Unit 2: Med/Surg Review Questions (Ch. 24, 25, 26, 27, 28)

Which statement made by a client scheduled for a total laryngectomy indicates to the nurse that further teaching about the procedure is needed? A. "It is hard to believe that I will never hear my own voice again." B. "I hope I can learn esophageal speech." C. "I will have to take special care not to aspirate while eating." D. "I won't be able to breathe through my nose anymore."

"I will have to take special care not to aspirate while eating." Aspiration cannot occur after a total laryngectomy because the airway is completely separated from the esophagus.The client will not be able to breathe through the nose. The client will be able to vocalize after working with a speech/language pathologist if he or she chooses; however, the voice will sound different than the client is used to. Esophageal or mechanical speech will permit the client to speak, but the voice will not sound like his or her own.

Which nursing action will the nurse take to prevent harm from disruption of oxygen therapy for the client receiving low-flow oxygen by simple facemask? A. Keeping a small cylinder of oxygen at client's bedside stand for emergency use in case the central oxygen delivery system fails B. Changing to a nasal cannula during meals C. Sealing the edges of the mask to the client's skin with a water-soluble lubricant. D. Ensuring that the flaps are closed over the exhalation ports

B. Changing to a nasal cannula during meals The facemask covers the client's mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes.Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients' bedsides for this potential emergency.

Which changes in a client receiving oxygen therapy at 60% for more than 24 hours alert the nurse to the possibility of oxygen toxicity? A. Decreased PaCO2 B. Client report of increased dyspnea C. Production of thick, white, frothy sputum D. Client demand to remove the mask

B. Client report of increased dyspnea Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic.The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client's demand to remove the mask is not specific to oxygen toxicity.

Which complication does the nurse suspect when a client with severe chronic obstructive pulmonary disease COPD has new-onset increased fatigue, dependent edema, neck vein distension, and oral cyanosis? A. Lung cancer B. Cor pulmonale C. Pneumonia D. Asthma

B. Cor pulmonale The client with long-term COPD develops higher pressures in pulmonary blood vessels making the right ventricle of the heart work harder to generate pressures that are high enough to perfuse the lungs. This persistent over-working of the right ventricle leads to right-sided heart failure that is not related to independent cardiac damage (cor pulmonale). This complication remains a constant risk for anyone with COPD.These symptoms are not related to asthma or pneumonia. Although some are also associated the lung cancer, they would appear slowly over time.

For which problem does the nurse assess the client who cannot breathe through the nose because of a severe septal deviation? A. Difficulty swallowing B. Dry respiratory tract membranes C. Development of nasal polyps D. Frequent episodes of tonsillitis

B. Dry respiratory tract membranes When inspired air passes through the nose, it is filtered, warmed, and humidified. When a person is unable to breathe through the nose because of an anatomical obstruction, he or she is at risk for excessive drying of the respiratory mucous membranes. This anatomical problem does not influence the development of tonsillitis or difficulty swallowing. Nasal polyps can contribute to nasal obstruction but is not caused by a septal deviation.

Which laboratory finding does the nurse expect in a client who has metastatic lung cancer and new-onset back pain? A. Hypernatremia B. Hypercalcemia C. Hyperglycemia D. Hyperkalemia

B. Hypercalcemia Hypercalcemia is the result of increasing parathyroid hormone as a paraneoplastic complication of lung cancer as well as bone metastasis, which is suspected in the presence of back pain.Paraneoplastic syndromes are manifested by Cushing's syndrome, weight gain and dilution of electrolytes (SIADH) with resulting hyponatremia. Gynecomastia and hypoglycemia may also occur. Hyperkalemia most typically occurs with tumor lysis syndrome where multiple electrolyte imbalances develop impaired renal function and oliguria. INCORRECT

Which best practice technique will the nurse use when suctioning a client's tracheostomy tube place earlier today? A. Applying suction only during insertion of the catheter B. Hyperoxygenating the client before and after suctioning C. Ensuring each suction pass lasts no longer 30 seconds D. Suctioning repeatedly until the secretions are is clear

B. Hyperoxygenating the client before and after suctioning The client needs to be preoxygenated/hyperoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client needs to be hyperoxygenated for 1 to 5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits.Repeat suctioning can be performed as needed for up to three total suction passes. Any additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult and is traumatic to the airway. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; a suction pass should last 10 to 15 seconds.

Why will the nurse administer vitamin supplements to a client who has cystic fibrosis (CF)? A. Clients are too fatigued to ingest sufficient vitamins and nutrients. B. Steatorrhea causes a deficiency of fat-soluble vitamins. C. Increased blood levels of vitamins enhance chloride transport activity. D. High doses of vitamins can slow the progression of the disease.

B. Steatorrhea causes a deficiency of fat-soluble vitamins. The stool of clients with CF contains large amounts of fat (steatorrhea), which promotes loss of fat-soluble vitamins, leaving the client deficient of such vitamins and malnourished.Vitamins are important for general health and nutrition and play no role in the disease or its progression. INCORRECT

Which action to prevent harm is has the highest priority for the nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy regimen? A. Be sure to drink at least 2 L of fluids daily. B. Take these drugs daily exactly as prescribed. C. Expect a change in urine color. D. Wear use sunscreen and wear protective clothing when you are out-of-doors.

B. Take these drugs daily exactly as prescribed. The most important action is to take the drugs as prescribed to be effective and to prevent development of drug-resistant tuberculosis organisms. One drug in the regimen does change urine to a reddish color, but this is harmless. Two other drugs cause some degree of photosensitivity and increase the risk for sunburn; however, this is not a reason to stop the therapy.

What is the primary indication for the nurse to apply supplemental oxygen to the client with pulmonary artery hypertension (PAH)? A. Oxygen therapy is part of the client's ongoing clinical management and is applied continuously. B. The client determines when oxygen supplementation is needed. C. The nurse applies oxygen when the client's respiratory rate is decreased. D. The nurse applies oxygen when the client's respiratory rate is increased.

B. The client determines when oxygen supplementation is needed. The nurse applies supplemental oxygen when the client finds the dyspnea to be uncomfortable. This action is not dependent on a particular respiratory rate. It is also not a continuous therapy.

Which client will the nurse recognize as being at risk for bacterial sinusitis? A. A 45 year old with multiple dental caries and infected gums B. A 25 year old with seasonal pollen allergies C. A 65 year old who has a poor gag reflex after a stroke D. A 35 year old with a 20-pack-year smoking history who now vapes

A. A 45 year old with multiple dental caries and infected gums Dental infections of any kind greatly increase the risk for bacterial sinus infection. Smoking and vaping do not increase the risk for sinusitis although they do increase the risk for head and neck cancers. Allergies alone do not increase the risk. A poor gag reflect increases the risk for aspiration pneumonia but not sinusitis.

Which client will the nurse consider to be a poor candidate for continuous positive airway pressure (CPAP) management for obstructive sleep apnea? A. A 65 year old with chronic confusion B. A 45 year old with septal deviation who is a mouth-breather C. A 75 year old who lives alone D. A 55 year old with an unusually large uvula

A. A 65 year old with chronic confusion Use of CPAP for management of OSA requires client cooperation and understanding of the therapy, as well as maintaining the device in the correct position throughout sleeping. A confused client is not likely to keep any type of mask on tightly enough for CPAP to be effective.A deviated septum is not a contraindication to CPAP therapy because a mask that covers the mouth can be used. A large uvula is one cause of OSA and not a contraindication for CPAP therapy. Clients do not require a partner to use CPAP therapy.

Which action will the nurse teach a client with chronic bronchitis to use to mobilize secretions? A. Drinking at least 2 L of fluid daily B. Avoiding triggers that cause coughing C. Elevating the head of the bed 45 degrees D. Assuming the tripod position as often as possible

A. Drinking at least 2 L of fluid daily Clients with chronic bronchitis tend to have thick secretions. Hydration with at least 2 L of fluid daily thins tenacious (sticky) secretions, making them easier to expectorate. If health issues require fluid restriction, the client would attempt to consume the total amount permitted.Head of bed elevation may promote oxygenation and lung expansion, but does not promote secretion mobilization. Clients need to sit with both feet on the floor when performing controlled coughing. The tripod position is assumed during episodes of hypoxemia, but will not facilitate mobilization of fluid.

For which problem in a client with a tracheostomy will the nurse collaborate with the speech-language pathologist (SLP) member of the interprofessional team? A. Ensuring effective communication B. Determining the proper cuff pressure C. Identifying early indications of infection D. Assessing for vocal cord damage

A. Ensuring effective communication One of the many roles of the SLP is helping health care professionals work with clients who have communication problems to find the most effective means of maintaining communication. They also may be involved in assessing clients for aspiration risk. They are not involved in vocal cord assessment (primary health care provider responsibility), infection assessment, or determining correct cuff pressure (respiratory therapist responsibility).

Which oxygen delivery device will the nurse consider best to meet the needs to apply for a newly admitted client who requires high-flow oxygen therapy after suffering facial burns and smoke inhalation? A. Face tent B. Nasal cannula C. Venturi mask D. Nonrebreather mask

A. Face tent The nurse will initially select a fact tent for this client. A client with smoke inhalation and facial burns who requires high-flow oxygen must initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue.Although a Venturi mask and a nonrebreather mask are high-flow oxygen delivery devices, they are snugly fitted on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

For which symptom or problem will the nurse instruct a client who is being discharged after a modified uvulopalatopharyngoplasty (modUPPP) surgery to notify the surgeon immediately? (Select all that apply.) A. Fever B. Anorexia C. Pain only during swallowing D. Oozing of bright red blood where the uvula was removed E. Beefy red color of the soft palate F. Foul-smelling breath

A. Fever D. Oozing of bright red blood where the uvula was removed E. Beefy red color of the soft palate F. Foul-smelling breath The two major complications requiring immediate action are infection and bleeding. Indicators of infection including the present of purulent exudate, foul-smelling breath, or a change in color of mucous membranes to beefy red. Although oozing of some dark red blood is expected; however, bright red oozing is an indication of new-onset bleeding that could lead to hemorrhage.Pain during swallowing is expected during the first week or so after surgery, and contributes to anorexia.

Which associated health problems will the nurse expect a client with long-term obstructive sleep apnea (OSA) to have? A. Hypertension and weight gain B. Cancer and autoimmune disorders C. Hypotension and chronic hypoglycemia D. Asthma and chronic obstructive pulmonary disease

A. Hypertension and weight gain Long-term effects of chronic OSA include increased risk for hypertension, stroke, cognitive deficits, weight gain, diabetes, and cardiovascular disease.Although asthma and COPD can be worsened by OSA, they are not caused by them. No research has implicated with a risk for cancer or the development of autoimmune disorders.

For which side effect will the nurse monitor a client with pulmonary arterial hypertension (PAH) who is receiving endothelin receptor antagonist therapy? A. Hypotension B. Increased clot formation C. Sepsis D. Decreased urine output

A. Hypotension Endothelin receptor antagonists cause vasodilation of systemic as well as pulmonary blood vessels, which can lead to severe hypotension.These oral drugs do not increase clot formation or lead to sepsis. Urine output is only affected when hypotension becomes profound.

Which action is most important for the nurse to take when preparing a client with cystic fibrosis (CF) for a lung transplantation procedure? A. Teaching the client how to perform pulmonary muscle strengthening exercises B. Collaborating with the registered dietitian nutritionist to provide high-calorie, high-protein meals C. Reminding the client to continue taking prescribed vitamin supplementation D. Using aseptic technique when assisting the client to perform pulmonary hygiene

A. Teaching the client how to perform pulmonary muscle strengthening exercises Surgery for lung transplantation involves large "clam-shell" incisions that cut through ribs and muscle. This procedure is very painful and clients have a difficult time breathing deeply enough to wean from the ventilator. A critical factor in the outcome of the surgery and prevention of atelectasis and pneumonia in the new lungs is the strength of the muscles used for ventilation. These muscles must be strengthened before the transplantation.

Which adults will the nurse identify as having a higher risk for active tuberculosis? (Select all that apply.) A. Those who were treated previously for active tuberculosis B. Kidney transplant recipients C. Homeless adults D. Those who have received bacille Calmette-Guérin (BCG) vaccine E. Those in the local prison F. Recent immigrants to the United States

A. Those who were treated previously for active tuberculosis B. Kidney transplant recipients C. Homeless adults E. Those in the local prison F. Recent immigrants to the United States Adults who are at highest risk for TB include those who live in crowded areas such as prisons and homeless shelters, those who are recent immigrants to the United States, those who are taking long-term immunosuppressive agents, and those who have already had active TB.Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.

Which problem does the nurse suspect when a client who has been receiving 50% oxygen by Venturi mask for 2 days now has crackles and decreased breath sounds on auscultation? A. New-onset asthma B. Absorptive atelectasis C. Bronchiolar infection D. Stasis pneumonia

B. Absorptive atelectasis Absorptive atelectasis occurs when high oxygen levels are delivered that causes nitrogen dilution when oxygen diffuses from the alveoli into the blood. The alveoli collapse, which is detected as crackles and decreased breath sounds on auscultation. The problem is in the alveoli, not the airways. Although decreased breath sounds accompany pneumonia, crackles are not present with the increased density.

Which action will the nurse take first when caring for a client with pneumonia who has ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness? A. Administer oxygen to prevent hypoxemia and atelectasis. B. Administer the prescribed bronchodilator therapy to decrease bronchospasms. C. Encourage oral fluids to greater than 3000 mL/day to ensure adequate hydration. D. Maintain semi-Fowler position to facilitate breathing and prevent further fatigue.

B. Administer the prescribed bronchodilator therapy to decrease bronchospasms. Although all actions are helpful and important, bronchodilator therapy is performed first to increase the size of the airways to improve clearance.

Which action will the nurse take first when a client with obstructive sleep apnea (OSA) who has been using continuous positive airway pressure (CPAP) with a facemask, returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness? A. Reminding the client that sleep is important and to go ahead and take daytime naps B. Asking the client whether the mask fits tightly over the mouth and nose C. Encouraging the client to consider using over-the-counter sleep aids for deeper sleeping at night D. Suggesting that a nasal mask be used instead of a nose and mouth facemask

B. Asking the client whether the mask fits tightly over the mouth and nose The nurse needs to assess whether the mask fits tightly over the mouth and nose and if the client has been consistently using CPAP at night, as initial adjustments to this therapy may be needed.A nasal mask also requires a tight seal to be effective. Taking daytime naps can interfere with restorative nighttime sleep. Sleep aids do not treat OSA and are no longer recommended.

Which behavior indicates to the nurse that a client preparing for discharge after surgery understands how to perform self-care to prevent harm from aspiration? A. Eats small frequent meals that include a variety of textures and nutrients. B. Uses a straw when drinking liquid nutrition supplements. C. Positions self upright before eating or drinking anything. D. Chooses thin liquids that cause coughing but knows to take small sips.

C. Positions self upright before eating or drinking anything. Remaining upright while eating and drinking reduces the risk for aspiration by preventing substances from pooling in the pharynx.Drinking thin liquids and using a straw can result in excessive liquids entering the mouth more quickly than the client can swallow, which increases aspiration risk. Eating frequent meals that include a variety of textures and nutrients does not help prevent aspiration.

What is the nurse's best response to a client who smokes and is being discharged home on oxygen states, "My lungs are already damaged, so I'm not going to quit smoking?" A. "Tell me more about why you think quitting wont's help you." B. "For safety, lower your oxygen flow rate when you smoke." C. "The progression to damage to your lungs can be slowed if you stop smoking now." D. "For now, let's discuss why smoking around oxygen is dangerous."

D. "For now, let's discuss why smoking around oxygen is dangerous." The nurse's best response is to ask the client to discuss why smoking around oxygen is dangerous. The nurse would use this opportunity to educate the client about the dangers of smoking in the presence of oxygen. Although knowing the benefits of quitting smoking could be helpful for this client, safety is the most important issue at this time. Decreasing the oxygen flow rate while smoking still poses a safety risk.

What is the nurse's best response when a client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck?" A. "Your family and those who love you won't care." B. "It won't take you long to learn to manage." C. "But you know you need this to breathe, right?" D. "The hole can be hidden with a light scarf."

D. "The hole can be hidden with a light scarf." The nurse's best response is to suggest some strategies to cover the tracheostomy. This statement recognizes the client's concerns and explores options for dealing with the effects of the procedure.Reiterating the reason for the tracheostomy, suggesting that the client's loved ones won't care, and telling the client that he or she will learn to live with the tracheostomy are insensitive responses and minimize the client's concerns.

What is the nurse's best next question after observing that a 60-year-old client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter? A. "What are your hobbies?" B. No questions are needed regarding this normal finding. C. "Do you have any chronic breathing problems?" D. "How often do you perform aerobic exercise?"

c. "Do you have any chronic breathing problems?" The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a "barrel" chest. Most commonly, a barrel chest occurs as a result of a long-term chronic airflow limitation problem such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at high altitudes for many years.

What is the priority action for the nurse to take when a client comes to the emergency department with extremely labored breathing and a history of asthma that is unresponsive to prescribed inhalers? A. Establishing IV access to give emergency medications. B. Asking the client how long he or she has had asthma and what triggered this attack C. Preparing the client for intubation D. Placing the client in a high-Fowler position, and starting oxygen

D. Placing the client in a high-Fowler position, and starting oxygen With labored breathing, the client is most likely hypoxemic and the first priority is ensuring gas exchange by placing the client in a high-Fowler position and starting oxygen.The length of time the client has had asthma and the probably trigger for this attack are not important and will not affect how this attack is managed. Establishing IV access is important but not the first priority. Preparing a client for intubation is not needed unless all other methods to improve gas exchange are not effective.

What is the nurse's best first action on finding the client's oxygen saturation by pulse oximetry on the finger is 84%? A. Apply supplemental oxygen by mask or nasal cannula. B. Notify the Rapid Response Team immediately. C. Assess the client's cognitive function. D. Recheck the value on the forehead.

D. Recheck the value on the forehead. Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented

Which point is most important to prevent harm for the nurse to teach a client with chronic obstructive pulmonary disease (COPD) who is being discharged on home oxygen th A. Correct performance when setting up the oxygen delivery system B. Understanding the signs and symptoms of hypoxemia C. Demonstrating how to use a pulse oximetry device D. Removing combustion hazards present in the home

D. Removing combustion hazards present in the home The highest priority of education is that oxygen is highly combustible. The nurse must ensure that no open flames or combustion hazards will be present in a room where oxygen is in use.The oxygen delivery system in the home will be different than in the hospital. Therefore, this skill may be verified by the visiting nurse or company providing the oxygen. The client must be able to state signs and symptoms of hypoxemia, although safety is the priority. Pulse oximetry may be useful for monitoring the client's oxygenation status and the visiting nurse or respiratory therapy partner can assess this.

Which outcome indicates to the nurse that oxygen therapy for the client with chronic obstructive pulmonary disease (COPD) who has hypoxemia and hypercarbia is effective? A. PCO2 is within normal range. B. Finger clubbing has resolved. C. Client reports decreased distress. D. SpO2 is between 88% and 90%.

D. SpO2 is between 88% and 90%. Clients with hypoxemia, even those with COPD and hypercarbia, need to receive oxygen therapy at rates appropriate to reduce hypoxia and maintain SpO2 levels between 88% and 92%.Gases diffuse independently, therefore applying oxygen will not decrease the carbon dioxide level and hypoxemia may still be present. A report of less distress is appropriate but not an objective indicator of therapy effectiveness. Finger clubbing in a client with long-term COPD does not resolve.

Which primary health care provider's instruction will the nurse question for a client being discharged with nasal packing in place after a posterior nosebleed? A. Sleep in a recliner or with the head in an elevated position. B. Go to the nearest emergency room if bleeding recurs. C. Use a home humidifier for at least 5 days. D. Take ibuprofen 800 mg every 8 hours as needed for pain.

D. Take ibuprofen 800 mg every 8 hours as needed for pain. The nurse must question the prescription for ibuprofen. Ibuprofen is contraindicated in a client with a nosebleed because NSAIDs inhibit clotting and increase the risk for bleeding.Elevation of the head of the bed is recommended for client comfort and to facilitate drainage of secretions. Humidified air is recommended because dryness of the nasal mucosa can be a cause of epistaxis (nosebleed). Recurrence of excessive bleeding from posterior epistaxis is an emergency.

Which type of ADL assistance will the nurse plan for a client with long-standing pulmonary problems who has Class IV dyspnea? A. Dyspnea is minimal and no assistance is required. B. The client is severely dyspneic at rest and cannot participate in any self-care. C. The client may complete ADLs without assistance but requires rest periods during performance. D. The client is severely dyspneic with activity and requires assistance for bathing and dressing.

D. The client is severely dyspneic with activity and requires assistance for bathing and dressing. Class IV dyspnea occurs during usual activities, such as showering and dressing, and requires assistance from others. Dyspnea is usually not present at rest, but is with minimal exertion.

Which action is most important to teach a client living with progressing idiopathic pulmonary fibrosis? A. Maintaining an oral fluid intake of at least 2 L daily B. Taking oral temperature daily C. Using oxygen by nasal cannula whenever dyspnea is present D. Using energy conservation measures

D. Using energy conservation measures The client with progressing pulmonary fibrosis is extremely fatigued and has little energy. Using energy conservation measures helps the client have more energy to perform the work of breathing.

Which blood gas value indicates to the nurse that a client is experiencing hypercarbia? A. Bicarbonate = 20 mEq/L B. pH = 7.33 C. PaO2 = 80 mm Hg D. PaCO2 = 60 mm Hg

D. PaCO2 = 60 mm Hg The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia.

What is the nurse's best response when a client with emphysema asks how removing part of the lungs through lung volume reduction surgery will improve breathing? A. "By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best." B. "This surgery is preventive, because the parts of the lungs being removed are those that having the highest probability for developing cancer." C. "Breathing will be improved because diseased lung parts are removed and replaced with healthy parts." D. "This surgery makes room for the new lungs when a lung transplant is available."

A. "By removing only the over-inflated parts of the lungs, the air you breathe in will be going only to the lung areas that work best." Lung volume reduction surgery removes hyperinflated lung areas that contain only stale air and do not contribute to gas exchange. This ensures that respiratory effort results in better gas exchange in the remaining alveoli. Removing some volume also allows respiratory muscle contraction to be more effective.This surgery does not replace any lung tissue and is not performed as a precursor to lung transplantation. The hyperinflated areas are not more susceptible to cancer development than any other lung tissue.

What is the nurse's best response to a client with obstructive sleep apnea (OSA) who asks, "Why does it feel like I wake up every 5 minutes?" A. "Carbon dioxide builds up while you are not breathing, which stimulates your body to wake up and breathe." B. "Excessive sleeping during the day interferes with deeper sleep at night." C. "Your tongue may be blocking your throat, and you wake up because you are choking." D. "You really aren't waking up that often. It just feels that way."

A. "Carbon dioxide builds up while you are not breathing, which stimulates your body to wake up and breathe." OSA is related to the buildup of carbon dioxide stimulating the body to wake up and breathe. During sleep, the muscles relax and the tongue and neck structures are displaced with the tongue falling back, causing an upper airway obstruction. This obstruction leads to apnea and increased levels of carbon dioxide, that stimulate neural centers in the brain, and the client awakens, takes a deep breath, and goes back to sleep. This cycle may be repeated as often as every 5 minutes as the airway is reobstructed.Tongue relaxation can cause OSA but is not the actual mechanism of the repeated waking cycle.Telling the client he is choking is not accurate. Telling the client that he or she isn't really awakening that often minimizes his or her and is not correct.

Which statements made by a client going home with a tracheostomy indicate to the nurse the need for further teaching about correct tracheostomy care? (Select all that apply.) A. "I can only take baths, but no showers." B. "I will be unable to wear a necklace." C. "I should put cotton or foam over the tracheostomy hole." D. "I will have to learn to suction myself." E. "I will notify my primary health care provider if my secretions develop a foul odor." F. "I can put normal saline in my tracheostomy to keep the secretions from getting thick."

A. "I can only take baths, but no showers." B. "I will be unable to wear a necklace." C. "I should put cotton or foam over the tracheostomy hole." F. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." Need for teaching is indicated when the client says that only baths and no showers can be taken. The client is permitted to shower with the use of a shower shield over the tracheostomy, which prevents water from entering the airway. Also, the client does not instill anything into the artificial airway unless prescribed. The client would not put cotton or foam over the tracheostomy hole; this action may cause airway obstruction. The stoma may be covered loosely with a small cotton cloth or light scarf to protect it during the day. This filters the air entering the stoma, keeps humidity in the airway, and enhances appearance.The client is correct when commenting about learning to suction self, and will be taught clean suction technique to use at home. Also, foul-smelling secretions or drainage indicates possible infection and needs to be reported to the primary health care provider.

Which client statements about using an aerosol inhaler for asthma management indicate to the nurse that he has correct understanding of this drug delivery system? (Select all that apply.) A. "I will hold my breath for 1 full minute after inhaling the drug." B. "When I suspect the canister is close to empty, I will shake it to check how much is left."e. "I will hold my breath for at least 10 seconds after inhaling the drug." C. "If I use a spacer, I don't have to wait a minute between the two puffs." D. "If the spacer makes a whistling sound, I am breathing in too rapidly." E. "Rinsing my mouth after using the inhaler and then swallowing the rinse ensures I will get all of the drug."

A. "I will hold my breath for 1 full minute after inhaling the drug." D. "If the spacer makes a whistling sound, I am breathing in too rapidly." Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client is instructed to hold the breath for at least 10 seconds, however attempting to hold the breath for a minute is unnecessary and could pose a threat to oxygenation.The client must wait 1 minute between puffs regardless of the method of delivery of the medication. The client is taught to rinse the mouth but not swallow the water. The mouth needs to be rinsed after using an inhaler with or without a spacer. This is especially important if the inhaled drug is a corticosteroid; rinsing will help prevent the development of an oral fungal infection. Shaking an inhaler helps ensure that the medication is dispersed and the same dose is delivered in each puff, it does not indicate how much drug remains in the inhaler. The client is taught to read the counter on the inhaler to know how many drug doses remain.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 45 year old with a peritonsillar abscess who can no longer swallow. B. A 65 year old with rhinosinusitis and a fever of 102° F (38.9° C) C. A 25 year old who had endoscopic sinus surgery 8 hours ago. D. A 55 year old with tuberculosis who is standard first-line therapy.

A. A 45 year old with a peritonsillar abscess who can no longer swallow. The client at greatest risk for a respiratory complication is the one with a peritonsillar abscess who is no longer able to swallow. This abscess is enlarging and could completely obstruct the client's airway. Rapid assessment is needed immediately to determine the degree of intervention urgency. No other client listed has indications of the need for potential emergency action.

Which action will the nurse take to ensure that a client who requires drug therapy for multi-drug resistant tuberculosis and also is addicted to heroin adheres to the treatment regimen? A. Arranging for a health care worker to directly observe the client take the drugs B. Giving the client written instructions about how and when to take the drugs C. Instructing the client about the consequences of not taking the drugs D. Having the client repeat the drug names and side effects

A. Arranging for a health care worker to directly observe the client take the drugs The most effective action for the nurse to take to ensure that the client complies with the treatment regimen is to arrange for the client to be directly observed during therapy. The heroin addiction reduces the client's likelihood of adherence to long-term treatment unless closely supervised while taking the drugs.Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. Even if the client can state the names and side effects of the drugs does not indicate understanding of the importance of this therapy.

Which assessment findings in a client with asthma indicate to the nurse that the client's asthma condition is deteriorating and progressing toward respiratory failure? A. Audible wheezing with use of accessory muscles on inhalation B. Crackles, rhonchi, and productive cough with yellow sputum C. Tachypnea, thick and tenacious sputum, and hemoptysis D. Respiratory alkalosis; slow, shallow respiratory rate

A. Audible wheezing with use of accessory muscles on inhalation Normal exhalation is passive. When airways narrow, wheezing is first heard on exhalation. Wheezing on inhalation along with the use of accessory muscles for inhalation indicates more severe airway problems and a worsening of asthma.Worsening asthma would cause acidosis, not alkalosis. Hemoptysis is not associated with asthma. Crackles are not present because asthma is an airway problem, not an alveolar problem.

Which statements regarding noninvasive positive-pressure ventilation (NPPV) are true? (Select all that apply.) A. Can only be used safely by alert clients. B. Risk for ventilator-associated pneumonia is reduced but still present. C. An endotracheal tube is required for oxygen therapy. D. Masks must have a tight seal for effective ventilation. E. The system operates with either room air or oxygen. F. Vomiting with potential aspiration can occur.

A. Can only be used safely by alert clients. D. Masks must have a tight seal for effective ventilation. E. The system operates with either room air or oxygen. F. Vomiting with potential aspiration can occur. The NPPV technique uses positive pressure to keep alveoli open and improve gas exchange without the dangers of intubation, such as ventilator-associated pneumonia. NPPV can deliver oxygen or may use just room air. Masks must fit tightly to form a proper seal. Pressure can cause gastric insufflation, which can lead to vomiting and the potential for aspiration. Thus, NPPV is recommended only for use with on alert patients who have the ability to protect their airway.

Development of which symptoms indicates to the nurse that a 48-year-old client with seasonal influenza may actually have COVID-19? A. Chest tightness and SpO2 of 86% B. Productive cough and yellow-colored sputum C. Anorexia and weight loss D. Intermittent fever and sweating

A. Chest tightness and SpO2 of 86% Symptoms of COVID-19 are similar to those of seasonal asthma. However, the inflammatory responses occurring in the lungs with serious COVID-19 infection causes lung stiffness with chest tightness and greatly reduced gas exchange. The other symptoms are not specific to COVID-19 or other pandemic respiratory infections.

Which personal factors or health problems will the nurse suspect as possible causes of a client's diagnosis of cancer of the sinuses? A. Chronic exposure to wood dust and cigarette smoking B. Yearly colds leading to development of sinus infections C. Heavy sun exposure and use of antihistamine nasal spray D. Swimming in the ocean and heating the home with a forced-air furnace

A. Chronic exposure to wood dust and cigarette smoking Cancer of the sinuses is most common among adults with chronic exposure to wood dusts, dusts from textiles, leather dusts, flour, nickel and chromium dust, mustard gas, and radium. Cigarette smoking along with these exposures increases the risk.None of the other factors listed are associated with development of cancer of the sinuses.

Which condition indicates to the nurse that the treatment plan for a client with streptococcal pneumonia is effective? A. Client has been afebrile for 48 hours. B. Oxygen saturation ranges between 90% and 92% on room air. C. White blood cell count is 16, 000 cells/mm3 (16 × 109/L). D. Bronchial breath sounds present in lung periphery.

A. Client has been afebrile for 48 hours. A positive outcome is indicated by the client having been afebrile for 48 hours.Bronchial breath sounds in lung peripheral areas are abnormal. The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). The listed count is elevated and indicates continuing infection. The normal oxygen saturation is expected to be above 95%.

Which factors or conditions will the nurse identify as increasing the risk for clients to develop aspiration pneumonia? (Select all that apply.) A. Continuous nasogastric (NG) tube feedings B. Bronchoscopy procedure C. Decreased level of consciousness D. Magnetic resonance imaging (MRI) procedure E. Stroke F. Chest tube

A. Continuous nasogastric (NG) tube feedings B. Bronchoscopy procedure C. Decreased level of consciousness E. Stroke The risk for aspiration pneumonia is increased whenever the client has a reduced or absent gas reflex (e.g., decreased level of consciousness, stroke, following local anesthesia for a bronchoscopy procedure), and when a client's lower esophageal sphincter does not close complete. This situation occurs when an NG tube is in place, preventing complete or tight constriction of the sphincter.

Which changes in arterial blood gas (ABG) values will the nurse expect in a client with long-term chronic obstructive pulmonary disease (COPD)? A. Decreased pH; Decreased PaO2; Increased PaCO2; Increased bicarbonate level B. Increased pH; increased PaO2; increased PaCO2; Increased bicarbonate level C. Increased pH; increased PaO2; increased PaCO2; decreased bicarbonate level D. Decreased pH; decreased PaO2; decreased PaCO2; decreased bicarbonate level

A. Decreased pH; Decreased PaO2; Increased PaCO2; Increased bicarbonate level Hallmark changes in ABGs for long-term COPD is respiratory acidosis (increased arterial carbon dioxide [Paco2]); metabolic alkalosis (increased arterial bicarbonate) as compensation by kidney retention of bicarbonate (seen as an elevation of HCO3− although pH remains lower than normal); and lower-than-normal PaO2 from poor gas exchange.

Which features will the nurse expect to be present in a client who has long-term chronic obstructive pulmonary disease? (Select all that apply.) A. Increased anteroposterior chest diameter from air-trapping B. Respiratory acidosis with a low pH C. Poor gas exchange from decreased alveolar surface area D. Increased eosinophil count E. Hypercapnia from retained PaCO2 F. Arterial blood gas value with increased PaO2 level

A. Increased anteroposterior chest diameter from air-trapping B. Respiratory acidosis with a low pH C. Poor gas exchange from decreased alveolar surface area E. Hypercapnia from retained PaCO2 Gas exchange is decreased by the increased work of breathing and the loss of alveolar tissue. Although some alveoli enlarge, the overall functional area available for gas exchange is decreased. The client also has a low arterial oxygen (PaO2) level because it is difficult for oxygen to move from diseased alveoli into the blood. Chronic retention of carbon dioxide increases the PaCO2 (hypercapnia) and results in respiratory acidosis. The anteroposterior chest diameter increases from air trapping.The PaO2 level is lower than normal and the eosinophil count does not change unless the client also has eosinophilic asthma.

What is the nurse's best first action when a client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused? A. Increasing the oxygen flow rate B. Documenting the observation as the only action C. Notifying the primary health care provider immediately D. Repositioning the client from a high-Fowler to a low-Fowler position

A. Increasing the oxygen flow rate Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client's condition, the best action is to first increase the oxygen flow rate and then notify the physician.Changing the client's position to less upright, would not improve gas exchange.

Which client conditions will the nurse recognize as most likely to cause a "right shift" of the oxyhemoglobin dissociation curve? (Select all that apply.) A. Reduced blood and tissue levels of oxygen B. Alkalosis C. Increased metabolic demands D. Reduced blood and tissue levels of diphosphoglycerate (DPG) E. Increased body temperature F. Reduced blood and tissue pH

A. Reduced blood and tissue levels of oxygen C. Increased metabolic demands E. Increased body temperature F. Reduced blood and tissue pH

Which action is most important for the nurse to take when a client with chronic obstructive pulmonary disease who is taking a cholinergic antagonist now reports nausea, blurred vision, headache, and inability to sleep? A. Reporting the symptoms to the primary health care provider immediately B. Asking the client to explain the exact techniques he or she uses when taking the drug C. Requesting an order to draw blood to determine the drug level D. Reminding the client that these side effects are normal and not to worry

A. Reporting the symptoms to the primary health care provider immediately The symptoms the client describes represent a drug overdose placing the client in danger of even more adverse effects.It is possible that the client is taking the drug more frequently or at higher doses than prescribed; however, the first priority is to notify the primary health care provider. The drug is only taken as an inhalation and blood levels will not provide any useful information.

Which complication will the nurse assess for first in any client with cystic fibrosis (CF)? A. Respiratory infection B. Pneumothorax C. Weight loss D. Osteoporosis

A. Respiratory infection In addition to respiratory failure, the most common cause of death for any client with CF is respiratory infection. Recognizing infections early and initiating appropriate therapy are essential life-saving strategies.Although weight loss and osteoporosis are complications of CF, they are not immediately life threatening. Pneumothorax is not a common complication of CF.

Which change in the condition of a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen indicates to the nurse that an increase in the fraction of inspired oxygen (FiO2) may need to be increased? A. Restlessness has increased over the past hour. B. Client reports increased mouth dryness. C. Heart rate has decreased from 90 to 82 beats/min. D. Blood pressure has changed from 106/80 to 110/70.

A. Restlessness has increased over the past hour. The nurse needs to assess the client who has recently become restless for the need to increase this client's FiO2. This client may be exhibiting symptoms of hypoxemia including restlessness. Additional symptoms of hypoxemia include increased heart rate and blood pressure, oxygen desaturation, cyanosis, restlessness, and dysrhythmias.A heart rate decrease to 82 beats/min and not cause for alarm or a change in FiO2. The change in blood pressure is a positive indicator of reasonable perfusion and gas exchange. Mouth dryness is not an indicator of poor gas exchange and the need for more oxygen.

Which oral hygiene measures will the nurse teach a client to use during the first week after having modified uvulopalatopharyngoplasty (modUPPP) surgery? A. Rinsing with mouthwash and gently wiping oral structures with oral sponges B. Only flossing and forgoing toothbrushing C. Avoiding all oral hygiene practices except saline rinses D. Swishing and swallowing an oral antibiotic solution

A. Rinsing with mouthwash and gently wiping oral structures with oral sponges After modUPPP surgery, the oral mucous membranes are at an increased risk for bleeding from trauma and for infection. Clients must continue good oral hygiene practices to prevent infection while avoiding trauma from flossing and using a toothbrush. Oral antibiotic solutions are not used for oral hygiene. Saline rinses are encouraged to help with pain and mouth dryness but are not sufficient alone to prevent infection.

Which is the priority action for the nurse to take first after applying oxygen when caring for an older client admitted with symptoms of possible seasonal influenza accompanied by vomiting and high fever? A. Starting an IV line to begin hydration therapy B. Administering IM influenza vaccination C. Asking the client when symptoms began D. Placing the client in a negative air pressure room

A. Starting an IV line to begin hydration therapy The nurse's first priority is to start an IV line and begin intravenous hydration to maintain perfusion. Older clients with influenza symptoms can develop dehydration quickly because of fever, vomiting, and possible diarrhea.Asking when the symptoms first started is not important. A negative airflow room is not required and is usually in short supply. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority because it takes weeks for full immunity to develop.

Which questions are most relevant for the nurse to ask a client when assessing for risk factors and indications for head and neck cancer? (Select all that apply.) A. "When was the last time you saw your dentist?" B. "Do you have recurrent laryngitis or frequent episodes of sore throat?" C. "Have you had frequent episodes of acute or chronic visual problems?" D. "How many packs per day do you smoke and for how many years?" E. "Have you had a problem with sores in your mouth?" F. "How many servings per day of alcohol do you typically drink?"

B. "Do you have recurrent laryngitis or frequent episodes of sore throat?" D. "How many packs per day do you smoke and for how many years?" E. "Have you had a problem with sores in your mouth?" F. "How many servings per day of alcohol do you typically drink?" The most common risk factors for head and neck cancer are cigarette smoking and alcohol consumption. Common signs and symptoms of laryngeal cancer are chronic laryngitis and sore throat. Oral cancers often start as a mouth sore that does not heal.Although dental examinations can help identify suspicious lesions, not visiting a dentist does not contribute to development of head and neck cancer (although poor oral care and mouth infections can). Visual problems are not associated as causes or manifestations of head and neck cancer.

What is the nurse's first priority action to prevent harm when an 82-year-old client with pneumonia has become increasingly confused with an SpO2 change from 91% 1 hour ago to 88% now, and a respiratory rate that has increased from 26 to 32 breaths/min? A. Increasing the flow rate of the IV piggy-back antibiotic B. Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes C. Assisting the client to a more upright position D. Reporting the change in status to the client's primary health care provider

B. Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes The client is becoming increasingly hypoxemic and needs more supplemental oxygen. After oxygen delivery is increased, the nurse will determine the client's response to this action.Although moving the client to a more upright position is not harmful and can increase oxygenation, it is not as effective in managing hypoxemia as increasing the oxygen flow rate. It should be the second action, not the first. Although the pneumonia may be worsening, giving the IV antibiotic at a faster rate is not going to make an immediate difference. In addition, infusing it faster may increase the risk for side effects and adverse effects. Before notifying the primary health care provider, the nurse will assess the client's response to increased oxygen flow rate. If the oxygen saturation has not improved or has decreased further in 5 minutes, the nurse would then immediately notify the primary health care provider.

Which sign or symptom will the nurse report immediately to the pulmonary health care provider to prevent harm for a client who had a percutaneous lung biopsy 2 hours ago? A. Bruising at the puncture site B. Lateral displacement of the trachea C. Oxygen saturation of 97% D. Pink-tinged sputum

B. Lateral displacement of the trachea The trachea should always be midline. Lateral displacement after a percutaneous lung biopsy is associated with complications, especially pneumothorax, which requires immediate intervention.

For which situation will the nurse take immediate action to prevent harm for a client with pneumonia who is receiving 100% oxygen via a nonrebreather mask? A. Sputum is now rust-colored. B. Oxygen reservoir deflates during inspiration. C. Crackles are present in the lung bases. D. Skin is pink and flushed.

B. Oxygen reservoir deflates during inspiration. The nurse takes action immediately if the reservoir bag is deflated. Suffocation can occur if the reservoir bag deflates, kinks, or if the oxygen source disconnects. The nurse needs to remove the device, refill the reservoir, and then reapply the mask.It is anticipated that the client's color is now pink. The client's color is expected to improve (from ashen or gray to pink) because of an increase in PaO2 level. Crackles in lung bases are an expected finding in a client with pneumonia, as is expectorating rust-colored sputum.

Which problem experienced by a man with late-stage lung cancer is the priority for immediate action by the nurse? A. Anorexia and weight loss B. Pain rating of 9 on a 0-10 scale C. Constipation for 2 days D. Extreme fatigue

B. Pain rating of 9 on a 0-10 scale Although all the client problems list are distressing, effective pain management is the most important issue for this client. The constipation can be helped after pain control is achieved. The anorexia, weight loss, and extreme fatigue may not respond to any interventions in late-stage lung cancer.

How will the nurse categorize the level of asthma control for a client who reports usually waking at night with wheezing once weekly and needing to use the prescribed reliever inhaler to stop the episode? A. Minimally controlled B. Partly controlled C. Controlled D. Uncontrolled

B. Partly controlled The client meets the criteria for partly controlled asthma, which are that any of these symptoms occur one to two times per week:Daytime symptoms of wheezing, dyspnea, coughingWaking from night sleep with symptoms of wheezing, dyspnea, coughingReliever (rescue) drug needed no more than twice weekly

Which complication of seasonal influenza will the nurse suspect in a 78-year-old client whose temperature remains elevated and now has new-onset confusion? A. Tuberculosis B. Pneumonia C. Emphysema D. Heart failure

B. Pneumonia Pneumonia is the most common complication of seasonal influenza, especially among older clients. The symptoms of pneumonia include fever that does not resolve and acute confusion.Although heart failure is a complication of pneumonia, it is less common and not accompanied by fever. Neither emphysema nor tuberculosis is a complication of seasonal influenza.

Which action will the nurse take to prevent harm from tracheal stenosis in a client after tracheostomy? A. Using commercial tube holders instead of standard tracheostomy ties B. Securing the tube in a midline position C. Assessing bilateral breath sound every 2 hours D. Ensuring maximum cuff pressure

B. Securing the tube in a midline position Tracheal stenosis, a narrowed tracheal lumen, is caused to scar tissue formation from irritation. Two methods of preventing this complication is to keep the tube from moving in the trachea and to maintain proper cuff pressure. Securing the tube in the midline position is critical regardless of whether the tube is secured with commercial tube holders or standard tape ties. Although assessing breath sounds bilateral is an important action whenever a client has a tracheostomy, but does not prevent harm from tracheal stenosis.

For which symptoms would a nurse assess a client who worries a thoracentesis earlier today may have caused a pneumothorax? (Select all that apply.) A. Slowing heart rate B. Sensation of air hunger C. Pain at the insertion site D. Cyanosis of oral mucous membranes E. Wheezing on inhalation and exhalation F. Tracheal deviation

B. Sensation of air hunger D. Cyanosis of oral mucous membranes F. Tracheal deviation

Which action with the nurse take to prevent harm when prescribed to administer an IV antibiotic to a client with pulmonary artery hypertension (PAH) who is being managed with a continuous prostacyclin agonist infusion? A. Requesting a prescription for an oral antibiotic B. Starting a peripheral IV access to use for administering the antibiotic C. Stopping the prostacyclin agonist infusion for 15 minutes to administer the IV antibiotic D. Administering the IV antibiotic through the continuous infusion's side port

B. Starting a peripheral IV access to use for administering the antibiotic The prostacyclin agonist infusion cannot be stopped for even 15 minutes without endangering the client's life. The drug also cannot be mixed with any other drug. Clients with PAH are at high risk for sepsis. Thus, the antibiotic must be administered intravenously and the safest action is to insert a separate peripheral IV access for this purpose.

What is the most important personal infection control measure that the nurse will take when suctioning a client with COVID-19 or any other pandemic influenza? A. Performing oral care before, as well as after, suctioning the oropharynx B. Wearing a disposable particulate mask N95 respirator with face shield or goggles C. Washing hands and donning gloves prior to the procedure D. Keeping the door to the client room closed

B. Wearing a disposable particulate mask N95 respirator with face shield or goggles The most important infection control precaution the nurse must take before suctioning a client with any pandemic influenza is to wear a particulate mask respirator with protective eyewear or a face shield to prevent infectious organisms from entering the nurse's mucous membranes and respiratory tract.The door to the room needs to be closed during any care of the client with a pandemic influenza. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure.

Which statement made by a client prescribed a reliever drug inhaler for asthma indicates to the nurse correct understanding of this therapy? A. "If I forget a dose, I will use the inhaler as soon as I remember it." B. "At night, I will be sure to store the inhaler in a cool, dry place." C. "I will keep this inhaler with me at all times." D. "Reliever drugs are needed to prevent asthma attacks."

C. "I will keep this inhaler with me at all times." The statement by the client that indicates a correct understanding of the instructions is that the emergency inhaler must be with the client at all times because asthma attacks cannot always be predicted.The inhaler is not to be stored at night; it needs to remain with the client for emergency use.Reliever drugs stop an attack and are used when needed, not on a schedule.

How will the nurse document the pack-year smoking history for a client who reports smoking 3 packs of cigarettes per day for 25 years and then smoking 2 packs per day for the past 20 years? A. 45-pack-year B. 90-pack-year C. 115-pack-year D. 80-pack-year

C. 115-pack-year Smoking history is documented in pack-years (number of packs per day smoked multiplied by the number of years the client has smoked). 3 packs/day × 25 years = 75-pack-year, plus 2 packs/day × 20 years = 40-pack-year.

Which assessment finding in a client who has had a lobectomy and placement of a chest tube 8 hours ago requires immediate follow-up by the nurse? A. Report of pain at the chest tube insertion site B. 3-cm area of red drainage on the incisional dressing C. 200 mL red drainage from chest tube over 2 hours D. Client sleepy but able to be aroused

C. 200 mL red drainage from chest tube over 2 hours The nurse must immediately report 200 mL of red drainage over a 2-hour span of time. Chest drainage should slow down after surgery. More than 70 mL of drainage/hour must be reported to the surgeon.A client who had a surgical procedure, anesthesia, and analgesia may spend most of the day sleeping, but should be able to be aroused. A small amount of drainage after surgery is expected, such as a 3-cm area. The nurse should circle the area and report increasing amounts to the surgeon. Pain at the surgical and chest tube insertion site is expected and will be man-aged by the nurse in collaboration with the provider after airway, breathing, and circulation are ensured.B.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 62 year old with chronic obstructive pulmonary disease (COPD) being discharged with an oxygen saturation of 90% B. A 42 year old with lung cancer who needs an IV antibiotic administered before going to surgery C. A 22 year old with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min D. A 52 year old with end-stage pulmonary fibrosis and an oxygen saturation of 89%

C. A 22 year old with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min The client with CF with an elevated temperature and respiratory rate of 38 breaths/min is exhibiting signs of an exacerbation/infection and needs to be assessed first.The nurse will need to speak with the client who has COPD to help find a plan that will enable the client to obtain his or her prescribed medications. This may involve contacting case management or social services and discussing the discharge with the discharge health care provider. An oxygen saturation of 89% may be normal and expected for a client with end-stage pulmonary fibrosis. There is no indication that this client is in distress. The nurse can delegate administration of the IV antibiotic to another RN, or it could be administered before the client is brought to the operating room.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 40 year old admitted 3 hours ago for a scheduled thoracentesis in 30 minutes. B. A 55 year old with bronchogenic lung cancer who returned from bronchoscopy 4 hours ago. C. A 30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry. D. A 68 year old with pleural effusion who has decreased breath sounds at the right base.

C. A 30 year old with acute asthma who has an oxygen saturation of 89% by pulse oximetry. The client in need of the most immediate assessment is the one with acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen saturation level less than 91% indicates hypoxemia and instability requiring immediate assessment and intervention to improve blood and tissue oxygenation.The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed. There is no evidence the client who had a bronchoscopy 3 hours ago is unstable and therefore does not require attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion.

Which client will the nurse consider to be at greatest risk for an airway obstruction? A. A 25 year old with a sinus infection B. A 65 year old who has chronic mouth dryness and many dental caries C. A 35 year old with a traumatic brain injury D. A 55 year old who wears upper and lower dentures

C. A 35 year old with a traumatic brain injury Clients at greatest risk for an obstructed airway from any cause, including foreign body presence or mucoid impaction, are those who are unable to protect the airway, such as clients who are unconscious or with poor cognition.None of the other client factors contribute to risk for obstruction in an alert client of any age.

Which symptom will the nurse expect as typical in an 82-year-old client with pneumonia? A. High fever B. Profound bradycardia C. Acute confusion D. Coughing spasms

C. Acute confusion The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present. Tachycardia is triggered by hypoxia, not bradycardia.

What is the nurse's interpretation of a 50-year-old client's respiratory assessment findings when hearing bronchial breath sounds over the left lower lobe and noting decreased fremitus and dullness to percussion in the same area? A. Obstruction of the larger airways B. Normal physical exam for a 50 year old C. An area of increased density D. Subcutaneous emphysema

C. An area of increased density Peripheral bronchial breath sounds are abnormal and can indicate atelectasis, tumor, or pneumonia. Decreased fremitus and dullness to percussion may indicate pleural effusion, which is more dense than air.Bronchial breath sounds are normally heard only over the large airways in patients of any age, not in the periphery. An obstructed airway would have reduced bronchial breath sounds, and they would not be present in the periphery. Subcutaneous emphysema is a condition in which air is trapped within or beneath the skin. It is felt and heard as a "crackling" in the skin and subcutaneous tissues, not within any part of the respiratory tract.

Which action has the highest priority for the nurse caring for a client with facial trauma who has new-onset restlessness? A. Preparing the next dose of prescribed pain medication B. Providing ventilation with a manual resuscitation bag C. Applying oxygen D. Assessing for bleeding on the drip moustache dressing

C. Applying oxygen The nurse's first priority is to apply oxygen to any client who recently developed restlessness. Restlessness could be a sign of poor gas exchange and partial airway obstruction and requires immediate attention.Although bleeding is important in all trauma clients, it is not the first priority. Restlessness is not an indication of hypoventilation or apnea that would require manual resuscitation. Although restlessness could be associated with pain, applying oxygen before assessing for is the priority action.

Which action will the nurse take first when a client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure? Which nursing action must be taken first? A. Cleaning the tracheostomy inner cannula and stoma B. Observing for indications that suctioning is needed C. Auscultating lung sounds D. Changing the tracheostomy dressing immediately

C. Auscultating lung sounds The first step of the nursing process and nursing action for a client following an airway procedure is to assess for a patent airway by auscultating the client's lungs and assessing the client's respiratory status.Suction is not needed if the lungs and airways are clear to auscultation. Although cleanliness is important, the PACU nurse will not typically perform this procedure immediately after the tracheotomy is created, unless copious secretions are blocking the tube.Performing a dressing change is done every 8 hours or per hospital policy. The PACU nurse will perform this if the dressing is soiled or bloody, but assessment of airway must be performed first.

What is the priority assessment the will make for a client with a posterior nosebleed who has posterior packing and is receiving oxygen therapy, antibiotics, and opioid analgesics. What is the priority assessment? A. Determining the degree of mouth dryness B. Examining the skin around the nares for breakdown C. Checking gag and cough reflexes D. Asking about pain relief

C. Checking gag and cough reflexes Although assessing pain is always important, in this situation safety is the priority. The packing could slip and obstruct the airway. If the client's gag reflex is impaired for any reason, such as opioid therapy, he or she may not be aware of the packing slippage and take no action to protect the airway.

Which precaution to prevent harm is most important for the nurse to teach a client who is newly prescribed nicotine replacement therapy (NRT)? A. Immediately report any change in thought process or suicide ideation because this drug can alter behavior. B. Avoid crowds and people who are ill because your immunity is reduced while on this drug. C. Do not smoke cigarettes or use nicotine in any form while on this drug because the risk for heart attack or stroke is increased. D. Be sure to remain in an upright position for an hour after taking the drug to avoid esophageal reflux and ulceration.

C. Do not smoke cigarettes or use nicotine in any form while on this drug because the risk for heart attack or stroke is increased. NRT contains nicotine and cannot be used when smoking or with nicotine use in any other form because this will greatly increase circulating nicotine levels and the risk for stroke or heart attack.NRT does not have psychotropic properties and does not increase feelings of self-harm or suicide ideation. NRT does not induce esophageal irritation or ulcers nor does it reduce immunity.

Which teaching point is most important for the nurse to emphasize for a client who is scheduled to undergo pulmonary function testing (PFT)? A. Avoid strenuous physical activity for 24 hours before the procedure. B. Use your bronchodilating inhaler right before arriving for the procedure. C. Do not smoke for 6 hours before the test. D. Eat only clear liquids for 12 hours before the procedure.

C. Do not smoke for 6 hours before the test. The essential teaching point for a client being prepared for a PFT is to make sure that the client does not smoke for 6 hours before the test. Smoking can alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results.Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Encouraging fluid intake does not have an effect on PFT testing. Supplemental oxygen is not required and will alter the results of PFT. However, oxygen may be given if the client develops distress during testing.

Which order or prescription will the nurse perform first for a client admitted with pneumonia who is febrile and also agitated as a result of alcohol intoxication? A. Assessing the need for an immediate dose of lorazepam B. Requesting a referral to a social worker for alcohol counseling C. Drawing blood for aerobic and anaerobic blood cultures D. Administering intravenous antibiotics

C. Drawing blood for aerobic and anaerobic blood cultures The nurse will first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed to identify the specific causative organism. Initiating antibiotic therapy before cultures are obtained could affect the results of the culture and possibly delay identification an antibiotic more for the infection. Thus, antibiotic therapy is started after blood for cultures is obtained.Unless this client is a danger to self or staff, giving lorazepam for agitation is not the first action. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.

What action does the nurse take first when a client who has a "do not resuscitate" (DNR) order and a nonrebreather oxygen mask, has labored breathing? A. Only provide comfort to the client. B. Notify the chaplain and the family member of record. C. Ensure that the tubing is patent and that oxygen flow is high. D. Initiate the Rapid Response Team (RRT).

C. Ensure that the tubing is patent and that oxygen flow is high. The nurse needs to first ensure that the tubing is patent and that the O2 flow is high. Labored breathing and ultimately suffocation can occur if the reservoir bag on a nonrebreather mask kinks, or if the oxygen source disconnects or is not set to high-flow levels.The chaplain and the family member of record would not be notified until assessment confirms that death is imminent at this time. The RRT team can be called but the client may not want to be intubated, as indicated in the DNR orders. The RRT needs to know the client's wishes when they arrive. Comforting the client must be done but is not the first action by the action.

Which assessment finding in an older client with pneumonia will the nurse report immediately to the primary health care provider? A. Productive cough and normal temperature B. Flushed cheeks and increased respiratory rate C. Hypotension and rapid, weak pulse D. SpO2 of 86% and confusion

C. Hypotension and rapid, weak pulse Hypotension and a rapid, weak pulse are indications of dehydration with possible impending sepsis and shock. This condition all result in poor perfusion and can progress to extreme hypoxemia and death. These symptoms require immediate attention and intervention.The other symptoms are expected with pneumonia and do not represent rapid progression to a more serious problem.

When performing an assessment on an older client, which finding is most important for the nurse to assess further? A. Soft speaking voice B. Slight kyphoscoliosis C. Inability to state name and date of birth D. Need to rest after activity

C. Inability to state name and date of birth The nurse would further assess the client who is unable to state name and date of birth. The older client has a higher risk for hypoxemia than a younger client, and often becomes confused during acute respiratory conditions. The other assessment findings are considered normal age-related conditions in an older client and do not warrant additional investigation.

Which action is most important for a nurse to take to prevent complications for a client with a history of chronic obstructive pulmonary disease (COPD) is admitted for a surgical procedure that is unrelated to the respiratory system? A. Assessing the client's respiratory system every 8 hours B. Instructing the client to use a tissue when coughing or sneezing C. Monitoring for signs and symptoms of pneumonia D. Ensuring the client remains in bed for a full 24 hours after surgery

C. Monitoring for signs and symptoms of pneumonia The client with COPD is always at greater risk for development of a respiratory infection, especially after any surgery requiring anesthesia. The nurse would assess the client's respiratory system at least every 2 hours. The client with COPD alone does not pose an infection risk to others, although everyone is urged to use a tissue to cover the mouth and nose when sneezing or coughing. Remaining in bed is avoided because it promotes atelectasis and pneumonia.

Which assessment has the highest priority for the nurse to make when caring for a client who had a tracheostomy placed yesterday? Which of these assessments is essential for the nurse to make? A. Examining the color and consistency of secretions B. Measuring the cuff pressure C. Observing for tachypnea D. Checking arterial blood gas values

C. Observing for tachypnea It is essential for the nurse to assess the client for tachypnea. Tachypnea can indicate hypoxia.Assessing secretions, checking arterial blood gas values, and measuring cuff pressure are all appropriate interventions, after assessing airway and breathing.

How will the nurse expect a client's age-related decreased skeletal muscle strength to affect gas exchange? A. Reduced gas exchange as a result of decreased alveolar surface B. Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles C. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity D. Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue

C. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.

Which action will the nurse teach an older client with a respiratory problem to make as an accommodation to promote adequate gas exchange? A. Notify your primary health care provider at the first sign of respiratory infection. B. If you must walk any distance in cool weather move quickly to keep warm. C. Replace at least one meal each day with a high-calorie liquid food supplement. D. Avoid any nonessential physical activity or exercise.

C. Replace at least one meal each day with a high-calorie liquid food supplement. A respiratory infection can become serious very quickly in an older client with a pre-existing respiratory problem and must be addressed as early as possible before complications occur.Older clients with respiratory problems are encouraged to perform low-impact exercises, such as walking, daily but should not rush through it. The client is taught to pace the exercise and stop and rest as often as needed. High-calorie liquid food drinks are meant to supplement meals, not replace them.

Which assessment finding is most important for the nurse caring for a client with laryngeal trauma to report immediately to health care provider to prevent harm? A. Productive cough B. Aphonia C. Stridor D. Hoarseness

C. Stridor Stridor, representing airway obstruction is the most critical sign/symptom exhibited by the client with laryngeal trauma and must be addressed immediately.Aphonia (the inability to produce sound) is associated with laryngeal trauma and may be caused by nerve damage, swelling, cartilage fracture, or other events. It does not require immediate action by the nurse. Hoarseness is commonly associated with laryngeal trauma, but does not require immediate attention. A productive cough may or may not be a result of laryngeal trauma and is not considered an emergency situation.

Which actions will the nurse take to reduce risk for aspiration for a client with a tracheostomy? (Select all that apply.) A. Inflating the tracheostomy cuff during meals B. Encouraging water with meals C. Teaching the client to "tuck" the chin down in the forward position to swallow D. Maintaining the client upright for 30 minutes after eating E. Encouraging frequent sipping from a cup F. Providing small, frequent meals

C. Teaching the client to "tuck" the chin down in the forward position to swallow D. Maintaining the client upright for 30 minutes after eating F. Providing small, frequent meals Interventions that must be noted in the client's plan of care include having the client remain upright for at least 30 minutes after eating to reduce the chance of aspiration. Also, making sure that small frequent meals are available for the client. Shorter and more frequent intervals of eating tire the client less and also reduce the chance for aspiration. Teaching the client how to tuck the chin down in the forward position helps to open the upper esophageal sphincter and again reduces the risk of aspiration.Sipping from a cup is contraindicated. Liquids are consumed using a spoon to ensure that the client is attempting to swallow only small volumes of liquid. Controlled small amounts of thickened liquids are given. Thin liquids such as water should be avoided because they are easily aspirated. The tracheostomy cuff needs to be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 50 year old who is 1 day postoperative from abdominal surgery and is receiving 2 L oxygen by nasal cannula. B. A 55 year old was admitted yesterday with pneumonia and is receiving antibiotics and oxygen through a nasal cannula. C. A 45 year old who is being discharged with a new prescription for home oxygen therapy by nasal cannula. D. A 60 year old admitted 2 hours ago who has a 90-pack-year smoking history and is receiving 50% oxygen by Venturi mask.

D. A 60 year old admitted 2 hours ago who has a 90-pack-year smoking history and is receiving 50% oxygen by Venturi mask. There is insufficient data to determine if this client is stable. The client is at risk for oxygen toxicity and must be assessed frequently.The postoperative client is receiving the low oxygen therapy typical for anyone having postoperative therapy who has no other respiratory problems. The client who meets discharge criteria does not require frequent assessment. Although the client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the client wearing the Venturi mask must be assessed first.

What is the most relevant technique for the nurse to use when assessing a client for dyspnea? A. Checking oxygen saturation by pulse oximetry B. Observing the client's rate, depth, and ease of inhalation and exhalation C. Comparing previous respiratory assessment information with current data D. Asking the client about whether any breathlessness is present

D. Asking the client about whether any breathlessness is present Dyspnea, difficulty in breathing or breathlessness, is a subjective perception and varies among clients. Thus, only the client can rate his or her level of dyspnea.The other measures listed for assessment of respiratory status and adequacy of ventilation and oxygenation are objective measures.

What is the nurse's best first action when finding that a client's skin flap created after laryngectomy now appears dusky in color? A. Massaging the flap site gently with the palms rather than the fingers B. Notifying the surgeon or the primary health care provider C. Applying moist heat over the flap site and surrounding tissue D. Assessing blood flow in the flap using a Doppler device

D. Assessing blood flow in the flap using a Doppler device A complete assessment of the area, including Doppler activity of major feeding vessels, needs to be completed before the surgeon is notified.Neither hot nor cold packs nor dressings (nor anything, for that matter) should be applied to the flap site. The site is delicate and should not be massaged.

The nurse is caring for a client who underwent a bronchoscopy performed under moderate sedation an hour ago. Which action will the nurse delegate to an assistive personnel (AP) at this time? A. Determine level of consciousness B. Offer clear liquids to moisten mucous membranes C. Auscultate breath sounds D. Assist with urinal or bedpan use for elimination

D. Assist with urinal or bedpan use for elimination

Which drug will the nurse expect to teach about to a client who has been exposed to inhalation anthrax but does not have symptoms? A. Vancomycin B. Oseltamivir C. Rifampin D. Ciprofloxacin

D. Ciprofloxacin The most recommended drug therapy for prophylaxis after exposure to inhalation anthrax is oral ciprofloxacin. Vancomycin is an intravenous drug used for treatment of actual anthrax infection. Oseltamivir is an antiviral agent, and rifampin is a first-line drug for treatment of tuberculosis.

Which action is most appropriate for the nurse to take first when the water seal chamber of the chest drainage device in a client who had a lobectomy has small bubbles when the client coughs the appropriate action by the nurse? A. Add additional sterile water to the water seal chamber B. Checking the tubing for blood clots C. Briefly increasing the amount of suction D. Documenting the finding in the medical record

D. Documenting the finding in the medical record The nurse recognizes that gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. This indicates air is leaving the pleural space which is the intended purpose of the chest drain.Bubbling in the water seal chamber is absent if a kink or a blockage is present because air would not be able to escape from the chest cavity. Increasing the amount of suction without an order could damage lung tissue. There is no indication that the level of fluid in the water seal chamber is low.

For which side effects of radiation therapy will the nurse prepare the client who has stage II lung cancer? (Select all that apply.) A. Scalp alopecia B. Increased risk for infection C. Increased bruising D. Dry, peeling skin on the chest E. Difficulty swallowing F. Fatigue

D. Dry, peeling skin on the chest E. Difficulty swallowing F. Fatigue Radiation therapy causes most side effects in the tissues within the radiation path. In this case the skin of the chest and the esophagus are likely to be affected, resulting in dry, peeling skin and reduced peristaltic movement of the esophagus, which makes swallowing more difficult. In addition to these local side effects, radiation therapy induces extreme fatigue.The most active blood cell forming bone marrow areas in adults are minimally affected by radiation therapy to the chest. Therefore, white blood cell numbers, red blood cell numbers, and platelet numbers remain normal. The client is not at increased risk for infection or bruising. The client's scalp hair is not in the radiation path and will be unaffected by this therapy.

How will the nurse document the client's respiratory assessment findings on auscultation that are heard as popping, discontinuous, high-pitched sounds at the end of exhalation? A. Coarse crackles B. Rhonchi C. Wheezes D. Fine crackles

D. Fine crackles Fine crackles are heard as popping, discontinuous sounds that are high-pitched heard at the end of inhalation. Squeaky, musical continuous sounds heard when the client inhales and exhales are abnormal (adventitious) and described as wheezes. Coarse crackles are a rattling sound. Rhonchi are heard as low-pitched continuous snoring sounds.

What is the nurse's best first action when the clear fluid draining from the nose of a client with a nasal fracture dries on a piece of filter paper and leaves a yellow "halo" ring at the dried edge of the fluid? A. Culture the sample. B. Elevate the head of the bed to 90 degrees. C. Document the finding as the only action. D. Notify the primary health care provider.

D. Notify the primary health care provider. Clear nasal fluid that dries on a piece of filter paper and results in a yellow "halo" appearing as a ring at the dried edge of the fluid indicates leakage of cerebral spinal fluid. This is a rare and critical complication of a nasal fracture and requires immediate intervention.Elevating the head of the bed to 90 degrees could increase the rate of CSF loss. Culturing the sample is not a priority action at this time.