Lewis Med-Surg
Which delivery device is used for long-term oxygen therapy?
An oxygen-conserving cannula is generally indicated for long-term therapy at home or during hospitalization. A nasal cannula is used for patients requiring low oxygen concentrations. A simple face mask is used only for short periods because longer use is typically not tolerated. Partial and non-rebreather masks are useful for short-term therapy in patients needing higher oxygen concentrations.
Which action by a student nurse who is suctioning a patient's tracheostomy tube indicates a need for further instruction?
A drop in heart rate in response to suctioning may indicate hypoxemia or a vagal response and is an indication that suctioning should be halted. The other actions by the student are correct. Washing the hands and wearing goggles are preventive measures against infection. A catheter should be inserted without suctioning to minimize the amount of oxygen removed from the lungs. Preoxygenation for 30 seconds is provided to ensure normal oxygenation during tracheostomy tube suctioning.
Which oxygen delivery device may be used for a patient who requires oxygen administration in low concentrations of 24% at 1 L/min for a long duration?
A nasal cannula is the most commonly used device for a patient requiring low concentrations of oxygen of 24% at 1 L/min. It is safe and simple and allows freedom of movement. It can be used for a long time. Simple face masks can be used only for a short duration, especially during transportation. Partial and non-rebreather masks are useful for short-term therapy with high concentrations of oxygen. A tracheostomy collar is used to deliver high humidity and oxygen.
A patient with a sudden onset of respiratory distress is scheduled for a ventilation-perfusion scan. Which instruction does the nurse provide to the patient about the procedure?
A ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is injected into the blood, and the pulmonary vasculature is outlined. In the ventilation part, the patient inhales a radioactive gas that outlines the alveoli. Sedation is not required; magnetic imaging is not a component of the examination, so the patient can have the test even if there is metal in the body. Chest pressure may indicate an adverse reaction and is not normal.
Which inhaler would the nurse be prepared to administer to the patient at the onset of an asthma attack?
Albuterol is a short-acting bronchodilator that should be given first when the patient experiences an asthma attack. Fluticasone is an inhaled corticosteroid (ICS) used to prevent asthma attacks and does not result in rapid bronchodilation. Salmeterol is a long-acting bronchodilator and will not work rapidly to relieve bronchospasm in an acute attack. Tiotropium is a long-acting anticholinergic bronchodilator that is recommended only for use in chronic obstructive pulmonary disease and would not work to rapidly improve breathing in an asthma attack.
Which assessment has the highest priority when the nurse is caring for a patient who is three hours postoperative laryngectomy?
Because postoperative swelling may compress the trachea, assessing for airway patency has the highest priority after laryngectomy. Assessment and management of postoperative pain are also important but not as high of a priority as maintaining airway patency. There are large blood vessels in the neck, and frequent assessment of incisional drainage is essential, but changes in respiratory status have a higher priority. BP and heart rate will be frequently monitored but are not as important as assessment for respiratory compromise.
Which function does the complement system serve during an immune response?
The complement system causes cellular lysis by creating holes in the cell membranes, causing those cells to rupture. The complement system increases vascular permeability. Thromboxane promotes clot formation during healing. Macrophages clean the injured area before healing.p. 159
The nose serves which primary function?
The nose functions to protect the lower airway by warming and humidifying air and filtering small particles before air enters the lungs. The nose does not help with phonation and vocalization or assist with deep breathing. The nose adds humidification before air enters the lungs.
Decreased tactile fremitus would indicate the patient may be experiencing which condition?
The nurse assesses fremitus in a patient by palpating the chest with his or her hands while asking the patient to say a phrase like "ninety-nine" in a deeper, louder than normal voice. If the patient has pleural effusion, there will be distance between the lung tissue and the nurse's hand, which will decrease the vibrations felt. Fremitus would be increased in cases of pneumonia and lung tumors, because the vibration of sound would be transmitted more through solid tissue. The nurse would not detect any fremitus in a patient with pneumothorax because the condition prevents any vibration from transmitting.
Which instruction will the nurse include when teaching a patient to use a hand-held nebulizer?
The patient is placed in an upright position that allows for most efficient breathing to ensure adequate penetration and deposition of the aerosolized medication. Deep and slow breaths help ensure deposition of the medication throughout the lung. To reduce bacterial growth, the patient is asked to wash the nebulizer equipment daily in soap and water, rinse it with water, and soak it for 20 to 30 minutes in a 1:1 white vinegar-water solution, followed by a water rinse and air drying. The patient is taught to hold the breath for two to three seconds during nebulizer treatments.
In which order will the nurse hear these sounds from percussion of the anterior chest over the clavicle, then the lung field, then the liver, and finally over the stomach?
The nurse would hear flatness with percussion over the clavicle, followed by resonance over the lung field. Dullness would be heard over the liver, and then tympany with percussion over the stomach.
Which instruction will the nurse include when teaching a patient to use a dry powder inhaler (DPI)?
The patient should hold the breath for as long as possible to increase the amount of medication absorbed by the lungs. DPIs are not shaken prior to use. Since delivery of medication to the airways depends on the patient's inspiratory effort when using a DPI, a rapid and deep respiration is needed. The patient's mouth should be sealed around the DPI mouthpiece to maximize delivery of the medication to the airways.
Which method of oral care helps to prevent oral infection for the patient who is taking fluticasone?
The patient should rinse the mouth with water after the second puff of medication to reduce the risk of fungal overgrowth and oral infection. An oral antibiotic solution is not indicated and would not treat a fungal infection. Brushing the teeth is not necessary before medication administration and the mouth should be rinsed after, not before, medication administration.
The nurse determines that additional discharge teaching is needed for a patient with pneumonia when the patient makes which statement?
"I should take antibiotics for all upper respiratory infections." Antibiotics are not indicated for all upper respiratory tract infections, such as viral infections, because they have side effects and promote antibiotic resistance. It is important for the patient to continue with coughing and deep breathing exercises for at least six weeks, until all of the infection has cleared from the lungs. The patient should take all medications as prescribed and seek medical attention for signs or symptoms of a new infection.
When a patient's heart rate falls from 80 to 60 beats/minute during suctioning, which action will the nurse take?
A drop in the heart rate during suctioning indicates a possible vagal response. If the heart rate drops or increases by 20 beats per minute while suctioning through a tracheostomy tube, suctioning should be stopped immediately. Continuous suctioning will result in worsening bradycardia. Rapid intermittent suctioning will lead to more bradycardia. Rotation of the suction catheter may stimulate the vagus nerve and lead to bradycardia.
A patient diagnosed with asthma who is experiencing airway irritation may present with which assessment finding?
A dry, hacking cough indicates the patient is experiencing airway irritation or obstruction. Hemoptysis often occurs with tuberculosis and does not indicate airway irritation. A harsh, barky cough suggests upper airway obstruction. A loose-sounding cough indicates secretions.p. 462
Which tracheostomy tube has openings on the surface of the cannula to permit airflow?
A fenestrated tube has openings on the surface of the outer cannula that permit air to flow over the vocal cords. Talking tracheostomy tubes allow speech by connecting a port to compressed air, which flows over the vocal cords. Tracheostomy tubes with foam-filled cuffs do not allow speech because the cuff self-inflates and is not deflated. A tracheostomy with a cuff and pilot balloon does not have any openings to allow airflow, but patients can speak when the cuff is deflated and the inner cannula removed.
Which cognitive changes are characteristic of a patient experiencing hypoxia? Select all that apply.
A patient who is hypoxic may have neurologic symptoms that include apprehension, restlessness, irritability, and memory changes. Mood will worsen rather than improve. Pursed lip breathing is not a cognitive symptom. Concentration will be poor with hypoxia rather than improved.p. 463
To determine whether a patient with a tracheostomy has swallowing dysfunction, which action by the nurse is best?
A speech therapist has the education and scope of practice to perform swallowing studies on the patient. Offering sips of water will help the nurse assess for swallowing dysfunction but may lead to aspiration. The patient certainly should have input in the assessment of swallowing ability but does not have the education or experience to determine whether there is swallowing dysfunction. An experienced nurse may be able to recognize clinical swallowing difficulty but is not as well educated in determining the causes and management of swallowing dysfunction as the speech therapist.
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20 breaths/minute. Which is an appropriate nursing diagnosis?
Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and the patient's breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.
The nurse provides education for a group of nursing students about acute bronchitis and includes which information?
Acute bronchitis is usually self-limiting, and the treatment for acute bronchitis is supportive. Chest x-rays will differentiate acute bronchitis from pneumonia. With bronchitis, no consolidation or infiltrates will be seen on an x-ray as there is with pneumonia. If patients with acute bronchitis develop a fever, have difficulty breathing, or have symptoms last longer than four weeks, they should see their HCP. Because there is no consolidation, egophony would not be auscultated. Egophony is an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis. It is caused by the enhanced transmission of high-frequency sound across fluid, such as in abnormal lung tissue, with lower frequencies filtered out.
The nurse would monitor which comorbidity in the patient who requires high doses of inhaled corticosteroids (ICSs) for asthma management?
Although ICS use is generally not associated with systemic complications, patients who use high doses of ICSs will need monitoring for corticosteroid-induced osteoporosis. Hyperlipidemia is not a complication of ICS use. Thyroid function is not impaired by ICS use. Cholecystitis is not caused by ICS use.
Which nursing intervention assists a patient with pneumonia in managing thick secretions and fatigue?
Although several interventions may help the patient expectorate mucus, the nursing interventions should focus on teaching the patient how to cough effectively and expectorate secretions. Postural drainage may help to loosen the secretions. Administering analgesics does not help to manage thick secretions. Administering oxygen also does not help the patient manage secretions.
Which diagnostic test is used to measure the efficiency of gas transfer in the lung and tissue oxygenation?
Arterial blood gases are used to assess the efficiency of gas transfer in the lung and tissue oxygenation, as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.
A patient is hospitalized with a diagnosis of pneumonia. When reviewing the patient's history, the nurse finds that the patient experienced a seizure with profuse vomiting four days prior to the hospital admission. Which type of pneumonia does the nurse suspect?
Aspiration pneumonia results from the abnormal entry of material from the mouth or stomach into the trachea and lungs. Conditions that increase the risk for aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and insertion of nasogastric (NG) tubes with or without enteral feeding. The aspirated material (food, water, vomitus, oropharyngeal secretions) triggers an inflammatory response. The history of the patient does not suggest any exposure to pneumonia in the community. The patient has never been in the hospital; therefore hospital-associated pneumonia is highly unlikely. The patient does not have a history of HIV, intake of immunosuppressive drugs, corticosteroids, or any disorders leading to immunosuppression; therefore opportunistic pneumonia did not occur in this patient.
A patient presents with a lung abscess. The nurse expects that which intervention will be included in the patient's treatment plan?
Because there are mixed bacteria in a lung abscess, starting a broad-spectrum antibiotic is the appropriate treatment option. Postural drainage and chest physiotherapy are not recommended because they may cause spillage of the infection to other bronchi and spread the infection. Reducing fluid intake is not advisable; instead, adequate fluid intake is recommended.
Which sputum characteristics, if present in the patient, may need further evaluation for a patient who is a smoker and has chronic obstructive pulmonary disease (COPD)? Select all that apply.
COPD may result in whitish to yellowish sputum; however, any change in the baseline characteristics of the sputum should be reported. Frothy sputum may indicate pulmonary edema and needs further evaluation. A foul odor in the sputum indicates presence of infection and needs immediate medical intervention. Pink-tinged sputum may indicate pulmonary edema and the patient may need further evaluation. Sputum with brown specks is a common finding in a person who smokes. Yellowish sputum is a normal finding in COPD.
A patient being treated for a large pressure ulcer on the heel reports new inflammation in the surrounding subcutaneous tissue. Which term describes the condition the patient is experiencing?
Cellulitis can occur due to untreated pressure ulcers and involves the spreading of inflammation to the subcutaneous (connective) tissue. Sepsis occurs when an infection spreads to the bloodstream. A keloid is a permanent protrusion of scar tissue beyond the edges of the wound or injury. Fistulas are abnormal passages that may occur secondary to a wound.p. 168
Which nursing actions will be included for a patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy through a mask? Select all that apply.
Choosing the optimal oxygen device, assessing the need for adjustment in oxygen flow rate, and monitoring signs of adverse effects of oxygen therapy are all duties that the nurse should perform when evaluating the response of the patient to oxygen therapy. Taking a chest radiograph and assessing the need to change IV fluids are not relevant to this situation.
Which statement by the student nurse indicates a need for further instruction about airway obstruction?
Complete airway obstruction should be corrected within three to five minutes because a delay can lead to permanent brain damage or death. Airway obstruction can be either partial or complete. Establishing ventilation can be performed by endotracheal intubation, tracheostomy, or cricothyroidotomy. Airway obstruction can be caused by aspiration of food contents into the windpipe, allergic reactions, malignancies, and trauma.
In which order do the four stages of pressure injuries to the tissue occur?
Correct1.Non-blanchable erythema of intact skin Correct2.Partial-thickness skin loss with exposed dermis Correct3.Full-thickness skin loss Correct4.Full-thickness skin-and-tissue loss
A patient is hospitalized with symptoms of tuberculosis (TB). The nurse recognizes that at least one of the sputum specimens for acid-fast bacilli (AFB) needs to be obtained at which time of the day?
Culture is the gold standard for diagnosing TB. Three consecutive sputum specimens are needed, each collected at 8- to 24-hour intervals, with at least one early-morning specimen. The initial test involves a microscopic examination of stained sputum smears for AFB. Early morning (6 a.m.) is the ideal time to collect sputum specimens for an AFB smear because secretions collect during the night. The times of 12 noon, 6 p.m., and 9 p.m. are not ideal times to collect the specimen because the amount of secretions for the specimen may not be optimal.
How many minutes is the appropriate recovery period after activity for the patient with chronic obstructive pulmonary disease (COPD)?
Developing exercise endurance is very important. If it takes longer than 5 minutes to return to baseline, the patient has most likely "overdone it" and should proceed at a slower pace during the next exercise period.
Which action by the student nurse when providing tracheostomy care to a patient indicates a need for further teaching?
Dried secretions from the stoma are removed using gauze that is soaked in sterile water or normal saline, not in alcohol. Hand hygiene reduces the risk of infection to the patient. Tracheostomy care is performed while the patient is in the semi-Fowler's position. The nurse can suction as needed when the patient is unable to cough up the thick and hard secretions.
The nurse is monitoring a patient who is undergoing a thoracentesis for recurrent pleural effusion. Which assessment finding is of concern?
During and after a thoracentesis, monitor the patient's vital signs and pulse oximetry, and observe the patient for any manifestations of respiratory distress, which may indicate a possible complication, such as pneumothorax or pulmonary edema. It is not unusual to remove up to 1000 to 1200 mL of pleural fluid at one time. The SpO2 reading of 96% and patient report of pressure at the needle insertion site are not abnormal findings.
The nurse discusses the beneficial aspects of fever with a group of nursing students and will include which information? Select all that apply.
Fever has several beneficial outcomes, including increased killing of microorganisms, increased proliferation of T cells, and enhancement of interferon activity. The increased release of epinephrine increases the metabolic rate and is involved in the development of fever. When a fever becomes too high, the temperature control center is impaired.p. 159
Which physiologic change is associated with fever during inflammatory conditions?
Fever is mediated by a host macrophage product called endogenous pyrogen (EP) that stimulates the proliferation of T cells. Fever increases the action of neutrophils and promotes phagocytosis. Vasodilators increase blood flow rate. Fever increases destruction of microorganisms by enhancing the activity of interferon.
Which instructions would the nurse provide to the patient in preparation for a chest x-ray?
For the chest x-ray, the nurse should instruct the patient to remove any metal between neck and waist. A chest x-ray does not require a signed consent, and there is no need to avoid food before the test. The patient is not required to undress completely; because it is a chest x-ray, undressing to the waist is sufficient.
Which action would the nurse take for a patient with acute pharyngitis whose laboratory reports indicate the presence of a candidiasis infection?
Gargling with warm salt water helps in relieving swelling and discomfort in the throat. The patient may have aspirin or ibuprofen as needed for pain. Lemon is a citrus fruit and would result in more throat irritation. Warm and cold fluids can reduce throat pain for patients with pharyngitis related to Candida.
A patient with an arm sprain asks the nurse about the benefit of heat application. Which rationale does the nurse provide?
Heat may be used later (e.g., after 24 to 48 hours) to promote healing by increasing the circulation to the inflamed site and subsequent removal of debris. Heat is used to localize the inflammatory agents. Cold application decreases congestion and promotes vasoconstriction at the site of inflammation. Immobilizing the inflamed area with a cast prevents further tissue injury.p. 161
Which information does the nurse need to obtain and document in the admission assessment on a patient who uses oxygen (O2) at home? Select all that apply.
If the patient is using O2 for a breathing problem, record the FIO2, flow rate (liters per minute), method of administration, number of hours used per day, and effectiveness of the therapy. Assess safety practices, including the patient's cognitive and physical ability related to using O2 and any metered-dose inhalers. What oxygen service the patient uses and the patient's method of payment are not necessary to determine in the admission assessment.p. 460
A positron emission tomography (PET) scan is used for which respiratory assessment?
PET scans use an IV radioactive glucose preparation to demonstrate increased uptake of glucose in malignant lung cells. A ventilation/perfusion (VQ) scan is used to assess ventilation and perfusion of lungs. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction. An MRI test is used to diagnose lesions difficult to assess by CT scan.p. 472
Which information will the nurse include when educating a patient with asthma about use of a peak flow meter?
It is important that the patient initially determine the personal best readings when first using a peak flow meter to evaluate for decreasing airway function. It should be used at least twice a day for the first two weeks to determine the patient's personal best, which will be used to monitor airway constriction. After the personal best peak flow is determined, daily peak flow readings are recommended. The peak flow meter does not reduce asthma attacks; it helps monitor symptoms of asthma. Peak flows are ideally measured between 12 noon and 2:00 p.m. because peak flows are highest in the early afternoon.
A patient with pulmonary edema will likely present with which mucous characteristics?
Large amounts of frothy, pink-tinged sputum support the diagnosis of pulmonary edema, which is characterized by a persistent cough. Foul-smelling sputum indicates an infection. Clear, whitish, or yellow sputum is often found in patients diagnosed with chronic obstructive pulmonary disease, especially in the early morning hours. Clear to gray sputum with brown specks indicates the patient is a smoker.p. 462
The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding?
Manifestations of a lung abscess usually occur slowly over a period of weeks to months, especially if anaerobic organisms are the cause. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. Fever and vomiting are not manifestations of a lung abscess. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung.
The nurse would expect which assessment finding in a patient with pulmonary fibrosis?
Normal percussion: Patients with pulmonary fibrosis have normal percussion findings. Inspection would reveal tachypnea, and palpation would show movement. Auscultation shows crackles or sounds like Velcro being pulled apart. Prolonged expiration occurs with asthma. Egophony over effusion often occurs with pleural effusion. Fremitus over the affected area occurs with pneumonia.p. 469
Which action will the nurse take when caring for a patient with pharyngitis?
Offering a drink of water is correct because cool, bland liquids, such as water, will not irritate the pharynx. Drinking warm or cold liquid is recommended, but consuming hot tea will irritate the pharynx and cause pain. Gargling with warm salt water can alleviate the symptoms of acute pharyngitis, but hydrogen peroxide will irritate pharyngeal tissues. Citrus juices are acidic and will be irritating and painful.
Which clinical manifestation does the nurse expect to find during the respiratory assessment of a patient with pneumonia?
On assessment of a patient with pneumonia, if consolidation is present, bronchial breath sounds, egophony (an increase in the sound of the patient's voice), and increased fremitus (vibration of the chest wall made by vocalization) may be present. Fine or coarse crackles may be auscultated over the affected region. Patients with pleural effusion may have dullness to percussion over the affected area.
Which diagnostic study is used to distinguish benign and cancerous lung nodules?
PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using a thoracentesis, pulmonary angiogram, or CT.p. 472
Which statement made by the student nurse indicates that education regarding tracheostomy tubes has been effective?
Patients who use a tracheostomy tube may be able to learn to speak with the tube in place. Patients with tracheostomy tubes can eat. Because a tracheostomy tube will move around less and does not have to go through the oropharynx, it will be more comfortable than an endotracheal tube. Because the tracheostomy tube moves around less within the trachea, there will be less risk of vocal cord damage.
Which action may be beneficial to a patient with chronic obstructive pulmonary disease (COPD) to maximize food intake?
Patients with COPD should limit fluid intake during mealtimes because too much liquid might make the patient feel too full to eat. COPD patients should eat cold foods rather than hot foods to feel less full. COPD patients should eat frequent meals and snacks because it helps the diaphragm move freely and makes gas exchange in the lungs easier. Performing physical activity before meals may increase breathlessness and may affect food intake.
When the patient with a persistent cough is diagnosed with pertussis, the nurse expects that which type of medication will be prescribed?
Pertussis is caused by a gram-negative bacillus, Bordetella pertussis, and must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.
Which disease processes are associated with a pleural friction rub? Select all that apply.
Pleural friction, characterized by a creaking or grating sound during inspiration or expiration, is caused by roughened, inflamed pleural surfaces rubbing together. Pneumonia and pulmonary infarction can lead to pleural friction. Cystic fibrosis causes continuous rumbling, snoring, or rattling sounds when rhonchi obstruct large airways. Wheezes are present in the patient with bronchospasm. Pulmonary edema is associated with coarse crackles caused by air passing through the airway when it is intermittently occluded by mucus.
A patient who is being treated for an inflammation receives a medication that promotes healing by preventing the liberation of lysosomes. The nurse recognizes that which drug has this mechanism of action?
Prednisone is an antiinflammatory drug that interferes with tissue granulation and induces immunosuppressive effects; thus this drug prevents the liberation of lysosomes. Ibuprofen inhibits the synthesis of prostaglandins. Piroxicam is an antiinflammatory drug that inhibits the synthesis of prostaglandins. Acetaminophen is an antipyretic drug that lowers body temperature by acting on the heat-regulating center in the hypothalamus.
A patient who is being treated for an inflammation receives a medication that promotes healing by preventing the liberation of lysosomes. The nurse recognizes that which drug has this mechanism of action?
Prednisone is an antiinflammatory drug that interferes with tissue granulation and induces immunosuppressive effects; thus this drug prevents the liberation of lysosomes. Ibuprofen inhibits the synthesis of prostaglandins. Piroxicam is an antiinflammatory drug that inhibits the synthesis of prostaglandins. Acetaminophen is an antipyretic drug that lowers body temperature by acting on the heat-regulating center in the hypothalamus.p. 160
The nurse pays close attention to which most common site for pressure ulcers when assessing a patient?
Pressure ulcers generally occur over bony prominences; the sacrum is the most common site, followed by the heels. Elbows and ankles are less susceptible to pressure ulcers.
The nurse will suggest which intervention for the patient experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD)?
Sometimes patients with COPD or those who use oxygen (O2) therapy have difficulty speaking because of shortness of breath. These patients should be encouraged to use typed messages as an alternative to phone conversations to communicate to avoid increased dyspnea. The patient should avoid exercise or walking during the attack because severe dyspnea may lead to respiratory failure. The patient should have an adequate diet to prevent weight loss. Hence the patient should avoid consuming more fluids at mealtime. Patients with dyspnea often cannot speak in continuous sentences because of difficulty in breathing.
When the nursing supervisor is observing a newly hired nurse during suctioning of a tracheostomy patient, which action by the new nurse would require intervention?
Suction is not applied while inserting the catheter because this will cause unnecessary trauma to the tracheal mucosa; suction is applied as the catheter is being withdrawn. Suction time should be limited to 10 to 15 seconds or less to help decrease discomfort and minimize hypoxemia. Preoxygenation prior to suctioning helps prevent hypoxemia during and after suctioning. Because hypoxemia is a complication of suctioning, it is imperative that the nurse monitor indicators of oxygenation status, such as SpO2, heart rate, and heart rhythm, during the procedure.
Which instructions would the nurse include when teaching self-care strategies to a patient with acute pharyngitis? Select all that apply.
Symptom relief is a major goal of nursing management in a patient with acute pharyngitis. The nurse would instruct the patient to gargle with warm salt water, suck on popsicles or hard candies, and use a cool mist vaporizer or humidifier. Citrus juices can irritate the throat and should not be recommended. The patient should increase fluid intake to keep the secretions thin so that they can be easily expectorated.
Which information will the nurse include when teaching a patient who has had a complete laryngectomy about transesophageal puncture (TEP)?
TEP provides a fistula between the esophagus and trachea with a one-way valved prosthesis that allows patients a good voice quality with minimal training. Esophageal speech takes a long time to learn and has a poorer voice quality. A mechanical voice quality is associated with the use of an electrolarynx. A one-way valve in the tracheoesophageal fistula allows speech with a TEP.
Which assessment finding by the nurse indicates a common adverse effect of a patient's prescribed albuterol inhaler?
Tachycardia is a common adverse effect of the use of inhaled β2-adrenergic agonists because of its stimulant effect. Headache is not a common adverse effect of albuterol. Diarrhea is not commonly seen with albuterol use. Oral candidiasis may be seen with inhaled corticosteroid use, but it is not an adverse effect with albuterol.
Which response by the nurse is best when a patient with asthma asks "How will I know when my metered-dose inhaler (MDI) is empty?"
The MDI canister will state how many total doses are available, and the patient will need to track how many doses are used to avoid running out of medication. Floating the canister in water was recommended in the past, but is no longer recommended because water can enter the chamber. The canister may or may not produce a sound when shaking. It is not safe for the patient to wait for wheezing to worsen before getting a new inhaler.
In the depicted complement cascade, which enzyme is a potent vasodilator that contributes to edema and increased blood flow?
The complement system is an enzyme cascade that mediates the inflammatory response. Prostaglandins are potent vasodilators that lead to increased blood flow and edema. After cell injury, arachidonic acid is converted to prostaglandins. Thromboxane leads to brief vasoconstriction and clot formation. The slow-reacting substance of anaphylaxis is formed by leukotrienes.p. 158
The epiglottis serves which respiratory function?
The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing. The function of the epiglottis is to prevent solids and liquids from entering the lungs. The olfactory nerve endings in the roof of the nose are responsible for the sense of smell. The bronchi and the trachea act as a pathway to conduct gases to the alveoli. The nose protects the lower airway by warming and humidifying air and filtering small particles before the air enters the lungs.
The health care provider prescribes IV vancomycin for a patient with pneumonia. Which action does the nurse perform first?
The nurse should ensure that the sputum for culture and sensitivity has been sent to the laboratory before administering the antibiotic. It is important that the organisms be correctly identified (in the culture) before their numbers are affected by the antibiotic; the test also will determine whether the proper antibiotic has been prescribed (sensitivity testing). Vital signs, education, and white blood cell count measurement can be assessed following the obtainment of sputum cultures.
Which action would the nurse include when suctioning a patient's tracheostomy tube?
The nurse should supply oxygen for 30 seconds after suctioning and before starting the next suction to prevent hypoxemia. To avoid hypoxemia, suctioning should be performed for a short period, such as for 10 to 15 seconds. Suction pressures should not exceed 125 mm Hg with the tubing occluded. To avoid trauma to the carina, the suction catheter should be inserted only until the patient coughs.
In which order will the nurse place the stethoscope on the anterior chest to auscultate breath sounds?
The nurse would auscultate the anterior chest on bilateral locations, starting at the apices of the lungs above the clavicles. The stethoscope would then be moved below the clavicles for auscultation. The nurse would continue to move down the chest, placing the stethoscope above the nipple line, then at the nipple line, and finally below the nipple line.
Which patient care goals are appropriate for a patient with chronic obstructive pulmonary disease (COPD)? Select all that apply.
The overall goals are that the patient with COPD will have (1) prevention of disease progression, (2) ability to perform ADLs and improved exercise tolerance, (3) relief from symptoms, (4) no complications related to COPD, (5) knowledge and ability to implement a long-term treatment regimen, and (6) overall improved quality of life. Lung tissue does not regenerate, so "healing" is not a realistic goal. Patients need to know that symptoms can be managed, but COPD cannot be cured.
In which order do the types of white blood cells appear during cellular response to tissue injury?
The pathophysiology of inflammation in the cellular response begins with the release of neutrophils, which engulf bacteria, foreign material, and damaged cells. Next, monocytes arrive and turn into macrophages after entering the tissue space. Macrophages help to clean up inflammatory debris. Lastly, lymphocytes arrive to provide humoral and cell-mediated immunity.
Which questions should the nurse ask when assessing a patient's sleep/rest pattern related to respiratory health? Select all that apply.
The patient with sleep apnea may have insomnia or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than eight hours per night or needing to urinate during the night is not indicative of impaired respiratory health.p. 461
Which patient findings indicate inadequate oxygenation? Select all that apply.
The symptoms of inadequate oxygenation in the patient include cyanosis, diaphoresis, and tachypnea. Cyanosis indicates inadequate perfusion due to compromised oxygenation. Diaphoresis and tachypnea occur due to sympathetic stimulation to compensate for inadequate oxygenation. Anemia occurs gradually and does not suddenly cause inadequate oxygenation. Hypertension does not indicate inadequate oxygenation in the patient.p. 458
When caring for a patient with pertussis, which intervention does the nurse prioritize?
The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. For the patient who cannot take macrolides, trimethoprim/sulfamethoxazole is used. Cough suppressants and antihistamines should not be used because they are ineffective and may induce coughing episodes. Corticosteroids and bronchodilators are not useful in reducing symptoms.
Which diagnostic procedure is used to remove pleural fluid for analysis?
Thoracentesis is a diagnostic procedure used to remove pleural fluid for analysis or to instill medication. A lung biopsy is used to obtain specimens for laboratory analysis. A bronchoscopy involves the use of a flexible fiberoptic scope for diagnosis, biopsy, or specimen collection. Samples for sputum studies are obtained by expectoration and tracheal suction.Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.p. 472
A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. Which instructions does the nurse provide for the patient? Select all that apply.
To ensure complete recovery after pneumonia, the patient should be advised to rest, avoid alcohol and smoking, and take every dose of the prescribed antibiotic. The patient should not resume work if feeling fatigued and should be encouraged to drink plenty of fluids during the recovery period.
The nurse will instruct a patient with asthma to perform the steps for using a peak flow meter in which order?
To use the peak flow meter, first move the indicator to the bottom of the numbered scale. Next, take a deep breath that fills the lungs. Then, place the mouthpiece in your mouth and close your lips around the mouthpiece. Finally, blow out as hard and fast as you can in one full exhalation.
Which chest palpation finding is a medical emergency?
Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.p. 468
Based on the surgical documentation of a postoperative head-and-neck case, which type of voice communication technique will the patient utilize postoperatively?
Tracheoesophageal puncture communication is done through a tracheoesophageal fistula when the valve is occluded. Electrolarynx uses a battery-powered device. Esophageal speech requires learning a technique for intake and expulsion of air from the esophagus. The patient is not required to be nonverbal if tracheoesophageal puncture speech is learned.
The nurse evaluates wound healing for a patient with an arm laceration. The nurse recalls that which deficiency may cause insufficient collagen production by fibroblasts?
Vitamin C is needed for capillary synthesis and collagen production by fibroblasts. Zinc deficiency impairs epithelialization in the wound-healing process. Protein deficiency decreases the supply of amino acids for tissue repair. If a vitamin B deficiency develops, a disruption of protein, fat, and carbohydrate metabolism will occur.
Which condition is associated with wheezing?
Wheezes are continuous high-pitched squeaking sounds produced by the rapid vibration of the bronchial walls. The rapid vibration is caused by a blockage in the airways, which often occurs with chronic obstructive pulmonary disease. Fine crackles are heard with atelectasis. Diminished breath sounds are heard in pleural effusion. Fine or coarse crackles are heard in patients with pulmonary edema.
The nurse is providing care to a patient who is experiencing delayed healing of a surgical wound. The nurse asks which question to assess for nutritional deficiencies?
When assessing for nutritional deficiencies related to delayed wound healing, the nurse should ask the patient about vitamin C, protein, and zinc consumption. Although smoking, poorly controlled blood glucose levels, and taking prescribed glucocorticoids can all delay wound healing, these questions are not appropriate when assessing the patient specifically for nutritional deficiencies.
After changing a patient's tracheostomy ties, how will the nurse best ensure that the ties are correctly applied?
When securing tracheostomy ties, two fingers are placed underneath the ties to ensure that the ties are not too tight around the patient's neck. Although the respiratory therapist may check the ties, the nurse doing tracheostomy care will not rely on another staff member to evaluate for a secure fit of the tracheostomy ties. Patient comfort should be assessed, but maintaining the ties to ensure that the tracheostomy tube is secure is a higher priority. The nurse may visually check the tracheostomy ties, but the tightness of the ties is best evaluated by inserting two fingers under the ties after tying them.
Which treatment may increase restlessness and insomnia in a patient with chronic obstructive pulmonary disease (COPD)?
β2 agonists may cause restlessness and insomnia in patients with COPD. Anticholinergics are not associated with insomnia. Massage and postural drainage techniques will not lead to insomnia and restlessness. Oxygen supplementation through a nasal mask will not cause restlessness and insomnia.
