MedSurg Respiratory Practice Questions
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? 1. (-20 cm H2O) 2. (15 cm H2O) 3. (-10 cm H2O) 4. (5 cm H2O)
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A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? 1.Crackling 2.Wheezing 3.Decreased sounds 4.Adventitious sounds
3 decreased sounds are indicative of a pneumothorax
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. 1.Post thoracotomy 2.Spontaneous pneumothorax 3.Need for postural drainage 4.Chest trauma resulting in pneumothorax 5.Pleurisy
1, 2, 4
An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? 1. Assess the client's mobility 2. Monitor respirations and breathing effort 3. Teach coughing and deep breathing exercises 4. Determine normal activity levels and note when the client tires
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A client who had a laryngectomy for cancer of the larynx is being transferred from the PACU. Which is the most important equipment that the nurse should place in the client's room? 1.Suction supplies 2.Writing materials 3.Tracheostomy set 4.Incentive spirometry
Answer: 1 1.Suction is the priority. Resp. complications can occur after a laryngectomy is performed because of the production of excessive secretions, edema of the glottis, or injury to the recurrent laryngeal nerve. They will also be able to cough to effectively clear secretions. 2.Although writing supplies along with a pic board are helpful for promoting communication, they are not the priority. 3.A trach set is unnecessary - permenant stoma is in the trachea and surgically created with a larygenctomy tube in place. An additional sterile laryngectomy tube and obturator should be kept at the bedside. 4.With a tracheal stoma - pt can not use incentive spirometry
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? 1.Presence of a cough and gag reflex 2.Absence of nausea 3.Ability to demonstrate deep inspiration 4.Oxygen saturation of 92%
Answer: 1 After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration.
The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? 1.A resident who suffered a severe stroke several weeks ago 2.A resident with mid-stage Alzheimers disease 3.A 92-year-old resident who needs extensive help with ADLs 4.A resident with severe and deforming rheumatoid arthritis
Answer: 1 Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A patient with mid-stage Alzheimers disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have severe arthritis should not have difficulty swallowing unless it exists secondary to another problem.
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? 1. To remove air from the pleural space 2. To drain copious sputum secretions 3. To monitor bleeding around the lungs 4. To assist with mechanical ventilation
Answer: 1 Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.
The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer? 1.Hoarseness 2.Dyspnea 3.Dysphagia 4.Frequent nosebleeds
Answer: 1 Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.
The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? 1.Pneumothorax 2.Anxiety 3.Acute bronchitis 4.Aspiration
Answer: 1 If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patients recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? 1.Diminished or absent breath sounds on the affected side 2.Paradoxical chest wall movement with respirations 3.Sudden loss of consciousness 4.Muffled heart sounds
Answer: 1 In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.
A nurse has been asked to give a workshop on COPD for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has what pathophysiologic effect? 1.Increases the amount of mucus production 2.Destabilizes hemoglobin 3. Shrinks the alveoli in the lungs 4.Collapses the alveoli in the lungs
Answer: 1 Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung.
The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? 1. Incentive spirometry 2. Intermittent positive pressure breathing (IPPB) 3. Positive end-expiratory pressure (PEEP) 4. Bronchoscopy
Answer: 1 Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first- line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.
An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize? 1.The importance of adhering closely to the prescribed medication regimen 2.The fact that the disease is a lifelong, chronic condition that will affect ADLs 3.The fact that TB is self-limiting, but can take up to 2 years to resolve 4.The need to work closely with the occupational and physical therapists
Answer: 1 Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.
The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment? 1.Lately, I have this cough that just never seems to go away. 2.I find that I dont have nearly the stamina that I used to. 3.I seem to get nearly every cold and flu that goes around my workplace. 4.I never used to have any allergies, but now I think Im developing allergies to dust and pet hair
Answer: 1 The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. A new onset of allergies, frequent respiratory infections and fatigue are not characteristic early signs of lung cancer.
A nurse is suctioning a client's airway. Which nursing action will limit hypoxia? 1.Apply suction only after catheter is inserted 2.Limit suctioning with catheter to half a minute 3.Lubricate the catheter with saline before insertion 4.Use sterile suction catheter for each suctioning episode
Answer: 1 The negative pressure from suctioning removes oxygen as well as secretions; suction should be applied only after the catheter is inserted and is being withdrawn. Limiting suctioning with catheter to half a minute is too long; suctioning should be limited to 10 SECONDS. Lubrication will facilitate insertion and minimize trauma; it will not prevent hypoxia. The use of sterile cath helps prevent infection, not hypoxia
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the patient has increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? 1. Increase oral fluids unless contraindicated 2. Call the nurse for oral suctioning as needed 3. Lie in a low Fowlers or supine position 4. Increase activity
Answer: 1 The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.
A patient with emphysema is experiencing shortness of breath. To relieve this patients symptoms, the nurse should assist her into what position? 1.Sitting upright, leaning forward slightly 2.Low Fowlers, with neck hyperextended 3.Prone 4.Trendelenburg
Answer: 1 The typical posture of a person with COPD is to lean forward and use the accessory muscles of respiration to breathe. Low Fowlers positioning would be less likely to aid oxygenation. Prone or Trendelenburg positioning would exacerbate shortness of breath.
The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patients chest and hears wheezing throughout the lung fields. What might this indicate? 1.The patient has a narrowed airway. 2.The patient has pneumonia. 3.The patient needs physiotherapy. 4. The patient has a hemothorax.
Answer: 1 Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? 1. Administer intradermal injections into the childrens inner forearms 2. Administer intramuscular injectiosn into each childs vastus lateralis 3. Administer a subcutaneous innjection into each childs umbilical area 4. Administer a subcutaneous injection at a 45 degree angle into each childs deltoid
Answer: 1 he purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.
During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. Which information in the client's history supports the HC provider's diagnosis of pulmonary tuberculosis? SATA 1.Fever 2.Dry cough 3.Night sweats 4.Frothy sputum 5.Engorged neck veins 6.Blood-tinged sputum
Answer: 1, 3 & 6 Recurrent fevers are present with TB, usually in the late afternoon. Profuse diaphoresis at night (night sweats), is a classic sign of TB. Blood-tinged sputum (hemoptysis) results from trauma to mucous membranes. The cough with TB is productive, not dry, because the inflammatory process causes pulm mucus. Frothy sputum is present in pulm edema and engorged neck veins is no a symptom of TB
A nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? Select all that apply. 1.Chest tightness 2.Crackles 3. Bradypnea 4. Wheezing 5. Cough
Answer: 1, 4, 5 Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma.
The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patients needs? 1.Non-rebreathing mask 2.Nasal cannula 3.Venturi mask 4. Partial-rebreathing mask
Answer: 2 A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The patients respiratory status does not require a partial- or non- rebreathing mask.
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what complication? 1.Acute respiratory distress syndrome (ARDS) 2.Atelectasis 3.Aspiration 4.Pulmonary embolism
Answer: 2 A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.
What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy? 1.A patient has a respiratory rate of 10 breaths per minute 2.A patient requires permanent mechanical ventilation 3.A patient exhibits symptoms of dyspnea 4.A patient has respiratory acidosis
Answer: 2 A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.
An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients? 1. Encouraging patients to carry a corticosteroid resuce inhaler at all times 2. Educating patients about recognizing and avoiding asthma triggers 3. Teaching patients to utilize alternative therapies in asthma management 4. Ensuring that patients keep their immunizations up to date
Answer: 2 Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate patients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not necessarily prevent asthma exacerbations.
A nurse assesses that several client have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula? 1.Has an upper respiratory infection (URI) 2.Has many visitors while sitting in a chair 3.Has an NG tube for gastric decompression 4.Has dry oral mucous membranes from mouth breathing
Answer: 2 Clients who receive many visitors while sitting in a chair are more mobile and will benefit from a less restrictive form of oxygen administration. The client will be able to talk without the impediment of a mask. A URI causes nasal mucousal edema; the mucous membranes may be irritated by the nasal prongs, and the effectiveness of nasal oxygen may be diminished. One naris is blocked by an NG tube - so effectiveness may be diminished. If the client is a mouth breather, the effectiveness of NC may be diminished.
A patient with thoracic trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? 1.A chest tube 2.A tracheostomy 3.An endotracheal tube 4.A feeding tube
Answer: 2 In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction.
While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? 1.Every 2 hours when the patient is awake 2.When adventitious breath sounds are auscultated 3.When there is a need to prevent the patient from coughing 4.When the nurse needs to stimulate the cough reflex
Answer: 2 It is usually necessary to suction the patients secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity? 1.Bradycardia and frontal headache 2.Dyspnea and substernal pain 3.Peripheral cyanosis and restlessness 4.Hypotension and tachycardia
Answer: 2 Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.
An asthma educator is teaching a patient newly diagnosed with asthma and her family about the use of a peak flow meter. The educator should teach the patient that a peak flow meter measures what value? 1.Highest airflow during a forced inspiration 2.Highest airflow during a forced expiration 3.Airflow during a normal inspiration 4. Airflow during a normal expiration
Answer: 2 Peak flow meters measure the highest airflow during a forced expiration.
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? 1.Administration of prophylactic antibiotics 2.Administration of pneumococcal vaccine to vulnerable individuals 3.Obtaining culture and sensitivity swabs from all newly admitted patients 4.Administration of antiretroviral medications to patients over age 65
Answer: 2 Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A onetime vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all patients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.
The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize? 1.The patients swallowing ability 2.The patients airway patency 3.The patients carotid pulses 4.Signs and symptoms of infection
Answer: 2 The patient with a laryngectomy is a risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters.
An admitting nurse is assessing a patient with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what? 1.Kyphosis and clubbing of the fingers 2. Dyspnea and hypoxemia 3.Sepsis and pneumothorax 4.Bradypnea and pursed lip breathing
Answer: 2 These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. Kyphosis is a musculoskeletal problem. Sepsis and pneumothorax are atypical complications. Tachypnea is much more likely than bradypnea. Pursed lip breathing can relieve dyspnea.
The nurse is performing an assessment on a patient who has been diagnosed with cancer of the larynx. Part of the nurses assessment addresses the patients general state of nutrition. Which laboratory values would be assessed when determining the nutritional status of the patient? Select all that apply. 1.White blood cell count 2.Protein level 3.Albumin level 4.Platelet count 5.Glucose level
Answer: 2, 3 & 5 The nurse also assesses the patients general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the patients nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the patients nutritional status.
A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply. 1.Coping 2.Level of consciousness 3.Oral intake 4.Arterial blood gases 5.Vital signs
Answer: 2, 4 & 5 Patients are usually treated in the ICU. The nurse assesses the patients respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment, but would become more important later during recovery.
A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing? 1. Gradually increase levels of physical exertion 2. Change filters on heaters and air conditioners frequently 3. Take prescribed medications as scheduled 4. Avoid goose-down pillows
Answer: 3 Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks.
The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first step in the suctioning process? 1. Explain the suctioning procedure to the patient and reposition the patient. 2. Turn on suction source at a pressure not exceeding 120 mmHg 3. Assess the patients lungs sounds and SAO2 via pulse oximeter 4. Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask
Answer: 3 Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patients level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step.
A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this clients airflow obstruction? 1. Administer corticosteroids by metered dose inhaler 2. Administer inhaled anticholinergics 3. Administer inhaled beta-adrenergic agonist 4. Utilize peak flow monitoring device
Answer: 3 Asthma exacerbations are best managed by early treatment and education of the patient. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath
A nurse is teaching a patient with asthma about Azmacort, an inhaled corticosteroid. Which adverse effects should the nurse be sure to address in patient teaching? 1.Dyspnea and increased respiratory secretions 2. Nausea and vomiting 3. Cough and oral thrush 4. Fatigue and decreased level of consciousness
Answer: 3 Azmacort has possible adverse effects of cough, dysphonia, oral thrush (candidiasis), and headache. In high doses, systemic effects may occur (e.g., adrenal suppression, osteoporosis, skin thinning, and easy bruising). The other listed adverse effects are not associated with this drug.
A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? 1.Lung cancer 2.Cystic fibrosis 3.Respiratory failure 4.Hemothorax
Answer: 3 Complications of COPD include respiratory failure, pneumothorax, atelectasis, pneumonia, and pulmonary hypertension (corpulmonale). Lung cancer, cystic fibrosis, and hemothorax are not common complications.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? 1. Deflate the cuff overnight to prevent tracheal tissue trauma. 2. Inflate the cuff to the highest possible pressure in order to prevent aspiration 3. monitor the pressure in the cuff at least every 8 hours 4. Keep the tracheostomy tube plugged at all times
Answer: 3 Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.
The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? 1.Anxiety related to diagnosis of cancer 2.Altered nutrition related to swallowing difficulties 3.Ineffective airway clearance related to airway alterations 4.Impaired verbal communication related to the removal of the larynx
Answer: 3 Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions.
The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patients airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? 1. Continue suctioning the patient until no more secretions are obtained 2. Perform chest physiotherapy rather than suctioning 3. Wait several minutes and the repeat 4. Perform postural drainage and the repeat suctioning
Answer: 3 If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.
The nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient? 1.Signs of oxygen toxicity 2.Chronic chest pain 3.A barrel chest 4.Long, thin fingers
Answer: 3 In COPD patients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The nurse most likely would not assess chest pain or long, thin fingers; these are not characteristic of emphysema. The patient would not show signs of oxygen toxicity unless he or she received excess supplementary oxygen.
A patient's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the patient's statements suggests a need for further education? 1.I know that these drugs can sometimes make my heart beat faster. 2. I've heard that this drug is particularly good at preventing asthma attacks during exercise. 3. I'll make sure to use this each time I feel an asthma attack coming on. 4. I've heard that this drug sometimes gets less effective over time.
Answer: 3 LABAs are not used for the management of acute asthma symptoms. Tachycardia is a potential adverse effect and decreased protection against exercise-induced bronchospasm may occur with regular use.
A 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem? 1.Adenoiditis 2.Chronic tonsillitis 3.Obstructive sleep apnea 4.Laryngeal cancers
Answer: 3 Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring. Daytime sleepiness and difficulty going to sleep at night are not indications of tonsillitis or adenoiditis. This patients symptoms are not suggestive of laryngeal cancer.
A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the HC provider, which action should the nurse take? 1.Place the client on the unaffected side 2.Administer 60% oxygen via a Venturi mask 3.Give oxygen at 2 L/min via NC 4.Prepare for intravenous (IV) admin of electrolytes
Answer: 3 Oxygen is supplied to prevent anoxia, but NOT in a high concentration WITHOUT a prescription. In an individual with emphysema, a low oxygen level, not a high carbon dioxide level may the the resp stimulus. May point - venturi masks are great, but a HIGH FLOW device such as this is not something we can immediately admin as a nurse. Especially since high concentration of oxygen may precipitate CO2 narcosis. Placing on the unaffected side may cause a mediastinal shift. Preparing for admin of electrolytes requires an order for such IV meds.
The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what? 1.Pleurisy 2.Emphysema 3.Asthma 4.Pneumonia
Answer: 3 Sibilant wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia.
The nurse is providing postop care to a client with cancer of the lung who had a lobectomy. The client has a chest tube attached to suction. Which assessment finding includes a complication? 1.Clots in the tubing during the first postop day 2.Bloody fluid in the drainage-collection chamber on the first postop day 3.Subcutaneous emphysema on the second postop day 4.Decreased bubbling in the water-seal chamber on the third postop day
Answer: 3 SubQ emphysema on the 2nd post op day should not occur; it is evidence of a leak from the chest tube or the lung into the subQ tissue. Clots are expected initially after surgery. Bloody drainage is expected immediately after surgery. Decreased bubbling in the water-seal chamber on the third post op day occurs as the lung is reexpanding or if there is an obstruction in the chest tube; bubbling stops completely when the lung is expanded fully.
The nurse is assessing a client's ABG and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? 1.PO2 value is 80 mm Hg 2.PCO2 value is 60 mm Hg 3.HCO3 value is 50 mEq/L 4.Serum potassium value is 4 mEq/L
Answer: 3 The HCO3 value is elevated. The urinary system compensates by retaining H+ ions which become part of bicarb ions; the bicarb level becomes elevated and increases the pH level to near the expected range. Although in compensated resp. acidosis the PCO2 may be elevated it is the increased HCO3 level that indicates compensation. Potassium is within NL.
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? 1.Non-rebreather air mask 2.Tracheostomy collar 3.Venturi mask 4.Face tent
Answer: 3 The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the precision of a Venturi mask.
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patients blood? 1.A capillary blood sample 2.Pulse oximetry 3.An arterial blood gas (ABG) 4.A complete blood count (CBC)
Answer: 3 The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG measurement, because it is not as accurate. A CBC does not indicate the concentration of oxygen.
The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? 1.Absence of breath sounds 2.Wheezing with discontinuous breath sounds 3.Faint breath sounds with prolonged expiration 4.Faint breath sounds with fine crackles
Answer: 3 The breath sounds of the patient with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged.
A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? 1.Older adults have less compliant lung tissue than younger adults. 2.Older adults are not normally candidates for pneumococcal vaccination. 3.Older adults often lack the classic signs and symptoms of pneumonia. 4.Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.
Answer: 3 The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in older adult patients. Mortality from pneumonia in the elderly is not a result of limited antibiotic options or lower lung compliance. The pneumococcal vaccine is appropriate for older adults.
The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic? 1. Assess the patients level of consciousness (LOC) 2. Assess the patients extremities for signs of cyanosis 3. Assess the patients oxygen saturation level 4. Review the patients hemoglobin, hematocrit, and red blodo cell levels
Answer: 3 The effectiveness of the patients oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The patients LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.
A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? 1. Determine whether the patient can now perform forced expiratory technique (FET) 2. Percuss the patients lungs and thorax 3. Measure the patients oxygen saturation 4. Have the patient perform incentive spirometry
Answer: 3 The patients response to suctioning is usually determined by performing chest auscultation and by measuring the patients oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.
A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? 1.Shallow respirations 2.Increased anterior-posterior (A-P) diameter 3.Bilateral wheezes 4.Bradypnea
Answer: 3 The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the childs A-P diameter does not normally change.
The nurse is caring for a patient who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment? 1.Assessment of body image 2.Assessment of jugular venous pressure 3.Assessment of carotid pulse 4.Assessment of swallowing ability
Answer: 4 A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration. Cardiovascular complications are less likely at this stage of recovery. The patients body image should be assessed, but dysphagia has the potential to affect the patients airway, and is a consequent priority.
A client is admitted with possible tuberculosis. To make a definitive diagnosis, the nurse expects which diagnostic test to be prescribed? 1.Chest x-ray 2.Tuberculin skin test 3.Pulmonary function test 4.Sputum test for acid-fast bacilli
Answer: 4 Chest x-ray reflects pulmonary status but does not identify the organism if a lesion is found. Tb skin tests indicates the presence of antibodies but is NOT a dx of the disease (further eval is needed), this just means the client has been exposed. Pulmonary function tests reflects pulm status but does not identify the organism is a lesion is found.
The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding? 1. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes 2. Inform the physician promptly that there is no imminent leak in the drainage system 3. Encourage the patient to do deep breathing and coughing exercises 4. Document that the chest drainage system is operating as it is intended
Answer: 4 Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.
A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient? 1.Assure the patient that everything will be all right and that remaining calm is the best strategy. 2.Ask a family member to interpret what the patient is trying to communicate. 3.Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely. 4.Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.
Answer: 4 If the patient uses an alternative method of communication, he will feel in better control and likely be less frustrated. Assuring the patient that everything will be all right offers false reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods helps the patient to communicate. In a patient with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the patients wishes. Making them responsible for interpreting the patients gestures may frustrate the family. The patient may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.
A patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? 1.Administer the treatment with the patient in a high Fowlers or semi-Fowlers position. 2.Perform the procedure immediately following the patients meals. 3.Apply percussion firmly to bare skin to facilitate drainage. 4.Assist the patient into a position that will allow gravity to move secretions.
Answer: 4 Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal.
A clinic nurse is caring for a patient who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The patient asks the nurse what he could have done to minimize the risk of contracting this disease. What would be the nurses best answer? 1.The most important risk factor for COPD is exposure to occupational toxins. 2.The most important risk factor for COPD is inadequate exercise. 3.The most important risk factor for COPD is exposure to dust and pollen. 4.The most important risk factor for COPD is cigarette smoking.
Answer: 4 The most important risk factor for COPD is cigarette smoking. Lack of exercise and exposure to dust and pollen are not risk factors for COPD. Occupational risks are significant but are far exceeded by smoking.
The nurse is explaining the safe and effective administration of nasal spray to a patient with seasonal allergies. What information is most important to include in this teaching? 1.Finish the bottle of nasal spray to clear the infection effectively. 2.Nasal spray can only be shared between immediate family members. 3.Nasal spray should be administered in a prone position. 4.Overuse of nasal spray may cause rebound congestion
Answer: 4 The use of topical decongestants is controversial because of the potential for a rebound effect. The patient should hold his or her head back for maximal distribution of the spray. Only the patient should use the bottle.
A nurse is caring for a patient with COPD. The patients medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in respiratory status? Select all that apply. 1.Negative sputum culture 2.Increased viscosity of lung secretions 3. Increased respiratory rate 4. Increased expiratory flow rate 5.Relief of dyspnea
Answer: 4 & 5 The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the patients respiratory status. Bronchodilators would not have a direct result on the patients infectious process.
