or more: a. "Do you walk upstairs every day?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Have you lost any weight lately?" e. "What color is your sputum?"

Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously. The correct answers are: "Do you have any difficulty sleeping?", "How long does it take to perform your morning routine?", "Have you lost any weight lately?"

A nursing student caring for a patient removes the patient's oxygen as prescribed. The patient is now breathing what percentage of oxygen in the room air? A. 14% B. 21% C. 28% D. 31%

B

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

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

A 242-lb patient is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL

660

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

A

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

A

A nurse is caring for a patient on mechanical ventilation and finds the patient agitated and thrashing about. What action by the nurse is most appropriate? A. Assess the cause of the agitation. B. Reassure the patient that he or she is safe. C. Restrain the patient's hands. D. Sedate the patient immediately.

A

A patient appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? A. Assess for other manifestations of hypoxia. B. Change the sensor on the pulse oximeter. C. Obtain a new oximeter from central supply. D. Tell the patient to take slow, deep breaths.

A

A patient with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) A. Acknowledge the frightening nature of the illness. B. Delegate a back rub to the unlicensed assistive personnel (UAP). C. Give simple explanations of what is happening. D. Request a prescription for antianxiety medication. E. Stay with the patient and speak in a quiet, calm voice.

A, B, C, E

A home health nurse is visiting a new patient who uses oxygen in the home. For which factors does the nurse assess when determining if the patient is using the oxygen safely? (Select all that apply.) A. The patient does not allow smoking in the house. B. Electrical cords are in good working order. C. Flammable liquids are stored in the garage. D. Household light bulbs are the fluorescent type. E. The patient does not have pets inside the home.

A, B, C

A nurse teaches a patient who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this patient's teaching? (Select all that apply.) A. "Avoid drinking fluids just before and during meals." B. "Rest before meals if you have dyspnea." C. "Have about six small meals a day." D. "Eat high-fiber foods to promote gastric emptying." E. "Increase carbohydrate intake for energy."

A, B, C

The nurse caring for mechanically ventilated patients uses best practices to prevent ventilator- associated pneumonia. What actions are included in this practice? (Select all that apply.) A. Adherence to proper hand hygiene B. Administering antiulcer medication C. Elevating the head of the bed D. Providing oral care per protocol E. Suctioning the patient on a regular schedule

A, B, C, D

A nurse is teaching a patient about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the patient? (Select all that apply.) A. Absorptive atelectasis B. Combustion C. Dried mucous membranes D. Oxygen-induced hyperventilation E. Toxicity

A, B, C, E

A nurse plans care for a patient who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this patient's plan of care? (Select all that apply.) A. Ask the patient to drink 2 L of fluids daily. B. Add humidity to the prescribed oxygen. C. Suction the patient every 2 to 3 hours. D. Use a vibrating positive expiratory pressure device. E. Encourage diaphragmatic breathing.

A, B, E

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

A, C, E

A nurse is caring for a patient who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) A. Applying water-soluble lip balm to the patient's lips B. Ensuring that the humidification provided is adequate C. Performing oral care with alcohol-based mouthwash D. Reminding the patient to cough and deep breathe often E. Suctioning excess secretions through the tracheostomy

A, D

A patient is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the patient maintain self-esteem? (Select all that apply.) A. Create a communication system. B. Don't go out in public alone. C. Find hobbies to enjoy at home. D. Try loose-fitting shirts with collars. E. Wear fashionable scarves.

A, D, E

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? A) Listen to at least one full respiration in each location. B) Listen as the patient inhales and then go to the next site during exhalation. C) Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. D) If the patient is modest, listen to sounds over his or her clothing or hospital gown.

ANS: A During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: A) atelectatic crackles, and that they are not pathologic. B) fine crackles, and that they may be a sign of pneumonia. C) vesicular breath sounds. D) fine wheezes.

ANS: A One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? A) Stridor B) Friction rub C) Crackles D) Wheezing

ANS: B A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This is the sound made when pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with several diseases, such as pneumonia, heart failure, chronic bronchitis, and others (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

When considering the biocultural differences in the respiratory systems, the nurse knows that which statement is true? A) The smallest chest volumes are found in Asians. B) The largest chest volumes are found in whites. C) Asians are most likely to develop asthma. D) Racial differences are of no significance when assessing the respiratory system.

ANS: B The largest chest volumes are found, in descending order, in whites, then African-Americans, Asians, and Native Americans. Even when the shorter height of Asians is considered, their chest volume remains significantly lower than that of whites and blacks. A disproportionately large number of tuberculosis cases are reported among blacks, most of whom were born in the United States.

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following? A) Bradypnea B) Cheyne-Stokes respirations C) Hypoventilation D) Chronic obstructive breathing

ANS: C Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. See Table 18-4 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.

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

B

A nurse answers a call light and finds a patient anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? A. Assess the patient's lung sounds. B. Notify the Rapid Response Team. C. Provide reassurance to the patient. D. Take a full set of vital signs.

B

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

B

A nurse is caring for a patient on the medical stepdown unit. The following data are related to this patient: Subjective Info S.O.B. for 20 minutes, Feels frightened, "Can't catch my breath" Lab Analysis pH: 7.12, PaCO2: 28 mm Hg, PaO2: 58 mm Hg, SaO2: 88% Physical Assessment Pulse: 120 beats/min, RR: 34 breaths/min, BP: 158/92 mm Hg, Lungs have crackles What action by the nurse is most appropriate? A. Call respiratory therapy for a breathing treatment. B. Facilitate a STAT pulmonary angiography. C. Prepare for immediate endotracheal intubation. D. Prepare to administer intravenous anticoagulants.

B

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

B

A nurse is caring for four patients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? A. Hemoglobin: 14.2 g/dL (142 g/L) B. Platelet count: 82,000/L (82 × 109/L) C. Red blood cell count: 4.8/mm3 (4.8 × 1012/L) D. White blood cell count: 8700/mm3 (8.7 × 109/L)

B

A nurse is preparing to admit a patient on mechanical ventilation from the emergency department. What action by the nurse takes priority? A. Assessing that the ventilator settings are correct. B. Ensuring that there is a bag-valve-mask in the room. C. Obtaining personal protective equipment. D. Planning to suction the patient upon arrival to the room.

B

A nurse is teaching a patient about warfarin. What assessment finding by the nurse indicates a possible barrier to self-management? A. Poor visual acuity B. Strict vegetarian C. Refusal to stop smoking D. Wants weight loss surgery

B

A patient has a tracheostomy tube in place. When the nurse suctions the patient, food particles are noted. What action by the nurse is best? A. Elevate the head of the patient's bed. B. Measure and compare cuff pressures. C. Place the patient on NPO status. D. Request that the patient have a swallow study.

B

A patient is being discharged soon on warfarin. What menu selection for dinner indicates that the patient needs more education regarding this medication? A. Hamburger and French fries B. Large chef's salad and muffin C. No selection; spouse brings pizza D. Tuna salad sandwich and chips

B

A patient is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the patient has an alteration in the gene CYP2C19. What action by the nurse is best? A. Instruct the patient to eliminate all vitamin K from the diet. B. Prepare preoperative teaching for an inferior vena cava (IVC) filter. C. Refer the patient to a chronic illness support group. D. Teach the patient to use a soft-bristled toothbrush.

B

A nurse is caring for five patients. For which patients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) A. Patient who had a reaction to contrast dye yesterday B. Patient with a new spinal cord injury on a rotating bed C. Middle-aged man with an exacerbation of asthma D. Older patient who is 1 day post-hip replacement surgery E. Young obese patient with a fractured femur

B, D, E

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

C

A nurse is assisting the healthcare provider who is intubating a patient. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? A. Ensure that the patient has adequate sedation. B. Find another provider to intubate. C. Interrupt the procedure to give oxygen. D. Monitor the patient's oxygen saturation.

C

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

C

A patient has a pulmonary embolism and is started on oxygen. The student nurse asks why the patient's oxygen saturation has not significantly improved. What response by the nurse is best? A. "Breathing so rapidly interferes with oxygenation." B. "Maybe the patient has respiratory distress syndrome." C. "The blood clot interferes with perfusion in the lungs." D. "The patient needs immediate intubation and mechanical ventilation."

C

A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? A. Apply oxygen at 100%. B. Assess the respiratory rate. C. Ensure a patent airway. D. Start two large-bore IV lines.

C

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? A. Holding the device securely when changing ties B. Suctioning the patient first if secretions are present C. Tying a square knot at the back of the neck D. Using half-strength peroxide for cleansing

C

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

C

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

C

An intubated patient's oxygen saturation has dropped to 88%. What action by the nurse takes priority? A. Determine if the tube is kinked. B. Ensure that all connections are patent. C. Listen to the patient's lung sounds. D. Suction the endotracheal tube.

C

The nurse instructs a patient on how to correctly use an inhaler with a spacer. In which order would these steps occur? 1. "Press down firmly on the canister to release one dose of medication." 2. "Breathe in slowly and deeply." 3. "Shake the whole unit vigorously three or four times." 4. "Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer." 5. "Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece." 6. "Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds." A. 2, 3, 4, 5, 6, 1 B. 3, 4, 5, 1, 6, 2 C. 4, 3, 5, 1, 2, 6 D. 5, 3, 6, 1, 2, 4

C

When working with women who are taking hormonal birth control, what health promotion measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) A. Avoid drinking alcohol. B. Eat more omega-3 fatty acids. C. Exercise on a regular basis. D. Maintain a healthy weight. E. Stop smoking cigarettes.

C, D, E

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) Select one or more: a. Client who is taking medication for hypertension b. Client who had a cholecystectomy last year c. 22-year-old client with asthma d. Healthy 72-year-old client e. Client with well-controlled diabetes

Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition. The correct answers are: 22-year-old client with asthma, Client with well-controlled diabetes, Healthy 72-year-old client, Client who is taking medication for hypertension

A nurse is caring for a patient on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? A. The patient is able to initiate spontaneous breaths. B. The inspired oxygen has adequate humidification. C. The upper peak airway pressure limit alarm is off. D. The upper peak airway pressure limit alarm is on.

D

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

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

A nurse assesses several patients who have a history of asthma. Which patient would the nurse assess first? A. A 66-year-old patient with a barrel chest and clubbed fingernails B. A 48-year-old patient with an oxygen saturation level of 92% at rest C. A 35-year-old patient who has a longer expiratory phase than inspiratory phase D. A 27-year-old patient with a heart rate of 120 beats/min

D

A nurse cares for a patient 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? A. Ambulate the patient in the hallway to promote deep breathing. B. Auscultate the patient's anterior and posterior lung fields. C. Encourage the patient to take shallow breaths to help with the pain. D. Administer pain medication and encourage the patient to take deep breaths.

D

A nurse evaluates the following arterial blood gas and vital sign results for a patient with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results and Vital Signs pH = 7.32 Heart rate = 110 beats/min PaCO2 = 62 mm Hg Respiratory rate = 12 breaths/min PaO2 = 46 mm Hg Blood pressure = 145/65 mm Hg HCO3- = 28 mEq/L (28 mmol/L) Oxygen saturation = 76% What action would the nurse take first? A. Administer a short-acting beta2 agonist inhaler. B. Document the findings as normal for a patient with COPD. C. Teach the patient diaphragmatic breathing techniques. D. Initiate oxygenation therapy to increase saturation to 92%.

D

A nurse is assessing a patient who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the patient's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? A. Call the operating room to inform them of a pending emergency case. B. No action is needed at this time; this is a normal finding in some patients. C. Remove the tracheostomy tube; ventilate the patient with a bag-valve-mask. D. Stay with the patient and have someone else call the provider immediately.

D

A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority? A. Administer oxygen and reassess. B. Auscultate the patient's lung sounds. C. Facilitate a portable chest x-ray. D. Prepare to assist with intubation.

D

A patient is on mechanical ventilation and the patient's spouse wonders why ranitidine (Zantac) is needed since the patient "only has lung problems." What response by the nurse is best? A. "It will increase the motility of the gastrointestinal tract." B. "It will keep the gastrointestinal tract functioning normally." C. "It will prepare the gastrointestinal tract for enteral feedings." D. "It will prevent ulcers from the stress of mechanical ventilation."

D

A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best? A. "It is chronic hypoxemia that accompanies restrictive airway disease." B. "It is hypoxemia from lung damage due to mechanical ventilation." C. "It is hypoxemia that continues even after the patient is weaned from oxygen." D. "It is hypoxemia that persists even with 100% oxygen administration."

D

The nurse is caring for a patient who is prescribed a long-acting beta2 agonist. The patient states, "The medication is too expensive to use every day. I only use my inhaler when I have an attack." How would the nurse respond? A. "You are using the inhaler incorrectly. This medication should be taken daily." B. "If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks." C. "Tell me more about your fears related to feelings of breathlessness." D. "It is important to use this type of inhaler every day. Let's identify potential community services to help you."

D

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? Select one: a. Physical therapy for homebound therapy services b. Community social worker for Meals on Wheels c. Visiting Nurses for directly observed therapy d. Occupational therapy for job retraining

Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate. The correct answer is: Visiting Nurses for directly observed therapy

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

INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection. The correct answer is: Alanine aminotransferase (ALT): 180 U/L

A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain? Select one: a. Average daily fluid intake b. Height and weight c. Occupation and hobbies d. Neck circumference

Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment. The correct answer is: Occupation and hobbies

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

Room air is 21% oxygen. The correct answer is: 21%

nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) Select one or more: a. Swollen chin b. Edema of the cheek c. Ecchymosis behind the ear d. Stridor e. Eye pain f. Nasal stuffiness

Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called "battle sign" and indicates basilar skull fracture. Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention. The correct answers are: Stridor, Ecchymosis behind the ear

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? Select one: a. The client has joined a book club that meets at the library. b. Skin around the stoma is intact without signs of infection. c. Family members take turns assisting with stoma care. d. The client demonstrates good understanding of stoma care.

The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis. The correct answer is: The client has joined a book club that meets at the library.

A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention? Select one: a. Hollow sounds are heard over the trachea. - The nurse increases the oxygen flow rate. b. Vesicular sounds are heard over the periphery. - The nurse has the client breathe deeply. c. Crackles are heard in bases. - The nurse encourages the client to cough forcefully. d. Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator.

Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention. The correct answer is: Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator.

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first? Select one: a. Bone displacement b. Facial pain c. Vital signs d. Airway patency

A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred. The correct answer is: Airway patency