Respiratory NCLEX Questions Asthma and More
15. A patient with an acute exacerbation of COPD has the following ABG analysis: pH 7.32, PaO2 58 mm Hg, PaCO2 55 mm Hg, and SaO2 86%. The nurse recognizes these values as evidence of a. normal acid-base balance with hypoxemia. b. normal acid-base balance with hypercapnia. c. respiratory acidosis. d. respiratory alkalosis.
C Rationale: The elevated PaCO2 and low pH indicate respiratory acidosis. The patient is hypoxemic and hypercapnic, but the pH indicates acidosis, not a normal acid-base balance. Cognitive Level: Comprehension Text Reference: p. 650 Nursing Process: Assessment NCLEX: Physiological Integrity
32. A 19-year-old male patient with CF and his wife are considering having a child. Which statement by the patient indicates that the nurse's teaching has been effective? a. "We will plan on having genetic counseling before we make a decision." b. "My erectile dysfunction will make it more difficult to have a child." c. "It is likely that I will die before any children we have are grown." d. "There should not be any problems as long as I take my medications."
A Rationale: Children of patients with CF are either CF carriers or have the disease. Most men with CF are sterile, but erectile dysfunction is not associated with CF. The life expectancy for CF is getting longer, with a mean age of 35. Despite appropriate therapy, the couple is likely to experience problems becoming pregnant. Cognitive Level: Application Text Reference: p. 659 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
11. While teaching a patient with asthma the appropriate use of a peak flow meter, the nurse instructs the patient to a. take and record peak flow readings when having asthma symptoms or an attack. b. increase the doses of long-term control medications for peak flows in the red zone. c. use the flow meter each morning after taking asthma medications. d. empty the lungs and then inhale rapidly through the mouthpiece.
A Rationale: It is recommended that patients check peak flows when asthma symptoms or attacks occur to compare the peak flow with the baseline. Increased doses of rapidly acting 2-agonists are indicated for peak flows in the red zone. Peak flows should be checked every morning before using medications. Peak flows are assessed during rapid exhalation. Cognitive Level: Application Text Reference: pp. 625, 628 Nursing Process: Implementation NCLEX: Physiological Integrity
7. Which finding would be the best indication to the nurse that the patient having an acute asthma attack was responding to the prescribed bronchodilator therapy? a. Wheezes are more easily heard. b. The oxygen saturation is 89%. c. Vesicular breath sounds resolve. d. The respiratory effort decreases.
A Rationale: Louder wheezes indicate that more air is moving through the airways and that the bronchodilator therapy is working. An oxygen saturation level less than 90% indicates continued hypoxemia. Vesicular breath sounds are normal. A decreased respiratory effort may indicate that the patient is becoming too fatigued to breathe effectively and needs mechanical ventilation. Cognitive Level: Application Text Reference: p. 617 Nursing Process: Evaluation NCLEX: Physiological Integrity
27. A patient with COPD is admitted to the hospital. How can the nurse best position the patient to improve gas exchange? a. Sitting up at the bedside in a chair and leaning slightly forward b. Resting in bed with the head elevated to 45 to 60 degrees c. In the Trendelenburg's position with several pillows behind the head d. Resting in bed in a high-Fowler's position with the knees flexed
A Rationale: Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg's position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well. Cognitive Level: Application Text Reference: p. 634 Nursing Process: Implementation NCLEX: Physiological Integrity
24. Postural drainage with percussion and vibration is ordered bid for a patient with chronic bronchitis. The nurse will plan to a. carry out the procedure 3 hours after the patient eats. b. maintain the patient in the lateral positions for 20 minutes. c. perform percussion and vibration before placing the patient in the drainage position. d. give the ordered albuterol (Proventil) after the patient has received the therapy.
A Rationale: Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 to 15 minutes. Percussion and vibration are done after the postural drainage. Bronchodilators are administered before chest physiotherapy. Cognitive Level: Application Text Reference: p. 647 Nursing Process: Planning NCLEX: Physiological Integrity
22. A patient with COPD asks the home health nurse about home oxygen use. The nurse should teach the patient that long-term home O2 therapy a. can improve the patient's prognosis and quality of life. b. may cause oxygen dependency in patients with COPD. c. is used only for patients who have severe end-stage respiratory disease. d. should never be used at night because the patient cannot monitor its effect.
A Rationale: Research supports the use of home oxygen to improve quality of life and prognosis. Oxygen dependency is not an issue for patients with COPD. Although most patients using home oxygen have SpO2 levels less than 89% on room air, it would not be appropriate to tell the patient that he or she was at the end stage of the disease. Oxygen use at night can improve sleep quality and is frequently recommended. Cognitive Level: Application Text Reference: p. 644 Nursing Process: Implementation NCLEX: Physiological Integrity
19. The nurse makes a diagnosis of impaired gas exchange for a patient with COPD in acute respiratory distress, based on the assessment finding of a. a pulse oximetry reading of 86%. b. dyspnea and respiratory rate of 36. c. use of the accessory respiratory muscles. d. the presence of crackles in both lungs.
A Rationale: The best data to support the diagnosis of impaired gas exchange are abnormalities in the ABGs or pulse oximetry. The other data would support a diagnosis of risk for impaired gas exchange. Cognitive Level: Application Text Reference: pp. 650-651 Nursing Process: Diagnosis NCLEX: Physiological Integrity
12. A 32-year-old patient is seen in the clinic for dyspnea associated with the diagnosis of emphysema. The patient denies any history of smoking. The nurse will anticipate teaching the patient about a. 1-antitrypsin testing. b. use of the nicotine patch. c. continuous pulse oximetry. d. effects of leukotriene modifiers.
A Rationale: When emphysema occurs in young patients, especially without a smoking history, a congenital deficiency in 1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with emphysema. Cognitive Level: Application Text Reference: p. 632 Nursing Process: Planning NCLEX: Physiological Integrity
39. When taking an admission history of a patient with possible asthma who has new-onset wheezing and shortness of breath, the nurse will be most concerned about which information? a. The patient has a history of pneumonia 2 years ago. b. The patient takes propranolol (Inderal) for hypertension. c. The patient uses acetaminophen (Tylenol) for headaches. d. The patient has chronic inflammatory bowel disease.
B Rationale: -blockers such as propranolol can cause bronchospasm in some patients. The other information will be documented in the health history but does not indicate a need for a change in therapy. Cognitive Level: Application Text Reference: p. 610 Nursing Process: Assessment NCLEX: Physiological Integrity
33. The nurse caring for a patient with CF recognizes that the manifestations of the disease are caused by the pathophysiologic processes of a. inflammation and fibrosis of lung tissue. b. altered function of exocrine glands. c. failure of the mucus-producing goblet cells. d. thickening and fibrosis of the pleural linings.
B Rationale: CF is characterized by abnormal secretions of exocrine glands, mainly of the lungs, pancreas, and sweat glands. Damage to lung tissue develops late in the disease. The goblet cells continue to produce mucus. Cognitive Level: Comprehension Text Reference: pp. 655-656 Nursing Process: Assessment NCLEX: Physiological Integrity
8. A patient who has mild persistent asthma uses an albuterol (Proventil) inhaler for chest tightness and wheezing has a new prescription for cromolyn (Intal). To increase the patient's management and control of the asthma, the nurse should teach the patient to a. use the cromolyn when the albuterol does not relieve symptoms. b. use the cromolyn to prevent inflammatory airway changes. c. administer the cromolyn first for chest tightness or wheezing. d. administer the albuterol regularly to prevent airway inflammation.
B Rationale: Cromolyn is prescribed to reduce airway inflammation. It takes several weeks for maximal effect and is not used to treat acute asthma symptoms Albuterol is used as a rescue medication in mild persistent asthma and will not decrease inflammation. Cognitive Level: Application Text Reference: p. 620 Nursing Process: Implementation NCLEX: Physiological Integrity
16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements for a patient with COPD. An appropriate intervention for this problem is to a. have the patient exercise for 10 minutes before meals. b. offer high calorie snacks between meals and at bedtime. c. assist the patient in choosing foods with a lot of texture. d. increase the patient's intake of fruits and fruit juices.
B Rationale: Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice. Cognitive Level: Application Text Reference: pp. 649,652 Nursing Process: Planning NCLEX: Physiological Integrity
35. Which statement by the COPD patient indicates that the nurse's teaching about nutrition has been effective? a. "I will drink lots of fluids with my meals." b. "I will have ice cream as a snack every day." c. "I should exercise for 15 minutes before meals." d. "I should avoid much meat or dairy products."
B Rationale: High-calorie foods like ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD. Cognitive Level: Application Text Reference: p. 649 Nursing Process: Evaluation NCLEX: Physiological Integrity
38. Which information given by an asthmatic patient during the admission assessment will be of most concern to the nurse? a. The patient says that the asthma symptoms are worse every spring. b. The patient's only asthma medications are albuterol (Proventil) and salmeterol (Serevent). c. The patient uses cromolyn (Intal) before any aerobic exercise. d. The patient's heart rate increases after using the albuterol (Proventil) inhaler.
B Rationale: Long-acting 2-agonists should be used only in patients who are also using another medication for long-term control (typically an inhaled corticosteroid). Salmeterol should not be used as the first-line therapy for long-term control. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma. Cognitive Level: Application Text Reference: pp. 615, 621 Nursing Process: Assessment NCLEX: Physiological Integrity
4. The health care provider has prescribed triamcinolone (Azmacort) metered-dose inhaler (MDI) two puffs every 8 hours and pirbuterol (Maxair) MDI 2 puffs four times a day for a patient with asthma. In teaching the patient about the use of the inhalers, the best instruction by the nurse is a. "Use the Maxair inhaler first, wait a few minutes, then use the Azmacort inhaler." b. "Using a spacer with the MDIs will improve the inhalation of the medications." c. "To avoid side effects, the inhalers should not be used within 1 hour of each other." d. "To maximize the effectiveness of the drugs, inhale quickly when using the inhalers."
B Rationale: More medication reaches the bronchioles when a spacer is used along with an MDI. There is no evidence that using a bronchodilator before a corticosteroid inhaler is helpful. The medications can be used at the same time. The patient should inhale slowly when using an MDI. Cognitive Level: Application Text Reference: p. 621 Nursing Process: Implementation NCLEX: Physiological Integrity
25. When developing a teaching plan to help increase activity tolerance at home for a 70-year-old with severe COPD, the nurse should teach the patient that an appropriate exercise goal is to a. exercise until shortness of breath occurs. b. walk for a total of 20 minutes daily. c. limit exercise to activities of daily living (ADLs). d. walk until pulse rate exceeds 150.
B Rationale: The goal for exercise programs for patients with COPD is to increase exercise time gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-year-old patient should have a pulse rate of 120 or less with exercise (80% of the maximal heart rate of 150). Cognitive Level: Application Text Reference: p. 653 Nursing Process: Planning NCLEX: Physiological Integrity
10. A patient with an acute attack of asthma comes to the emergency department, where ABGs are drawn. The nurse determines the patient is in the early phase of the attack, based on the ABG results of a. pH 7.0, PaCO2 50 mm Hg, and PaO2 74 mm Hg. b. pH 7.4, PaCO2 32 mm Hg, and PaO2 70 mm Hg. c. pH 7.36, PaCO2 40 mm Hg, and PaO2 80 mm Hg. d. pH 7.32, PaCO2 58 mm Hg, and PaO2 60 mm Hg.
B Rationale: The initial response to hypoxemia caused by airway narrowing in a patient having an acute asthma attack is an increase in respiratory rate, which causes a drop in PaCO2. The other PaCO2 levels are normal or elevated, which would indicate that the attack was progressing and that the patient is decompensating. Cognitive Level: Application Text Reference: pp. 614, 626 Nursing Process: Assessment NCLEX: Physiological Integrity
13. When teaching a patient with chronic obstructive pulmonary disease (COPD) about reasons to quit smoking, the nurse will explain that long-term exposure to tobacco smoke leads to a a. weakening of the smooth muscle lining the airways. b. decrease in the area available for oxygen absorption. c. lesser number of red blood cells for oxygen delivery. d. decreased production of protective respiratory secretions.
B Rationale: Tobacco smoke leads to an increase in proteolytic enzymes, which break down alveolar walls and lead to less alveolar surface area for gas exchange. Bronchial smooth muscle is not weakened by chronic smoking. Polycythemia is a common compensatory mechanism for patients with COPD. The quantity of respiratory secretions increases as a result of smoking. Cognitive Level: Application Text Reference: p. 633 Nursing Process: Implementation NCLEX: Physiological Integrity
36. When teaching the patient with COPD about exercise, which information should the nurse include? a. "Stop exercising if you start to feel short of breath." b. "Use the bronchodilator before you start to exercise." c. "Breathe in and out through the mouth while you exercise." d. "Upper body exercise should be avoided to prevent dyspnea."
B Rationale: Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD. Cognitive Level: Application Text Reference: p. 653 Nursing Process: Implementation NCLEX: Physiological Integrity
40. A patient who is experiencing an acute asthma attack is admitted to the emergency department. The nurse's first action should be to a. determine when the dyspnea started. b. obtain the forced expiratory flow rate. c. listen to the patient's breath sounds. d. ask about inhaled corticosteroid use.
C Rationale: Assessment of the patient's breath sounds will help to 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 patient's status at present. Most patients having an acute attack will be unable to cooperate with a FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds. Cognitive Level: Application Text Reference: p. 626 Nursing Process: Assessment NCLEX: Physiological Integrity
5. When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to a. avoid eating or drinking for 4 hours before the forced expiratory volume in 1 second (FEV1)/forced expiratory volume (FEV) test. b. take oral corticosteroids at least 2 hours before the examination. c. withhold bronchodilators for 6 to 12 hours before the examination. d. use rescue medications immediately before the FEV1/FEV testing.
C Rationale: Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should also be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed. Cognitive Level: Application Text Reference: p. 614 Nursing Process: Planning NCLEX: Physiological Integrity
28. A patient with COPD tells the nurse, "At home, I only have to use an albuterol (Proventil) inhaler. Why did the doctor add an ipratropium (Atrovent) inhaler while I'm in the hospital? The appropriate response by the nurse is a. "Atrovent will dilate the airways and allow the Proventil to penetrate more deeply." b. "Atrovent is being used to decrease airway inflammation and sputum production." c. "Atrovent works differently to dilate the bronchi, and the two drugs together are more effective." d. "Atrovent is a potent bronchodilator and patients need to be hospitalized when receiving it."
C Rationale: Combining bronchodilators improves effectiveness. Atrovent does not have to be used before Proventil, it does not decrease airway inflammation, and it does not require hospitalization. Cognitive Level: Application Text Reference: p. 640 Nursing Process: Implementation NCLEX: Physiological Integrity
20. When reading the chart for a patient with COPD, the nurse notes that the patient has cor pulmonale. To assess for cor pulmonale, the nurse will monitor the patient for a. elevated temperature. b. complaints of chest pain. c. jugular vein distension. d. clubbing of the fingers.
C Rationale: Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular vein distension. The other clinical manifestations may occur in the patient with other complications of COPD but are not indicators of cor pulmonale. Cognitive Level: Application Text Reference: pp. 635-636 Nursing Process: Assessment NCLEX: Physiological Integrity
1. A patient with a history of asthma is admitted to the hospital in acute respiratory distress. During assessment of the patient, the nurse would notify the health care provider immediately about a. a pulse oximetry reading of 90%. b. a peak expiratory flow rate of 240 ml/min. c. decreased breath sounds and wheezing. d. a respiratory rate of 26 breaths/min.
C Rationale: Decreased breath sounds and wheezing would indicate that the patient was experiencing an asthma attack, and immediate bronchodilator treatment would be indicated. The other data indicate that the patient needs ongoing monitoring and assessment but do not indicate a need for immediate treatment. Cognitive Level: Application Text Reference: pp. 608, 612, 614 Nursing Process: Assessment NCLEX: Physiological Integrity
18. The nurse teaches a patient with COPD how to perform pursed-lip breathing, explaining that this technique will assist respiration by a. loosening secretions so that they may be coughed up more easily. b. promoting maximal inhalation for better oxygenation of the lungs. c. preventing airway collapse and air trapping in the lungs during expiration. d. decreasing anxiety by giving the patient control of respiratory patterns.
C Rationale: Pursed-lip breathing increases the airway pressure during the expiratory phase and prevents collapse of the airways, allowing for more complete exhalation. Although loosening of secretions, improving inhalation, and decreasing anxiety are desirable outcomes for the patient with COPD, pursed-lip breathing does not directly impact these. Cognitive Level: Comprehension Text Reference: p. 646 Nursing Process: Implementation NCLEX: Physiological Integrity
3. An asthmatic patient who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that a. Advair is a combination of long-acting and slow-acting bronchodilators. b. the two drugs work together to block the effects of histamine on the bronchioles. c. one drug decreases inflammation, and the other is a bronchodilator. d. the combination of two drugs works more quickly in an acute asthma attack.
C Rationale: Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid; they work together to prevent asthma attacks. Neither medication is an antihistamine. Advair is not used during an acute attack because the medications do not work rapidly. Cognitive Level: Application Text Reference: pp. 621 Nursing Process: Implementation NCLEX: Physiological Integrity
6. The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. A common etiologic factor for this nursing diagnosis in patients with asthma is a. anxiety about dyspnea. b. side effects of medications. c. work of breathing. d. fear of suffocation.
C Rationale: The activity intolerance patients with asthma experience is related to the increased effort needed to breathe when airways are inflamed and narrowed and interventions are focused on decreasing inflammation and bronchoconstriction. The other listed etiologies are not as appropriate for this diagnosis but would be appropriate for diagnoses seen in patients with asthma, such as social isolation, knowledge deficit, and anxiety. Cognitive Level: Application Text Reference: pp. 612, 624 Nursing Process: Diagnosis NCLEX: Physiological Integrity
14. Which of these is the best goal for the patient admitted with chronic bronchitis who has a nursing diagnosis of ineffective airway clearance? a. Patient denies having dyspnea. b. Patient's mental status is improved. c. Patient has a productive cough. d. Patient's O2 saturation is 90%.
C Rationale: The goal for the nursing diagnosis of ineffective airway clearance is to maintain a clear airway by coughing effectively. The other goals may be appropriate for the patient with COPD, but they do not address the problem of ineffective airway clearance. Cognitive Level: Application Text Reference: p. 660 Nursing Process: Evaluation NCLEX: Physiological Integrity
31. A 26-year-old patient has had CF since birth and has severe lung changes and cor pulmonale as a result of the disease. An appropriate expected outcome is that the patient will a. engage in aerobic exercise without dyspnea. b. be weaned from home oxygen use. c. achieve a realistic attitude toward treatment. d. develop no CF-related complications.
C Rationale: The patient's severe lung disease and cor pulmonale are late complications of CF, and a realistic attitude about what outcome can be expected from treatment is an appropriate outcome. Exercising without dyspnea and weaning from home oxygen therapy are not realistic outcomes for this patient with end-stage disease. The patient already has multiple CF-related complications and is likely to continue to develop complications. Cognitive Level: Application Text Reference: pp. 657-658 Nursing Process: Planning NCLEX: Health Promotion and Maintenance
9. During assessment of a patient with a history of asthma, the nurse notes wheezing and dyspnea. The nurse will anticipate giving medications to reduce a. laryngospasm. b. pulmonary edema. c. airway narrowing. d. alveolar distention.
C Rationale: The symptoms of asthma are caused by inflammation and spasm of the bronchioles, leading to airway narrowing. Treatment for laryngospasm or pulmonary edema would not be appropriate. There are no medications used to treat alveolar distention. Cognitive Level: Comprehension Text Reference: pp. 608, 611-612 Nursing Process: Assessment NCLEX: Physiological Integrity
29. The nurse has completed teaching a patient about MDI use. Which patient statement indicates that further patient teaching is needed? a. "I will shake the MDI each time before giving the medication." b. "I will take a slow, deep breath in after pushing down on the MDI." c. "I will float the canister in water to decide whether I need to get a new MDI." d. "I will attach a spacer to the MDI to make it easier for me to use."
C Rationale: This method is no longer recommended as a means of determining whether the medication needs replacement. The other patient statements are accurate and indicate the patient understands how to use the MDI. Cognitive Level: Application Text Reference: p. 622 Nursing Process: Evaluation NCLEX: Physiological Integrity
17. A patient is seen in the clinic with COPD. Which information given by the patient would help most in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patient denies having any respiratory problems until the last 6 months. c. The patient's history indicates a 40 pack-year cigarette history. d. The patient complains about having a productive cough every winter for 2 months.
D Rationale: A diagnosis of chronic bronchitis is based on a history of having a productive cough for several 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. Cognitive Level: Application Text Reference: p. 629 Nursing Process: Assessment NCLEX: Physiological Integrity
37. The nurse has received a change-of-shift report about these patients with COPD. Which patient should the nurse assess first? a. A patient with loud expiratory wheezes b. A patient who has a cough productive of thick, green mucus c. A patient with jugular vein distension and peripheral edema d. A patient with a respiratory rate of 38
D Rationale: A respiratory rate of 38 indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic patient. Cognitive Level: Application Text Reference: pp. 612, 626 Nursing Process: Assessment NCLEX: Safe and Effective Care Environment
34. All of these orders are received for a patient having an acute asthma attack. Which one will the nurse administer first? a. IV methylprednisolone (Solu-Medrol) 60 mg b. triamcinolone (Azmacort) 2 puffs per MDI c. salmeterol (Serevent) 50 mcg per DPI d. albuterol (Ventolin) 2.5 mg per nebulizer
D Rationale: Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly. Cognitive Level: Application Text Reference: p. 620 Nursing Process: Implementation NCLEX: Physiological Integrity
2. The nurse recognizes that intubation and mechanical ventilation are indicated for a patient in status asthmaticus when a. ventricular dysrhythmias and dyspnea occur. b. loud wheezes are audible throughout the lungs. c. pulsus paradoxus is greater than 40 mm Hg. d. fatigue and an O2 saturation of 88% develop.
D Rationale: Although all of the assessment data indicate the need for rapid intervention, the fatigue and hypoxia indicate that the patient is no longer able to maintain an adequate respiratory effort and needs mechanical ventilation. The initial treatment for the other clinical manifestations would initially be administration of rapidly acting bronchodilators and oxygen. Cognitive Level: Application Text Reference: pp. 612-613 Nursing Process: Assessment NCLEX: Physiological Integrity
41. After teaching the patient with asthma about home care, the nurse will evaluate that the teaching has been successful if the patient states, a. "I will use my corticosteroid inhaler as soon as I start to get short of breath." b. "I will only turn the home oxygen level up after checking with the doctor first." c. "My medications are working if I wake up short of breath only once during the night." d. "No changes in my medications are needed if my peak flow is at 80% of normal."
D Rationale: Peak flows of 80% or greater indicate that the asthma is well controlled. Corticosteroids are long-acting, prophylactic therapy for asthma and are not used to treat acute dyspnea. Because asthma is an acute and intermittent process, home oxygen is not used. The patient who has effective treatment should sleep throughout the night without waking up with dyspnea. Cognitive Level: Application Text Reference: p. 628 Nursing Process: Evaluation NCLEX: Physiological Integrity
30. A 23-year-old with cystic fibrosis (CF) is admitted to the hospital. Which intervention will be included in the plan of care? a. Schedule sweat chloride test to evaluate the effectiveness of therapy. b. Arrange for a hospice nurse to visit with the patient regarding home care. c. Place the patient on a low-sodium diet to prevent cor pulmonale. d. Perform chest physiotherapy every 4 hours to mobilize secretions.
D Rationale: Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium. Cognitive Level: Application Text Reference: p. 658 Nursing Process: Planning NCLEX: Physiological Integrity
23. A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, it is most important that the nurse a. give a high enough flow rate to keep the bag from collapsing. b. use an appropriate adaptor to ensure adequate oxygen delivery. c. drain moisture condensation from the oxygen tubing every hour. d. keep the air entrainment ports clean and unobstructed.
D Rationale: The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or non-rebreather masks. The use of an adaptor can improve humidification but not oxygen delivery. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation. Cognitive Level: Comprehension Text Reference: p. 642 Nursing Process: Implementation NCLEX: Physiological Integrity
21. When a patient with COPD is receiving oxygen, the best action by the nurse is to a. avoid administration of oxygen at a rate of more than 2 L/min. b. minimize oxygen use to avoid oxygen dependency. c. administer oxygen according to the patient's level of dyspnea. d. maintain the pulse oximetry level at 90% or greater.
D Rationale: The best way to determine the appropriate oxygen flow rate is by monitoring the patient's oxygenation either by ABGs or pulse oximetry; an oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an oxygen flow rate of 2 L/min may not be adequate. Because oxygen use improves survival rate in patients with COPD, there is not a concern about oxygen dependency. The patient's perceived dyspnea level may be affected by other factors (such as anxiety) besides blood oxygen level. Cognitive Level: Application Text Reference: p. 640 Nursing Process: Implementation NCLEX: Physiological Integrity
26. A patient with severe COPD tells the nurse, "I wish I were dead! I cannot do anything for myself anymore." Based on this information, the nurse identifies the nursing diagnosis of a. hopelessness related to presence of long-term stress. b. anticipatory grieving related to expectation of death. c. ineffective coping related to unknown outcome of illness. d. disturbed self-esteem related to physical dependence.
D Rationale: The patient's statement about not being able to do anything for himself or herself supports this diagnosis. Although hopelessness, anticipatory grieving, and ineffective coping may also be appropriate diagnoses for patients with COPD, the patient does not mention long-term stress, death, or an unknown outcome as being concerns. Cognitive Level: Application Text Reference: p. 655 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity
