MSE3****

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

A. Ask the client to drink 2 liters of fluids daily. (More fluids are better) B. Add humidity to the prescribed oxygen. D. Use a vibrating positive expiratory pressure device. f. Administer the ordered mucolytic agent Rationale - Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client's ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

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.

Which patient should the nurse assess first? a. A patient with burns who reports a level 8 (0 to 10 scale) pain. b. A patient with smoke inhalation who has wheezes and altered mental status. c. A patient with full-thickness leg burns who is scheduled for a dressing change. d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr.

ANS: B Urine output of 41mL over past 2 hrs The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 mm Hg systolic and the pulse rate should be less than 120 beats/min. Serous exudate from the burns is expected during the emergent phase.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours b. Continuing to monitor the laboratory results c. Increasing the rate of the ordered IV solution d. Typing and crossmatching for a blood transfusion

ANS: C Increasing the rate of the ordered IV solition The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every hour).

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? a. 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg b. 32-year-old with ABG results: pH 7.50, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. 40-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. 64-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

ANS: a. 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The other patients also should be assessed as quickly as possible, but do not require interventions as quickly as the 20-year-old.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next? a. Increase the oxygen flow rate. b. Suction the patient's oropharynx. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.

ANS: a. Increase the oxygen and flow rate Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.

ANS: b. Notify the health care provider The decrease in pulse and numbness in a patient with circumferential burns shows decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation.

Which nursing action prevents cross contamination when the patient's full-thickness burn wounds to the face are exposed? a. Using sterile gloves when removing dressings. b. Keeping the room temperature at 70° F (20° C). c. Wearing gown, cap, mask, and gloves during care. d. Giving IV antibiotics to prevent bacterial colonization.

ANS: c. Wearing gown, cap, mask, and gloves during care. Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)

ANS: d. hydromorphone (Dilaudid) Opioid pain medications are the best choice for pain control. The other drugs are used as adjuvants to enhance the effects of opioids.

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 nursethe results of what the client calls "an allergy test," as shown below: Picture of arm 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

C. Immediately place the client on Airborne precautions This "allergy test" is actually a positive tuberculosis test.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?

Visiting Nurses for directly observed therapy

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Give IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

D, E, C, A, B

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? A. "I will seek immediate medical treatment for any upper respiratory infections." B. "I should continue to do deep-breathing and coughing exercises for at least 12 weeks." C. "I will increase my food intake to 2400 calories a day to keep my immune system well." D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

Educating the client on adherence to the treatment regimen

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospital's gift shop. e. Use aseptic technique and wear gloves when performing wound care.

a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. e.Use aseptic technique and wear gloves when performing wound care.

Which action should the nurse anticipate taking first when a patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing? a. Assist with endotracheal intubation. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (SoluMedrol).

a. Assist with endotracheal intubation. The patients assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time.

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. Elevate head of bed to 30 to 45 degrees. b. Suction the endotracheal tube every 2 to 4 hours. c. Limit the use of positive end-expiratory pressure. d. Give enteral feedings at no more than 10 mL/hr.

a. Elevate head of bed to 30 to 45 degrees. Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs.

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Pain level is 5 (on 0 to 10 scale) with a deep breath. d. Respiratory rate is 24 breaths/minute when lying flat.

a. O2 saturation is 88%.

An employee spills industrial acid on both arms and legs at work. What action should the occupational health nurse take? a. Remove nonadherent clothing and wristwatch. b. Apply an alkaline solution to the affected area. c. Place a cool compress on the area of exposure. d. Cover the affected area with dry, sterile dressings.

a. Remove nonadherent clothing and wristwatch. With chemical burns, the first action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if the face was exposed). Flush the chemical from the wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution can cause more injury.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

a. Weak, nonproductive cough effort The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. The nurses first action should be to a. listen to the patients breath sounds. b. ask about inhaled corticosteroid use. c. determine when the dyspnea started. d. obtain the forced expiratory volume (FEV) flow rate.

a. listen to the patients breath sounds. Assessment of the patients breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patients status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a.Administer analgesics. b.Prevent wound infections. c.Provide fluid replacement. d.Decrease core temperature. e.Initiate physical therapy.

a.Administer analgesics. b.Prevent wound infections. c.Provide fluid replacement.

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which response by the nurse is best? a. "Would you like to talk to the hospital chaplain about your feelings?" b. "Can you tell me what it is that makes you think you will die so soon?" c. "Are you afraid that the treatment for your cancer will not be effective?" d. "Do you think that taking an antidepressant medication would be helpful?"

b. "Can you tell me what it is that makes you think you will die so soon?" The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

b. A 46-year-old patient with cystic fibrosis who has pulmonary function testing scheduled

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.

b. A surgical face mask is applied before visiting the patient.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

b. Change gloves between wound care on different parts of the clients body. Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the clients body can prevent autocontamination.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased, and no wheezes are audible. What action should the nurse take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

b. Notify the health care provider and prepare for endotracheal intubation. The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified at once so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess pain level. b. Place on heart monitor. c. Check potassium level. d. Assess oral temperature.

b. Place on heart monitor. After an electrical burn, the patient is at risk for life-threatening dysrhythmias and should be placed on a heart monitor. Assessing the oral temperature and pain is not as important as assessing for dysrhythmias. Checking the potassium level is important, but it will take time before the laboratory results are back. The first intervention is to place the patient on a heart monitor and assess for dysrhythmias so that they can be monitored and treated if necessary.

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

b. Position the patient sitting upright on the edge of the bed and leaning forward. When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.

b. Tape a nonporous dressing on three sides over the chest wound.

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

c. "The blood clot interferes with perfusion in the lungs." A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

c. Auscultate breath sounds over the trachea and bronchi. Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? a. Ask the patient about any visual changes in red-green color discrimination. b. Question the patient about experiencing shortness of breath, hives, or itching. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.

c. Explain that orange discolored urine and tears are normal while taking this medication.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care? a. Positioning on the right side b. Bed rest for the first 24 hours c. Frequent use of an incentive spirometer d. Chest tube placement with continuous drainage

c. Frequent use of an incentive spirometer

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µL. d. Increased tactile fremitus is palpable over the right chest.

c. The patient's white blood cell (WBC) count is 9000/µL. The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Surgery is the treatment of choice for stage I lung cancer." d. "Tell me what you know about the various treatments available."

d. "Tell me what you know about the various treatments available."

After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

d. 60-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin (Robitussin) c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

d. Piperacillin/tazobactam (Zosyn)

When the nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD), which information will help most in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patients history indicates a 40 pack-year cigarette history. c. The patient denies having any respiratory problems until the last 6 months. d. The patient complains about a productive cough every winter for 3 months.

d. The patient complains about a productive cough every winter for 3 months. A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative

d. Three sputum smears for acid-fast bacilli are negative. Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation.

d. Use pulse oximetry to check oxygen saturation. Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.