N618: Ch 6 Respiratory Disorders

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.

1. A STAT chest x-ray would not be needed to determine why there is no fluctuation in the water-seal compartment. 2. Increasing the amount of wall suction does not address why there is no fluctuation in the water-seal compartment. 3. The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop. 4. The stem does not state the client is in respiratory distress, and a pulse oximeter reading detects hypoxemia but does not address any fluctuation in the water-seal compartment. TEST-TAKING HINT: The test taker should apply the nursing process to answer the question correctly. The first step in the nursing process is assessment, and "check" (option "3") is a word that can be used synonymously for "assess." Monitoring (option "4") is also assessing, but the test taker should not check a diagnostic test result before caring for the client.

The nurse is discussing the care of a child diagnosed with asthma with the parent. Which referral is important to include in the teaching? 1. Referral to a dietitian. 2. Referral for allergy testing. 3. Referral to the developmental psychologist. 4. Referral to a home health nurse.

1. A child with asthma can eat a regular diet if the child is not allergic to the components of the diet. 2.Because asthma can be a reaction to an allergen, it is important to determine which substances may trigger an attack. 3. The stem did not indicate the child is developmentally delayed. 4. The child does not require a home health nurse solely on the basis of asthma; the school nurse or any child-care provider should be informed of the child's diagnosis, and the parents must know the individual caring for the child is prepared to intervene during an attack. TEST-TAKING HINT: The test taker must be aware of the disease process, determine causes, and then make a decision based on interventions required.

Which nursing interventions should the nurse implement for the client who has a respiratory disorder? Select all that apply. 1. Administer oxygen via a nasal cannula. 2. Assess the client's lung sounds. 3. Encourage the client to cough and deep breathe. 4. Monitor the client's pulse oximeter reading. 5. Increase the client's fluid intake.

1. A client with a respiratory disorder may have decreased oxygen saturation; therefore, administering oxygen via a nasal cannula is appropriate. 2. The client's lung sounds should be assessed to determine how much air is being exchanged in the lungs. 3. Coughing and deep breathing will help the client expectorate sputum, thus clearing the bronchial tree. 4. The pulse oximeter evaluates how much oxygen is reaching the periphery. 5. Increasing fluids will help thin secretions, making them easier to expectorate.

The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client? 1. Complete blood count. 2. Pulmonary function test. 3. Allergy skin testing. 4. Drug cortisol level.

1. A complete blood count determines the oxygen-carrying capacity of the hemoglobin in the body, but it will not identify the immediate problem. 2.Pulmonary function test are completed to determine the forced vital capacity (FVC), the forced expiratory capacity in the first second (FEV1), and the peak expiratory flow (PEF). A decline in the FVC, FEV1, and PEF indicates respiratory compromise. 3.Allergy skin testing will be done to determine triggers for allergic asthma, but it is not done during an attack. 4.Drug cortisol levels do not relate to asthma. TEST-TAKING HINT: If the test taker is unsure about the correct response, it is helpful to choose the option that directly relates to the topic. Asthma is a pulmonary problem, and only one (1) option has the word "pulmonary" in it.

The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amounts of thick white sputum. 2. Oxygen flowmeter set on eight (8) liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.

1. A large amount of thick sputum is a common symptom of COPD. There is no cause for immediate intervention. 2.The nurse should decrease the oxygen rate to two (2) to three (3) liters. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the oxygen level increases, the drive to breathe may be eliminated. 3. It is common for clients with COPD to use accessory muscles when inhaling. These clients tend to lean forward. 4. In clients with COPD, there is a characteristic barrel chest from chronic hyperinflation, and dyspnea is common. TEST-TAKING HINT: This question requires interpreting the data to determine which are abnormal or unexpected and require intervention. Options "1," "3," and "4" are expected for the client's disease process.

The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription? 1. "These pills will make me feel better fast and I can return to work." 2. "The antibiotics will help prevent me from developing a bacterial pneumonia." 3. "If I had gotten this prescription sooner, I could have prevented this illness." 4. "I need to take these pills until I feel better; then I can stop taking the rest.

1. A person with a viral infection should not return to work until the virus has run its course because the antibiotics help prevent complications of the virus, but they do not make the client feel better faster. 2.Secondary bacterial infections often accompany influenza, and antibiotics are often prescribed to help prevent the development of a bacterial infection. 3.Antibiotics will not prevent the flu. Only the flu vaccine will prevent the flu. 4.When people take portions of the antibiotic prescription and stop taking the remainder, an antibiotic-resistant strain of bacteria may develop, and the client may experience a return of symptoms—but this time, the antibiotics will not be effective. TEST-TAKING HINT: Knowing drug classifications and how the drugs within the classification work would assist the test taker to determine the correct answer. Antibiotics work to destroy bacterial invasions of the body.

The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing? 1. The client's first skin test indicates a purple flat area at the site of injection. 2. The client's second skin test indicates a red area measuring four (4) mm. 3. The client's previous skin test was read as positive. 4. The client has never shown a reaction to the tuberculin medication.

1. A purple flat area indicates that the client became bruised when the intradermal injection was given, but it has no bearing on whether the test is positive. 2. A positive skin test is 10 mm or greater with induration, not redness. 3.If the client has ever reacted positively, then the client should have a chest x-ray to look for causation and inflammation. 4. These are negative findings and do not indicate the need to have x-ray determination of disease. TEST-TAKING HINT: The test taker should note descriptive terms such as "purple," "flat," or "4 mm" before determining the correct answer. Option "4" has the absolute word "never," and absolutes usually indicate incorrect answers.

The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy? 1. Vitamin C, 2,000 mg daily. 2. Strict bedrest. 3. Humidification of the air. 4. Decongestant therapy.

1. Alternative therapies are therapies not accepted as standard medical practice. These may be encouraged as long as they do not interfere with the medical regimen. Vitamin C in large doses is thought to improve the immune system's functions. 2.Bedrest is accepted standard advice for a client with a cold. 3.Humidifying the air helps to relieve congestion and is a standard practice. 4.Decongestant therapy is standard therapy for a cold. TEST-TAKING HINT: Only one of the answer options is not common advice for a client with a cold. When all options but one (1) match each other, then the odd option should be selected as the correct answer.

The client diagnosed with a cold is taking an antihistamine. Which statement indicates to the nurse the client needs more teaching concerning the medication? 1. "If my mouth gets dry I will suck on hard candy." 2. "I will not drink beer or any type of alcohol." 3. "I need to be careful when I drive my car." 4. "This medication will make me sleepy."

1. Antihistamines dry respiratory secretions through an anticholinergic effect; therefore, the client will have a dry mouth. 2. Antihistamines cause drowsiness; therefore, the client should not drink any type of alcohol. 3. Antihistamines cause drowsiness, so the client should not drive or operate any type of machinery. 4. Antihistamines cause drowsiness; therefore, the client understands the teaching.

The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective? 1. A decrease in the white blood cells in the sputum. 2. The client's symptoms are improving. 3. No change in the chest x-ray. 4. The skin test is now negative.

1. Antitubercular medications target the tubercular bacilli, not white blood cells. 2. As the bacilli are being destroyed, the client should begin to feel better and have fewer symptoms. 3. At six (6) weeks, the chest x-ray may not have changes. 4. The skin test will always be positive.

The nurse is planning the care of a client diagnosed with asthma and has written a problem of "anxiety." Which nursing intervention should be implemented? 1. Remain with the client. 2. Notify the health-care provider. 3. Administer an anxiolytic medication. 4. Encourage the client to drink fluids.

1. Anxiety is an expected sequela of being unable to meet the oxygen needs of the body. Staying with the client lets the client know the nurse will intervene and the client is not alone. 2. Because anxiety is an expected occurrence with asthma, it is not necessary to notify the health-care provider. 3. An anxiolytic medication could decrease respiratory drive and increase the respiratory distress. Also, the medication will require a delayed time period to begin to work. 4. Drinking fluids will not treat an asthma attack or anxiety. TEST-TAKING HINT: Before choosing an answer option that directs the test taker to notify a health-care provider, the test taker should determine if the option is describing an expected event or data for the disease process being discussed. If it is expected, then notifying the health-care provider would not be the correct answer.

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

1. Assessment of the lung sounds could indicate the client's lung has reexpanded because it has been three (3) days since the chest tube has been inserted. 2. This should be done to ensure the lung has reexpanded, but it is not the first intervention. 3. The HCP will need to be notified so the chest tube can be removed, but it is not the first intervention. 4. This situation needs to be documented, but it is not the first intervention. TEST-TAKING HINT: When the stem asks the test taker to identify the first intervention, all four (4) answer options could be interventions appropriate for the situation, but only one (1) is the first intervention. Remember to apply the nursing process: the first step is assessment.

The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? 1. Administer the ordered oral antibiotic STAT. 2. Order the meal tray to be delivered as soon as possible. 3. Obtain a sputum specimen for culture and sensitivity. 4. Have the unlicensed assistive personnel weigh the client.

1. Broad-spectrum IV antibiotics are priority, but before antibiotics are administered, it is important to obtain culture specimens to determine the correct antibiotic for the client's infection. Clients are placed on oral medications only after several days of IVPB therapy. 2.Meal trays are not priority over cultures. 3.To determine the antibiotic that will effectively treat an infection, specimens for culture are taken prior to beginning the medication. Administering antibi- otics prior to cultures may make it impossible to determine the actual agent causing the pneumonia. 4.Admission weights are important to determine appropriate dosing of medication, but they are not priority over sputum collection. TEST-TAKING HINT: Option "1" has a medication classification and a route, and the test taker should question if the route is appropriate for the client being admitted. Clients will not die from a delayed meal, but a client could die from delayed IV antibiotic therapy

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

1. Checking to see if someone has increased the suction rate is the simplest and a noninvasive action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system. 2. No fluctuation (tidaling) would cause the nurse to assess the tubing for a blood clot. 3. The tube is milked to help dislodge a blood clot that may be blocking the chest tube causing no fluctuation (tidaling) in the water-seal compartment. The chest tube is never stripped, which creates a negative air pressure and could suck lung tissue into the chest tube. 4. Encouraging the client to cough forcefully will help dislodge a blood clot blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment. TEST-TAKING HINT: The test taker should always think about assessing the client if there is a problem and the client is not in immediate danger. This would cause the test taker to eliminate options "3" and "4." If the test taker thinks about bubbling, he or she should know it has to do with suctioning.

Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD? 1. "I need to get an influenza vaccine each year, even when there is a shortage." 2. "I need to get a vaccine for pneumonia each year with my influenza shot." 3. "If I reduce my cigarettes to six (6) a day, I won't have difficulty breathing." 4. "I need to restrict my drinking liquids to keep from having so much phlegm."

1. Clients diagnosed with COPD should receive the influenza vaccine each year. If there is a shortage, these clients have top priority. 2. The pneumococcal vaccine should be ad- ministered every five (5) to seven (7) years. 3. Reducing the number of cigarettes smoked does not stop the progression of COPD, and the client will continue to experience signs and symptoms such as shortness of breath or dyspnea on exertion. 4. Clients diagnosed with COPD should increase their fluid intake unless contraindicated for another health condition. The increased fluid assists the client in expectorating the thick sputum. TEST-TAKING HINT: Nurses are expected to serve as community resources. The nurse should be knowledgeable about health promotion activities such as immunizations. One (1) option describes a desired goal, but the other three (3) do no

The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which is an expected outcome for this problem? 1. Performs chest physiotherapy three (3) times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall several times during each shift. 4. Alert and oriented to person, place, time, and events.

1. Clients do not perform chest physiotherapy; this is normally done by the respiratory therapist. This is a staff goal, not a client goal. 2.This would be a goal for self-care deficit but not for impaired gas exchange. 3.This would be a goal for the problem of activity intolerance. 4.Impaired gas exchange results in hypoxia, the earliest sign/symptom of which is a change in the level of consciousness. TEST-TAKING HINT: The test taker should match the answer option to the listed nursing problem. Option "1" is a staff goal to accomplish. When writing goals for the client, it is important to remember they are written in terms of what is expected of the client. Options "2" and "3" are appropriately written client goals, but they do not evaluate gas exchange.

The occupational nurse for a mining company is planning a class on the risks of working with toxic substances to comply with the "Right to Know" law. Which information should the nurse include in the presentation? Select all that apply. 1. A client who smokes cigarettes has a drastically increased risk for lung cancer. 2. Floors need to be clean and dust needs to be wet to prevent transfer of dust. 3. The air needs to be monitored at specific times to evaluate for exposure. 4. Surface areas need to be painted every year to prevent the accumulation of dust. 5. Employees should wear the appropriate personal protective equipment.

1. Clients who smoke cigarettes and work with toxic substances have increased risk of lung cancer because many of the substances are carcinogenic. 2. When floors and surfaces are kept clean, toxic dust particles, such as asbestos and silica, are controlled and this decreases exposure. Covering areas with water controls dust. 3. The quality of air is monitored to determine what toxic substances are present and in what amount. The information is then used in efforts to minimize the amount of exposure. 4. Applying paint to a surface does not eliminate or minimize exposure and can trap more dust. 5.Employees must wear protective coverings, goggles, and other equipment needed to eliminate exposure to the toxic substances.

The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse's best response? 1. Close the door and discuss the UAP's action after coming out of the room. 2. Make the UAP come back outside the room and then reenter, closing the door. 3. Say nothing to the UAP but report the incident to the nursing supervisor. 4. Enter the client's room and discuss the matter with the UAP immediately.

1. Closing the door reestablishes the negative air pressure, which prevents the air from entering the hall and contaminating the hospital environment. When correcting an individual, it is always best to do so in a private manner. 2. The employee is an adult and as such should be treated with respect and corrected accordingly. 3. Problems should be taken care of at the lowest level possible. The nurse is responsible for any task delegated, including the appropriate handling of isolation. 4. Correcting staff should never be done in the presence of the client. This undermines the UAP and creates doubt of the staff's competency in the client's mind. TEST-TAKING HINT: An action must be taken; the test taker must determine which action would have the desired results with the least amount of disruption to client care. Correcting the UAP in this manner has the greatest chance of creating a win-win situation.

Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD? 1. Clubbing of the client's fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough

1. Clubbing of the fingers is the result of chronic hypoxemia, which is expected with chronic COPD but not recently diagnosed COPD. 2. These clients have frequent respiratory infections. 3.Sputum production, along with cough and dyspnea on exertion, are the early signs/symptoms of COPD. 4. These clients have a productive cough, not a nonproductive cough. TEST-TAKING HINT: The test taker must be observant of terms such as "recently diagnosed," which help to rule out incorrect answers such as option "1." Option "2" has the word "infrequent." The test taker must notice these words.

The nurse is assessing the client diagnosed with a lung abscess. Which information supports this diagnosis of lung abscess? 1. Tympanic sounds elicited by percussion over the site. 2. Inspiratory and expiratory wheezes heard over the upper lobes. 3. Decreased breath sounds with a pleural friction rub. 4. Asymmetric movement of the chest wall with inspiration.

1. Dull sounds would be heard over the site of a lung abscess as a result of the solid mass. 2. Crackles may be heard, but wheezes indicate a narrowing of airways, not exudate-filled airways. 3. Diminished or absent sounds are heard with intermittent pleural friction rubs. A lung abscess is the accumulation of pus in an area where pneumonia was present that becomes encapsulated and can extend to the bronchus or pleural space. 4. Even with a lung abscess, the chest should move symmetrically.

Which intervention should the nurse implement for the client experiencing bronchospasms? 1. Administer intravenous epinephrine, a bronchodilator. 2. Administer Albuterol, a bronchodilator, via nebulizer. 3. Request a STAT portable chest x-ray at the bedside. 4. Insert a small nasal trumpet in the right nostril.

1. Epinephrine is administered intravenously during an arrest in a code situation, but it is not a treatment of choice for bronchospasms. 2. Albuterol given via nebulizer is administered to stop the bronchospasms. If the client continues to have the bronchospasms, intubation may be needed. 3. A STAT portable x-ray will be ordered, but the goal is to prevent respiratory arrest. 4. Nasal trumpet airways would not be helpful in stopping the bronchospasm and respiratory arrest.

The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find? 1. Fever and crepitus. 2. Rales and hives. 3. Dyspnea and wheezing. 4. Normal chest shape and eupnea.

1. Fever is a sign of infection, and crepitus is air trapped in the layers of the skin. 2.Rales indicate fluid in the lung, and hives are a skin reaction to a stimulus such as occurs with an allergy to a specific substance. 3.During an asthma attack, the muscles surrounding the bronchioles constrict, causing a narrowing of the bronchioles. The lungs then respond with the production of secretions that further narrow the lumen. The resulting symptoms include wheezing from air passing through the narrow, clogged spaces, and dyspnea. 4. During an attack, the chest will be expanded from air being trapped and not being exhaled. A chest x-ray will reveal a lowered diaphragm and hyperinflated lungs. TEST-TAKING HINT: The test taker must have a basic knowledge of common medical terms to answer this question. Dyspnea, wheezing, and rales are common terms used when describing respiratory function and lung sounds. Crepitus and eupnea are not as commonly used, but they are also terms that describe respiratory processes and problems.

Which intervention should the emergency department nurse implement first for the client admitted for an acute asthma attack? 1. Administer glucocorticoids intravenously. 2. Administer oxygen 5 L per nasal cannula. 3. Establish and maintain a 20-gauge saline lock. 4. Assess breath sounds every 15 minutes.

1. Glucocorticoids are a treatment of choice, but they are not the first intervention. 2.The client is in distress so the nurse must do something for the client's airway. 3. A saline lock is needed for intravenous fluids, but it is not the first intervention. 4.Assessment is the first step of the nursing process but in distress do not assess.

The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss? 1. Instruct the children to always keep a tissue or handkerchief with them. 2. Explain that children current with immunizations will not get a cold. 3. Tell the children they should go to the doctor if they get a cold. 4. Demonstrate to the students how to wash hands correctly.

1. It is not feasible for a child to always have a tissue or handkerchief available. 2.There is no immunization for the common cold. Colds are actually caused by at least 200 separate viruses and the viruses mutate frequently. 3. Colds are caused by a virus and antibiotics do not treat a virus; therefore, there is no need to go to a health-care provider. 4.Hand washing is the single most useful technique for prevention of disease. TEST-TAKING HINT: Option "1" contains the word "always," an absolute word, and in most questions, absolutes such as "always," "never," and "only" make that answer option incorrect.

The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The UAP keeps the chest tube below chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of the bed. 4. The UAP uses a bedside commode for the client.

1. Keeping the drainage system lower than the chest promotes drainage and prevents reflux. 2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the UAP. 3. Ambulation facilitates lung ventilation and expansion; drainage systems are portable to allow ambulation while chest tubes are in place. 4. The client should ambulate, but getting up and using the bedside commode is better than staying in the bed, so no action would be needed. TEST-TAKING HINT: "Warrants immediate intervention" means the test taker must identify the situation in which the nurse should correct the action, demonstrate a skill, or somehow intervene with the UAP's behavior.

. The nurse and an unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? Select all that apply. 1. Keep the head of the bed elevated. 2. Encourage deep breathing exercises. 3. Record pulse oximeter reading. 4. Assess level of conscious. 5. Auscultate breath sounds.

1. Keeping the head of the bed elevated maximizes lung excursion and improves gas exchange and can be delegated. 2. Encouraging breathing exercises can be delegated. 3. Recording pulse oximeter readings can be delegated. Evaluating is the responsibility of the nurse. 4.Assessment cannot be delegated. Confusion is one of the first symptoms of hypoxia. 5. Auscultation is a technique of assessment and cannot be delegated.

Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen? 1. "I will take Singulair, a leukotriene modifier, every day to prevent allergic asthma attacks." 2. "I need to use my Intal, cromolyn, inhaler 15 minutes before I begin my exercise." 3. "I need to take oral glucocorticoids every day to prevent my asthma attacks." 4. "If I have an asthma attack, I need to use my Albuterol, a beta2 agonist, inhaler."

1. Leukotriene modifiers, such as Singulair, should be taken daily to prevent an asthma attack triggered by an allergen response. 2.Cromolyn inhalers, such as Intal, are used to prevent exercise-induced asthma attacks. 3.Glucocorticoids are administered orally or intravenously during acute exacerbations of asthma, not on a daily basis because of the long-term complications of steroid therapy. 4. Albuterol, a beta2 agonist, is used during attacks because of the fast action.

The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication? 1. Muscle weakness. 2. Purulent sputum. 3. Nuchal rigidity. 4. Intermittent loss of muscle control.

1. Muscle weakness is a sign/symptom of myalgia, but it is not a life-threatening complication of sinusitis. 2.Purulent sputum would be a sign/symptom of a lung infection, but it is not a life-threatening complication of sinusitis. 3.Nuchal rigidity is a sign/symptom of meningitis, which is a life-threatening potential complication of sinusitis resulting from the close proximity of the sinus cavities to the meninges. 4.Intermittent loss of muscle control can be a symptom of multiple sclerosis, but it would not be a life-threatening complication of sinusitis. TEST-TAKING HINT: A basic knowledge of anatomy and physiology would help to answer this question. The sinuses lie in the head and surround the orbital cavity. Options "1" and "4" refer to muscle problems, so both could be ruled out as wrong.

The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.

1. No fluctuation in the water-seal chamber four (4) hours post insertion indicates the tubing is blocked; the nurse can milk the chest tube, but it is not the first action. 2. The nurse should implement the least invasive intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle. 3. Coughing may help push a clot in the tubing into the drainage bottle, but the first intervention is to check and see if the client is lying on the tubing or the tube is kinked somewhere. 4. The insertion site can be assessed, but it will not help determine why there is no fluctuation in the water-seal drainage compartment.

The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg. Which health-care provider order would the nurse question? 1. Administer intravenous fluids of normal saline at 125 mL/hr. 2. Provide supplemental oxygen per nasal cannula at 2 L/min. 3. Continuous telemetry monitoring with strips every four (4) hours. 4. Administer a loop diuretic intravenously every six (6) hours.

1. Normal mean pulmonary artery pressure is about 15 mm Hg and an elevation indicates right ventricular heart failure or cor pulmonale, which is a comorbid condition of chronic obstructive pulmonary disease. The nurse should question this order because the rate is too high. 2. Supplemental oxygen should be administered at the lowest amount; therefore, this order should not be questioned. 3. Clients with hypoxia and cor pulmonale are at risk for dysrhythmias, so monitoring the ECG is an appropriate intervention. 4. Loop diuretics are administered to decrease the fluid and decrease the circulatory load on the right side of the heart; therefore, this order would not be questioned.

The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? Select all that apply. 1. Nursing. 2. Pharmacy. 3. Social work. 4. Occupational therapy. 5. Speech therapy.

1. Nursing is the one discipline remaining with the client around the clock. Therefore, nurses have knowledge of the client that other disciplines might not know. 2. The pharmacist will be able to discuss the medication regimen the client is receiving and make suggestions regarding other medications or medication interactions. 3. The social worker may be able to assist with financial information or home care arrangements. 4. Occupational therapists help clients with activities of daily living and modifications to home environments; nothing in the stem indicates a need for these services. 5. Speech therapists assist clients with speech and swallowing problems; nothing in the stem indicates a need for these services. TEST-TAKING HINT: Cost containment issues are always a concern the nurse must address. The use of limited resources (health-care personnel) should be on an as-needed basis only. Cost containment must be considered when using other disciplines or supplies.

Which problem is appropriate for the nurse to identify for the client who is one (1) day postoperative thoracotomy? 1. Alteration in comfort. 2. Altered level of conscious. 3. Alteration in elimination pattern. 4. Knowledge deficit.

1. Pain and discomfort are major problems for a client who had a thoracotomy because the chest wall has been opened and closed. 2. The client would be on a mechanical ventilator and have an adequate airway; therefore, altered consciousness would not be an appropriate client problem. 3. Altered elimination problem is not specific for the client with a thoracotomy. 4. A knowledge deficit problem is not an appropriate problem for the client who is one (1) day postoperative thoracotomy because the client is on a ventilator.

The client diagnosed with pneumonia has arterial blood gases of pH 7.33, PaO2 94, PaCO2 47, HCO3 25. Which intervention should the nurse implement? 1. Administer sodium bicarbonate. 2. Administer oxygen via nasal cannula. 3. Have the client cough and deep breathe. 4. Instruct the client to breathe into a paper bag.

1. Sodium bicarbonate is administered for metabolic acidosis. 2. The arterial oxygen level is within normal limits (80 to 100); therefore, the client does not need oxygen. 3. The client is retaining CO2, which causes respiratory acidosis, and the nurse should help the client remove the CO2 by instructing the client to cough and deep breathe. 4. Breathing into a paper bag is not recommended for clients in respiratory acidosis.

Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD? 1. The client demonstrates the correct way to pursed-lip breathe. 2. The client lists three (3) signs/symptoms to report to the HCP. 3. The client will drink at least 2,500 mL of water daily. 4. The client will be able to ambulate 100 feet with dyspnea.

1. Pursed-lip breathing helps keep the alveoli open to allow for better oxygen and carbon dioxide exchange. 2. This would be an appropriate outcome for a knowledge-deficit problem. 3. This outcome does not ensure the client has an effective airway; increasing fluid does not ensure an effective airway. 4. This is not an appropriate outcome for any client problem because the client should be able to ambulate without dyspnea for 100 feet. TEST-TAKING HINT: The test taker needs to identify the outcome for the client problem cited—namely, "ineffective gas exchange." The only answer option addressing the airway is option "1," pursed-lip breathing.

The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching? 1. Take two (2) puffs on the rescue inhaler and wait five (5) minutes before exercise. 2. Warm-up exercises will increase the potential for developing the asthma attacks. 3. Use the bronchodilator inhaler immediately prior to beginning to exercise. 4. Increase dietary intake of food high in monosodium glutamate (MSG).

1. Rescue inhalers are used to treat attacks, not prevent them, so this should not be administered prior to exercising. 2. Warm-up exercises decrease the risk of developing an asthma attack. 3.Using a bronchodilator immediately prior to exercising will help reduce bronchospasms. 4. Monosodium glutamate, a food preservative, has been shown to initiate asthma attacks. TEST-TAKING HINT: Option "1" has two words that are opposed "rescue" and "wait"—which might lead the test taker to eliminate this option. Remember basic concepts, which are contradicted in option "2." There are a few disease processes that encourage intake of sodium, but asthma is not one of them, which would cause option "4" to be eliminated.

The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement? 1. Standard Precautions. 2. Contact Precautions. 3. Droplet Precautions. 4. Airborne Precautions.

1. Standard Precautions are used to prevent exposure to blood and body secretions on all clients. Tuberculosis is caused by airborne bacteria. 2. Contact Precautions are used for wounds. 3. Droplet Precautions are used for infections spread by sneezing or coughing but not transmitted over distances of more than three (3) to four (4) feet. 4. Tuberculosis bacteria are capable of disseminating over long distances on air currents. Clients with tuberculosis are placed in negative air pressure rooms where the air in the room is not allowed to cross-contaminate the air in the hallway. TEST-TAKING HINT: Standard Precautions and Contact Precautions can be ruled out as the correct answer if the test taker is aware that Tb is usually a respiratory illness. This at least gives the reader a 1:2 chance of selecting the correct answer if the answer is not known.

The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first? 1. Take the client's vital signs. 2. Check the client's pulse oximeter reading. 3. Administer oxygen via a nasal cannula. 4. Notify the respiratory therapist STAT.

1. Taking the client's vital signs will not help the client's shortness of breath and difficulty in breathing. 2.Checking the pulse oximeter reading will not help the client's shortness of breath and difficulty breathing. [Do NOT assess in Distress; we already know the pt has difficulty in breathing, so we need to intervene to help the pt out} 3.After elevating the head of the bed, the nurse should administer oxygen to the client who is in respiratory difficulty. 4. Notifying the respiratory therapist will not help the client's shortness of breath and difficulty breathing.

Which referral is most appropriate for a client diagnosed with end-stage COPD? 1. The Asthma Foundation of America. 2. The American Cancer Society. 3. The American Lung Association. 4. The American Heart Association.

1. The Asthma Foundation of America is not appropriate for a client in this stage of COPD. 2. The American Cancer Society is helpful for a client with lung cancer but not for a client with COPD. 3.The American Lung Association has information helpful for a client with COPD. 4.Many clients with COPD end up with heart problems, but the American Heart Association does not have information for clients with COPD.

The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication? 1. The client's partial thromboplastin time (PTT) is 38. 2. The client's international normalized ratio (INR) is 5. 3. The client's prothrombin time (PT) is 22. 4. The client's erythrocyte sedimentation rate (ESR) is 10.

1. The PTT is not monitored to determine a serum therapeutic level for warfarin; normal is 30 to 45. 2. The INR therapeutic range is 2 to 3 for a client receiving warfarin. The INR may be allowed to go to 3.5 if the client has a mechanical cardiac valve, but nothing in the stem of the question indicates this. {If INR is high, hold warfarin and prepare vitamin K} 3. The PT is monitored for oral anticoagulant therapy and should be 1.5 to 2 times the normal of 12; therefore, 22 is within therapeutic range and would not warrant the nurse questioning administering this medication. 4. The ESR is not monitored for oral anticoagulant therapy.

The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement? 1. Assess respiratory rate and depth. 2. Provide for adequate rest period. 3. Administer oxygen as prescribed. 4. Teach slow abdominal breathing.

1. The assessment of respiratory rate and depth is the priority intervention because tachypnea and dyspnea may be early indicators of respiratory compromise. 2. Rest reduces metabolic demands, fatigue, and the work of breathing, which promotes a more effective breathing pattern, but it is not priority over assessment. 3. Oxygen therapy increases the alveolar oxygen concentration, reducing hypoxia and anxiety, but it is not priority over assessment. 4. This breathing pattern promotes lung expansion, but it is not priority over assessment.

Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply. 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.

1. The client diagnosed with COPD has difficulty exchanging oxygen with carbon dioxide, which is manifested by physical signs such as fingernail clubbing and respiratory acidosis as seen on arterial blood gases. 2. The client should avoid extremes in temperatures. Warm temperatures cause an increase in the metabolism and increase the need for oxygen. Cold temperatures cause bronchospasms. 3. The client has increased respiratory effort during activities and can be fatigued. Activities should be timed so rest periods are scheduled to prevent fatigue. 4. The client may have difficulty adapting to the role changes brought about because of the disease process. Many cannot maintain the activities involved in meeting responsibilities at home and at work. Clients should be assessed for these issues. 5. Clients often lose weight because of the effort expended to breathe.

The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. 1. Place the client on oxygen delivered by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1,000 mL/day. 4. Restrict the client's smoking to two (2) to three (3) cigarettes per day. 5. Monitor the client's pulse oximetry readings every four (4) hours.

1. The client diagnosed with pneumonia will have some degree of gas-exchange deficit. Administering oxygen would help the client. 2. Activities of daily living require energy and therefore oxygen consumption. Spacing the activities allows the client to rebuild oxygen reserves between activities. 3. Clients are encouraged to drink at least 2,000 mL daily to thin secretions. 4. Cigarette smoking depresses the action of the cilia in the lungs. Any smoking should be prohibited {NOT DECREASED}. 5. Pulse oximetry readings provide the nurse with an estimate of oxygenation in the periphery. TEST-TAKING HINT: Maslow's hierarchy of needs lists oxygenation as the top priority. Therefore, the test taker should select interventions addressing oxygenation.

The nurse is discharging a client newly diagnosed with restrictive airway disease (asthma). Which statement indicates the client understands the discharge instructions? 1. "I will call 911 if my medications don't control an attack." 2. "I should wash my bedding in warm water." 3. "I can still eat at the Chinese restaurant when I want." 4. "If I get a headache, I should take a nonsteroidal anti-inflammatory drug."

1. The client must be able to recognize a life-threatening situation and initiate the correct procedure. 2. Bedding is washed in hot water to kill dust mites. 3. Many Chinese dishes are prepared with monosodium glutamate, an ingredient that can initiate an asthma attack. 4. Nonsteroidal anti-inflammatory medications, aspirin, and beta blockers have been known to initiate asthma attacks. TEST-TAKING HINT: Dietary questions or answer options should be analyzed for the content. The test taker should decide, "What about Chinese foods could be a problem for a client diagnosed with asthma?" or "What might be good for the client about this diet?"

Which intervention should the nurse implement for a male client who has had a left sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die.

1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis. 2. The client must take deep breaths; shallow breaths could lead to complications. 3. Deep breaths must be taken to prevent complications. 4. This is a cruel intervention; the nurse can medicate the client and then encourage deep breathing. TEST-TAKING HINT: If the test taker reads options "2" and "3" and notices that both reflect the same idea—namely, that deep breaths are not necessary—then both can either be eliminated as incorrect answers or kept as possible correct answers. Option "4" should be eliminated based on being a very rude and threatening comment.

The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse? 1. The client refuses to perform shoulder exercises. 2. The client complains of a sore throat and is hoarse. 3. The client has crackles that clear with cough. 4. The client is coughing up pink frothy sputum

1. The client refusing to perform shoulder exercises is pertinent, but it does not require immediate intervention. 2. Sore throats and hoarseness are common postintubation and would not require immediate intervention. 3. Crackles that clear with coughing would not require immediate intervention. 4. Pink frothy sputum indicates pulmonary edema and would require immediate intervention.

Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy? 1. "I must avoid hair spray and powders." 2. "I should take a shower instead of a tub bath." 3. "I will need to cleanse around the stoma daily." 4. "I can use an electric larynx to speak."

1. The client should not let any spray or powder enter the stoma because it goes directly into the lung. 2.The client should not allow water to enter the stoma; therefore, the client should take a tub bath, not a shower. 3. The stoma site should be cleansed to help prevent infection. 4. The client's vocal cords were removed; therefore, the client must use an alternate form of communication.

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client into a sitting position at 90 degrees. 2. Administer oxygen at six (6) LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health-care provider about the client's status.

1. The client should be assisted into a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain the client's safety. 2. Oxygen will be applied as soon as possible, but the least amount possible. If levels of oxygen are too high, the client may stop breathing. 3.Vital signs need to be monitored, but this is not the first priority. If the equipment is not in the room, another member of the health-care team should bring it to the nurse. The nurse should stay with the client. 4. The health-care provider needs to be notified, but the client must be treated first. The nurse should get assistance if possible so the nurse can treat this client quickly. TEST-TAKING HINT: When a question asks for the test taker to choose the intervention to implement first, the test taker should select an intervention directly caring for the client. Remember: in distress do not assess.

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

1. The client should be in the high Fowler's position to facilitate lung expansion. 2. The system must be patent and intact to function properly. 3. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion. 4. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and a potential clogging of the tube. 5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site. TEST-TAKING HINT: The test taker should be careful with adjectives. In option "1," the word "low" makes it incorrect; in option "3," the word "strict" makes this option incorrect.

Which information should the nurse teach the client diagnosed with acute sinusitis? 1. Instruct the client to complete all the ordered antibiotics. 2. Teach the client how to irrigate the nasal passages. 3. Have the client demonstrate how to blow the nose. 4. Give the client samples of a narcotic analgesic for the headache.

1. The client should be taught to take all antibiotics as ordered. Discontinuing antibiotics prior to the full dose results in the development of antibiotic- resistant bacteria. Sinus infections are difficult to treat and may become chronic, and will then require several weeks of therapy or possibly surgery to control. 2. If the sinuses are irrigated, it is done under anesthesia by a health-care provider. 3. Blowing the nose will increase pressure in the sinus cavities and will cause the client increased pain. 4. The nurse is not licensed to prescribe medications, so this is not in the nurse's scope of practice. Also, narcotic analgesic medications are controlled substances and require written documentation of being prescribed by the health-care provider; samples are not generally available. TEST-TAKING HINT: Note in this situation an "all" is in the correct answer. There are very few cases in which absolute adjectives will describe the correct answer. The test taker must be aware that general rules will not always apply.

The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? 1. The client's pulse oximeter reading is 92%. 2. The client's arterial blood gas level is 74. 3. The client has SOB when walking to the bathroom. 4. The client's sputum is rusty colored

1. The client with end-stage COPD has decreased peripheral oxygen levels; therefore, this would not warrant immediate intervention. 2. The client's ABGs would normally indicate a low oxygen level; therefore, this would not warrant immediate intervention. 3. The client who develops dyspnea on exertion should stop the exertion but does not require intervention by the nurse if the dyspnea resolves. 4. Rusty-colored sputum indicates blood in the sputum and requires further assessment by the nurse. TEST-TAKING HINT: The test taker could rule out options "1" and "2" as correct answers because both describe the same data of decreased oxygen, which is characteristic of COPD.

The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum and consolidation. 4. Barrel chest and polycythemia.

1. The client with pneumothorax has absent breath sounds and tachypnea. 2. Unequal lung expansion and dyspnea indicate a pneumothorax. 3. Consolidation occurs when there is no air moving through the alveoli, as in pneumonia; frothy sputum occurs with congestive heart failure. 4. Barrel chest and polycythemia are signs of chronic obstructive pulmonary disease. TEST-TAKING HINT: The test taker can use "chest trauma" or "pneumothorax" to help select the correct answer. Both of these terms should cause the test taker to select option "2" because unequal chest expansion would result from trauma.

Which intervention should the nurse implement first when administering the first dose of intravenous antibiotic to the client diagnosed with a respiratory infection? 1. Monitor the client's current temperature. 2. Monitor the client's white blood cells. 3. Determine if a culture has been collected. 4. Determine the compatibility of fluids.

1. The client's current temperature would not affect the administration of the antibiotic. 2. The client's white blood cells may be elevated because of the infection, but this would not affect administering the medication. 3. A culture needs to be collected prior to the first dose of antibiotic, or the culture and sensitivity will be skewed and the appropriate antibiotic needed to treat the respiratory infection may not be identified. 4. Compatibility of fluids should be assessed prior to administering each intravenous antibiotic, but when administering the first dose of an antibiotic, the nurse must check to make sure the sputum culture was obtained.

Which statement indicates to the nurse the client diagnosed with sleep apnea needs further teaching? 1. "If I lose weight I may not need treatment for sleep apnea." 2. "The CPAP machine holds my airway open with pressure." 3. "The CPAP will help me stay awake during the day while I am at work." 4. "It is all right to have a couple of beers because I have this CPAP machine."

1. The contributing factors to developing sleep apnea are obesity, smoking, drinking alcohol, and a short neck. In some situations, modifying lifestyle will improve sleep apnea. 2. Many clients need a continuous positive airway pressure (CPAP) machine, which continuously administers positive pressure to assist sleep during the night. 3. When clients have sleep apnea, the buildup of carbon dioxide causes the client to arouse constantly from sleep to breathe. This, in turn, causes the client to be sleepy during the day. 4. Drinking alcohol before sleep sedates the client, causing the muscles to relax, which, in turn, causes an obstruction of the client's airway. Drinking alcohol should be avoided even if the client uses a CPAP machine.

The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine? 1. Elderly and chronically ill clients. 2. Child-care workers and children <four (4) years of age. 3. Hospital chaplains and health-care workers. 4. Schoolteachers and students living in a dormitory.

1. The elderly and chronically ill are at greatest risk for developing serious complications if they contract the influenza virus. 2.It is recommended people in contact with children receive the flu vaccine whenever possible, but these clients should be able to withstand a bout with the flu if their immune systems are functioning normally. 3.It is probable these clients will be exposed to the virus, but they are not as likely to develop severe complications with intact functioning immune systems. 4.During flu season, the more people the individual comes into contact with, the greater the risk the client will be exposed to the influenza virus, but this group of people would not receive the vaccine before the elderly and chronically ill. TEST-TAKING HINT: Sometimes the test taker may think the answer is too easy and obvious, but the test taker should not try to second-guess the question. Item writers are not trying to trick the test taker; they are trying to evaluate knowledge.

The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client? 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention.

1. The elderly client diagnosed with pneumonia may present with {ATYPICAL SYMPTOMS such as} weakness, fatigue, lethargy, confusion, and poor appetite but not have any of the classic signs and symptoms of pneumonia. 2.Fever and chills are classic symptoms of pneumonia, but they are usually absent in the elderly client. 3.Frothy sputum and edema are signs and symptoms of heart failure, not pneumonia. 4.The client has tachypnea (fast respirations), not bradypnea (slow respirations), and jugular vein distention accompanies heart failure. TEST-TAKING HINT: The question provides an age range—"elderly"—so age can be expected to affect the disease process—in this case, causing atypical symptoms. The prefix brady- means "slow" when attached to a word. Knowing the definition of medical prefixes can assist the test taker in determining the correct answer.

The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care? 1. The client has no signs of respiratory distress. 2. The client shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.

1. The expected outcome showing no signs of respiratory distress indicates the plan of care is effective and should be continued. 2. An improved respiratory pattern indicates the plan should be continued. 3. The expected outcome should be that the client has tolerance for activity; because the client is not meeting the expected outcome, the plan of care needs revision. 4.The client should participate in planning the course of care. The client is meeting the expected outcome. TEST-TAKING HINT: This question is an "except" question. Three of the options indicate desired outcomes and only one (1) option indicates the need for improvement.

The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

1. The health-care provider will have to be notified, but this is not the first intervention. Air must be prevented from entering the pleural space from the outside atmosphere. 2. The client should breathe regularly or take deep breaths until the tubes are reinserted. 3. The nurse must take action and prevent air from entering the pleural space. 4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation. TEST-TAKING HINT: The words "implement first" in the stem of the question indicate to the test taker that possibly more than one (1) intervention could be warranted in the situation but only one (1) is implemented first. Remember, do not select assessment first without reading the question. If the client is in any type of crisis, then the nurse should first do something to help the client's situation.

The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery? 1. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%. 2. The client has an oral temperature of 100.2˚F and a dry cough. 3. There are one (1) to two (2) white blood cells in the urinalysis. 4. The client's current international normalized ratio (INR) is 1.0.

1. The hemoglobin and hematocrit given are within normal range. This would not warrant notifying the health-care provider. 2. A low-grade temperature and a cough could indicate the presence of an infection, in which case the health-care provider would not want to subject the client to anesthesia and the possibility of further complications. The surgery would be postponed. 3.One (1) to two (2) WBCs in a urinalysis is not uncommon because of the normal flora in the bladder. 4.The INR indicates that the client's bleeding time is within normal range. TEST-TAKING HINT: In this question, all the answer options contain normal data except for one. The nurse would not call the health-care provider to notify him or her of normal values.

The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain? 1. Number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medication. 4. Willingness to modify lifestyle.

1. The number of years of smoking is information needed to treat the client but not the most important in health promotion. 2.The risk factors for complications are important in planning care. 3. Assessing the ability to deliver medications is an important consideration when teaching the client. 4.The client's attitude toward lifestyle changes is the most important consideration in health promotion, in this case smoking cessation. The nurse should assess if the client is willing to consider cessation of smoking and carry out the plan. TEST-TAKING HINT: The test taker should read the stem for words such as "health promotion." These words make all the other answer options incorrect because they do not promote health.

The client with a cold asks the nurse, "Is it all right to take Echinacea for my cold?" Which statement is the nurse's best response? 1. "You should discuss that with your health-care provider." 2. "No, you should not take any type of herbal medicine." 3. "Yes, but do not take it for more than 3 days." 4. "Echinacea may help with the symptoms of your cold."

1. The nurse can answer client's questions concerning herbal medication. Passing the buck should be eliminated as a possible correct answer. 2. The nurse should not be judgmental. If the client does not have comorbid conditions, is not taking other medications, or is not pregnant, herbal medications may be helpful in treating the common cold. 3. Echinacea should not be taken for more than two (2) weeks, not three (3) days. Nothing cures the common cold; the cold must run its course. 4. Echinacea is an herb that may reduce the duration and symptoms of the common cold, but nothing cures the common cold. If the client does not have comorbid conditions, is not taking other medications, and is not pregnant, herbal medications may be helpful in treating the common cold.

The nurse is caring for a client on a ventilator and the alarm goes off. Which action should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Check the ventilator to determine the cause. 3. Elevate the head of the client's bed. 4. Assess the client's oxygen saturation.

1. The nurse needs to notify the respiratory therapist to check the ventilator, but it is not the first intervention. 2. The nurse must determine what is causing the alarm; a high or low alarm will make a difference in the nurse's action. {Please note that in this case it is important to check the machine before the patient in order to know the cause of the problem as the intervention differs based on whether the high pressure alarm or low pressure alarm goes off} 3. Elevating the head of the bed will help lung expansion, but it is not the first intervention. 4. The ventilator alarm indicates something is wrong, and the nurse must first determine if the problem is with the ventilator or the client.

The nurse is preparing to hang the next bag of aminophylline, a bronchodilator, for the client diagnosed with asthma. The current theophylline level is 18 mcg/mL.Which intervention should the nurse implement? 1. Hang the next bag and continue the infusion. 2. Do not hang the next bag and decrease the rate. 3. Notify the health-care provider of the level. 4. Confirm the current serum theophylline level.

1. The therapeutic level is 10 to 20 mcg/mL; therefore, the nurse should hang the bag and continue the infusion to maintain the aminophylline level. 2. There is no reason not to hang the next bag of aminophylline. 3. There is no need to notify the health-care provider for a level of 18 mcg/mL. 4. There is no need for the nurse to confirm the laboratory results.

he alert and oriented client is diagnosed with a spontaneous pneumothorax, and the health care provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client's bedside, but it is not the first intervention. 2. The insertion of a chest tube is an invasive procedure and requires informed consent. Without a consent form, this procedure should not be done on an alert and oriented client. 3. This is a correct position to place the client in for a chest tube insertion, but it is not the first intervention. 4. The health care provider will discuss the procedure with the client, then informed consent must be obtained, and the nurse can do further teaching. TEST-TAKING HINT: The test taker must know invasive procedures require informed consent, and legally it must be obtained first before anyone can touch the client.

Which intervention should the nurse implement first when caring for a client with a respiratory disorder? 1. Administer a respiratory treatment. 2. Check the client's radial pulses daily. 3. Monitor the client's vital signs daily. 4. Assess the client's capillary refill time.

1. The nurse should gather data before implementing an intervention. 2. The radial pulse would indicate the cardiovascular status of the client, not the respiratory status, and the nurse should assess the apical pulse. 3. Daily vital signs would not indicate the respiratory status of the client. 4. Assessing the client's capillary refill time has the highest priority for the nurse because it indicates the oxygenation of the client.

The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced? 1. Myocardial infarction. 2. Pneumonia. 3. Pulmonary embolus. 4. Pneumothorax.

1. The nurse would not suspect a myocardial infarction for a client with a DVT who suddenly has chest pain. 2. These signs and symptoms should not make the nurse think the client has pneumonia. 3. Part of the clot in the deep veins of the legs dislodges and travels up the inferior vena cava, lodges in the pulmonary artery, and causes the chest pain; the client often feels as if he or she is going to die. 4. Chest pain is a sign of pneumothorax, but it is not a complication of deep vein thrombosis.

The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? 1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the lab. 2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. 3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.

1. The specimen needs to be taken to the laboratory within a reasonable time frame, but a UAP can take specimens to the laboratory. 2. Clogged feeding tubes occur with some regularity. Delay in feeding a client will not result in permanent damage. 3. A pulse oximetry reading of 92% means that the arterial blood oxygen saturation is somewhere around 60% to 70%. 4. Arterial oxygenation normal values are 80% to 100%. TEST-TAKING HINT: Be sure to read all the answer options. Pulse oximetry readings do not give the same information as arterial blood gas readings

The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine? 1. The client diagnosed with congestive heart failure. 2. The client with a documented allergy to eggs. 3. The client who has had an anaphylactic reaction to penicillin. 4. The client who has an elevated blood pressure and pulse.

1. There would be no reason to question administering a vaccine to a client with heart failure. 2.In clients who are allergic to egg protein, a significant hypersensitivity response may occur when they are receiving the influenza vaccine. 3. There would be no reason to question administering a vaccine to a client who has had a reaction to penicillin. 4. There would be no reason to question administering a vaccine to a client who has elevated blood pressure and pulse.

Which arterial blood gas (ABG) results support the diagnosis of acute respiratory distress syndrome (ARDS) after the client has received O2 at 10 LPM? 1. pH 7.38, PaO2 94, PaCO2 44, HCO3 24. 2. pH 7.46, PaO2 82, PaCO2 34, HCO3 22. 3. pH 7.48, PaO2 59, PaCO2 30, HCO3 26. 4. pH 7.33, PaO2 94, PaCO2 44, HCO3 20.

1. This ABG is within normal limits and would not be expected in a client with ARDS. 2. These ABG levels indicate respiratory alkalosis, but the oxygen level is within normal limits and would not be expected in a client with ARDS. 3. ABGs initially show hypoxemia with a PaO2 of less than 60 mm Hg and respiratory alkalosis resulting from tachypnea in a client with ARDS. 4. This ABG is metabolic acidosis and would not be expected in a client with ARDS.

The client diagnosed with restrictive airway disease (asthma) has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication? 1. Do not abruptly stop taking this medication; it must be tapered off. 2. Immediately rinse the mouth following administration of the drug. 3. Hold the medication in the mouth for 15 seconds before swallowing. 4. Take the medication immediately when an attack starts.

1. This applies to systemically administered steroids, not to inhaled steroids. 2.The steroids must pass through the oral cavity before reaching the lungs. Allowing the medication to stay within the oral cavity will suppress the normal flora found there, and the client could develop a yeast infection of the mouth (oral candidiasis). 3. Holding the medication in the mouth increases the risk of an oral yeast infection, and the medication is inhaled, not swallowed. 4. Inhaled steroids are not used first; the beta-adrenergic inhalers are used for acute attack. TEST-TAKING HINT: Option "3" suggests that an inhaled medication is swallowed; the two (2) terms do not match.

The client is admitted with a diagnosis of rule-out severe acute respiratory syndrome (SARS). Which information is most important for the nurse to ask related to this diagnosis? 1. Current prescription and over-the-counter medication use. 2. Dates of and any complications associated with recent immunizations. 3. Any problems with recent or past use of blood or blood products. 4. Recent travel to mainland China, Hong Kong, or Taiwan.

1. This information is important during an admission interview but is not specific to SARS. 2. The information would not be specific to the diagnosis of SARS. 3.This would be important to ask prior to the administration of any blood products, but it is not specific for SARS. 4.Recent travel to mainland China, Taiwan, and Hong Kong is a risk factor for contracting SARS. NOTE: SARS is Airborne Precautions, NOT droplet

Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4. The client is able to deep breathe without any pain.

1. This is an expected finding in the suction compartment of the drainage system, indicating adequate suctioning is being applied. 2. At three (3) days post insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective. 3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have reexpanded the lung. 4. Taking a deep breath without pain is good, but it does not mean the lungs have reexpanded. TEST-TAKING HINT: The test taker must be knowledgeable about chest tubes to be able to answer this question. The test taker must know the normal time frame and what is expected for each compartment of the chest tube drainage system.

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the licensed practical nurse (LPN)? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hb of 9 g/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.

1. This pulse oximeter reading indicates the client is hypoxic and therefore is not stable and should be assigned to an RN. 2. This H&H are very low; therefore, the client is not stable and should be assigned to an RN. 3. Jugular vein distention and hypotension are signs of a tension pneumothorax, which is a medical emergency, and the client should be assigned to an RN. 4. A client two (2) hours post- bronchoscopy procedure could safely be assigned to an LPN. TEST-TAKING HINT: The test taker must understand that the LPN should be assigned the least critical client or the client who is stable and not exhibiting any complications secondary to the admitting disease or condition.

The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

1. This statement describes a spontaneous pneumothorax. 2. This statement describes an open pneumothorax. 3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life. 4. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but the statement does not describe a tension pneumothorax. TEST-TAKING HINT: The test taker must always be clear about what the question is asking before answering the question. If the test taker can eliminate options "1" and "2" and can't decide between options "3" and "4," the test taker must go back to the stem and clarify what the question is asking.

Which task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Feed a client who is postoperative tonsillectomy the first meal of clear liquids. 2. Encourage the client diagnosed with a cold to drink a glass of orange juice. 3. Obtain a throat culture on a client diagnosed with bacterial pharyngitis. 4. Escort the client diagnosed with laryngitis outside to smoke a cigarette.

1. Tonsillectomies cause throat edema and difficulty swallowing; the nurse must observe the client's ability to swallow before this task can be delegated. 2. Clients with colds are encouraged to drink 2,000 mL of liquids a day. The UAP could do this. 3.Throat swabs for culture must be done correctly or false-negative results can occur. The nurse should obtain the swab. 4. Clients with laryngitis are instructed not to smoke. Smoking is discouraged in all health- care facilities. Sending nursing personnel outside encourages an unhealthy practice, which is not the best use of the personnel. TEST-TAKING HINT: Interventions requiring assessment, teaching, and evaluation can- not be delegated. Levels of activities being delegated should be appropriate for the level of training of the staff member carrying out the task. Tasks delegated must conform to safe health-care practice.

The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube. Which intervention should the nurse include in the plan of care? 1. Inspect the insertion line at the naris prior to instilling formula. 2. Elevate the head of the bed after feeding the client. 3. Place the client in the Sims position following each feeding. 4. Change the dressing on the feeding tube every three (3) days.

1.A gastrostomy tube is placed directly into the stomach through the abdominal wall; the naris is the opening of the nostril. 2.Elevating the head of the bed uses gravity to keep the formula in the gastric cavity and help prevent it from refluxing into the esophagus, which predisposes the client to aspiration. 3.The Sims position is the left lateral side-lying flat position. This position is used for administering enemas and can be used to prevent aspiration in clients sedated by anesthesia. The sedated client would not have a full stomach. 4.Dressings on PEG tubes should be changed at least daily. If there is no dressing, the insertion site is still assessed daily. TEST-TAKING HINT: The test taker should try to picture the positioning of the client to determine the correct answer. In option "4," the test taker should question if the time given, three (3) days, is the correct time interval for performing this intervention.

The post-anesthesia care nurse is caring for the client diagnosed with lung cancer who had a thoracotomy and is experiencing frequent premature ventricular contractions (PVCs). Which intervention should the nurse implement first? 1. Request STAT arterial blood gases. 2. Administer lidocaine intravenous push. 3. Assess for possible causes. 4. Request a STAT electrocardiogram.

1.ABGs may show hypoxia, which is a cause of PVCs, but it is not the first intervention the nurse should implement. 2.Lidocaine is the treatment of choice for PVCs, but it is not the first intervention. 3.The nurse should assess for possible causes of the PVCs; these causes may include hypoxia or hypokalemia. 4. An ECG further evaluates the heart function, but it is not the first intervention.

The 56-year-old client diagnosed with tuberculosis (Tb) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? 1. "I will take my medication for the full three (3) weeks prescribed." 2. "I must stay on the medication for months if I am to get well." 3. "I can be around my friends because I have started taking antibiotics." 4. "I should get a Tb skin test every three (3) months to determine if I am well."

1.Clients diagnosed with Tb will need to take the medications for six (6) months to a year. 2.Compliance with treatment plans for Tb includes multidrug therapy for six (6) months to one (1) year for the client to be free of the Tb bacteria. 3.Clients are no longer contagious when three (3) morning sputum specimens are cultured negative, but this will not occur until after several weeks of therapy. 4.The Tb skin test only determines possible exposure to the bacteria, not active disease. TEST-TAKING HINT: The test taker should determine if the time of three (3) weeks in option "1," months in option "2," or immediately in option "3" is the correct time interval.

The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client? 1. Daily inhaled corticosteroids. 2. Use of a "rescue inhaler." 3. Use of systemic steroids. 4. Leukotriene agonists.

1.Daily inhaled steroids are used for mild, moderate, or severe persistent asthma, not for intermittent asthma. 2.Clients with intermittent asthma will have exacerbations treated with rescue inhalers. Therefore, the nurse should teach the client about rescue inhalers. 3.Systemic steroids are used frequently by clients with severe persistent asthma, not with mild intermittent asthma. 4. Leukotriene agonists are prescribed for clients diagnosed with mild persistent asthma. TEST-TAKING HINT: In the stem, there are two (2) words giving the test taker a clue about the correct answer. "Mild" and "intermittent" are words that indicate the client is not experiencing frequent or escalating symptoms. Steroid medications can have multiple side effects.

The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client? 1. Pleuritic chest discomfort and anxiety. 2. Asymmetrical chest expansion and pallor. 3. Leukopenia and CRT <three (3) seconds. 4. Substernal chest pain and diaphoresis.

1.Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever, chills, dyspnea, and cough. 2. Asymmetrical chest expansion occurs if the client has a collapsed lung from a pneumothorax or hemothorax, and the client would be cyanotic from decreased oxygenation. 3. The client would have leukocytosis, not leukopenia, and a capillary refill time (CRT) of <3 seconds is normal. 4. Substernal chest pain and diaphoresis are symptoms of myocardial infarction. TEST-TAKING HINT: Options "1" and "4" have chest pain as part of the answer. The adjectives describing the chest pain determine the correct answer.

The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem "altered communication." Which intervention should the nurse implement? 1. Instruct the client to drink a mixture of brandy and honey several times a day. 2. Encourage the client to whisper instead of trying to speak at a normal level. 3. Provide the client with a blank notepad for writing any communication. 4. Explain that the client's aphonia may become a permanent condition.

1.The client with laryngitis is instructed to avoid all alcohol. Alcohol causes increased irritation of the throat. 2.Whispering places added strain on the larynx. 3.Voice rest is encouraged for the client experiencing laryngitis. 4.Aphonia, or inability to speak, is a temporary condition associated with laryngitis. TEST-TAKING HINT: Encouraging the use of alcohol, with the exception of a glass of red wine, is not accepted medical practice; therefore, option "1" could be eliminated. Option "4" has an absolute— "permanent"—in it and therefore could be eliminated from consideration.

The nurse suspects the client admitted with a near-drowning is developing acute respiratory distress syndrome (ARDS). Which data support the nurse's suspicion? 1. The client's arterial blood gases are within normal limits. 2. The client appears anxious, has dyspnea, and is tachypneic. 3. The client has intercostal retractions and is using accessory muscles. 4. The client's bilateral lung sounds have crackles and rhonchi.

1.The client would have low arterial oxygen when developing ARDS. 2.Initial clinical manifestations of ARDS usually develop 24 to 48 hours after the initial insult leading to hypoxia and include anxiety, dyspnea, and tachypnea. 3.As ARDS progresses, the client has more difficulty breathing, resulting in intercostal retractions and use of accessory muscles. 4. Lungs are initially clear; crackles and rhonchi develop in later stages of ARDS.

20. The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first? 1. Suction the client's nares. 2. Turn the client to the side. 3. Place the client in Trendelenburg position. 4. Notify the health-care provider.

1.The nares are the openings of the nostrils. Suctioning, if done, would be of the posterior pharynx. 2.Turning the client to the side allows for the food to be coughed up and come out of the mouth, rather than be aspirated into the lungs. 3. Placing the client in the Trendelenburg position increases the risk of aspiration. 4. An immediate action is needed to protect the client. TEST-TAKING HINT: In a question requiring the test taker to determine the first action, all the answer options may be correct for the situation. The test taker must determine which has the greatest potential for improving the client's condition.

The health-care provider has ordered a continuous intravenous infusion of aminophylline. The client weighs 165 pounds. The infusion order is 0.3 mg/kg/hr. The bag is mixed with 500 mg of aminophylline in 250 mL of D5W. At which rate should the nurse set the pump? ________

11 mL/hr. First, convert pounds to kilograms: 165 pounds ÷ 2.2 75 kg Then, determine how many milligrams of aminophylline per hour should be administered: 0.3 mg 75 kg 22.5 mg/hr Then, determine how much aminophylline is delivered per milliliter: 500 mg ÷ 250 mL 2 mg/1 mL If 2 mg/1 mL is delivered, then to deliver the prescribed 22.5 mg/hr, the rate must be set at: 22.5 ÷ 2 11.25 mL/hr Less than 0.5 should be rounded down, 0.5 and above is rounded up.

he nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement? 1. Praise the UAP since this prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the UAP in front of the client oxygen must be left in place at all times. 4. Discuss the UAP's action with the charge nurse so appropriate action can be taken.

The client diagnosed with COPD needs oxygen at all times, especially when exerting energy such as ambulating to the bathroom. 2. The client needs the oxygen, and the nurse should not correct the UAP in front of the client; it is embarrassing for the UAP and the client loses confidence in the staff. 3. The nurse should not verbally correct a UAP in front of the client; the nurse should correct the behavior and then talk to the UAP in private. 4. The primary nurse should confront the UAP and take care of the situation. Continued unsafe client care would warrant notifying the charge nurse. TEST-TAKING HINT: The test taker must know management concepts, and the nurse should first address the behavior with the person directly, then follow the chain of command.