1620 HESI #6
A client comes into the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response?
1) "Cover your cough with your forearm." 2) "Dispose of used paper tissues in a paper bag." 3) "Encourage your roommate to get the flu vaccine." 4) "Move out your apartment until you are over your cold." ANSWER: 1) "Cover your cough with your forearm." RATIONALE: Covering the cough with your forearm limits the spread of respiratory droplets that may be inhaled by another.
A client with an upper respiratory infection asks the nurse why the healthcare provider did not prescribe an antibiotic. What would be the best response from the nurse?
1) "I don't know. I will ask the healthcare provider for a prescription." 2) "Antibiotics are used to treat viruses and you have a bacterial infection." 3) "Antibiotics are ineffective for treating the bacteria that cause upper respiratory infections." 4) "Upper respiratory infections are generally caused by viruses and therefore should not be treated with antibiotics." ANSWER: 4) "Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics." RATIONALE: Generally, upper respiratory infections are viral, therefore antibiotics should not be used. Overuse of antibiotics results in antibiotic-resistant strains of bacteria. Antibiotics are used to treat bacteria, not viruses.
A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply.
1) Anxiety 2) Oxygenation 3) Drowsiness 4) Mental confusion 5) Increased respirations ANSWER: 2) Oxygenation; 3) Drowsiness; 4) Mental confusion RATIONALE: Clients with chronic obstructive pulmonary disease (COPD) respond to the chemical stimulus of low oxygen levels. Administration of high concentrations of oxygen will decrease the stimulus to breathe, leading to decreased respirations, lethargy, and drowsiness. Oxygenation should be monitored to keep levels within a range to provide adequate oxygen without decreasing the client's drive to breathe. Clients with COPD experience the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia. Increased levels of carbon dioxide depresses the central nervous system, causing mental confusion and a lowered level of consciousness. Rising carbon dioxide levels cause lethargy rather than anxiety.
The nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client's condition?
1) Bacillus anthracis 2) Bordetella pertusis 3) Streptococcus pneumoniae 4) Mycobacterium tuberculosis ANSWER: 2) Bordetella pertussis RATIONALE: This disease is caused by Bordetella pertusis. Pertusis is a respiratory tract infection that begins with the common cold and progresses to whooping cough. The client also develops coughing fits that last for several minutes.
While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)?
1) Barrel chest 2) Cyanosis 3) Hyperventilation 4) Lordosis ANSWER: 1) Barrel chest RATIONALE: Clients with COPD often develop a barrel chest over time because of air being trapped, thus resulting in enlarged lungs and thoracic cavity. This also causes the lungs to have less flexibility.
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD?
1) Cardiac problems 2) Joint inflammation 3) Kidney dysfunction 4) Peripheral neuropathy ANSWER: 1) Cardiac problems RATIONALE: COPD causes increased pressure in the pulmonary circulation. The right side of the heart hypertrophies (cor pulmonale), causing right ventricular heart failure.
A client has been admitted for chronic obstructive pulmonary disease (COPD) exacerbation secondary to an upper respiratory tract infection. The nurse should expect which findings when auscultating the client's breath sounds?
1) Coarse crackles 2) Prolonged inspiration 3) Short, rapid inspiration 4) Normal breath sounds ANSWER: 1) Coarse crackles RATIONALE: Coarse crackles and rhonchi most often are auscultated in COPD clients who have had an exacerbation.
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response?
1) Decrease in red cell formation 2) Rupture of emphysematous bullae 3) Depression in the respiratory center 4) Excessive drying of the respiratory mucosa ANSWER: 3) Depression in the respiratory mucosa RATIONALE: It is believed that clients with COPD should be given low concentrations of oxygen because a decreased oxygen blood level is the stimulus for breathing for these clients. However, the results of a recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen concentrations higher than 2 L/min. More research is needed before this theory is applied clinically.
A nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take?
1) Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula 2) Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. 3) Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. 4) Assist the client in assuming a position of comfort and perform postural drainage. ANSWER: 3) Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. RATIONALE: Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically.
While assessing the medical reports of a client with upper respiratory tract infections, the nurse notices that there are alterations in the platelet count. The client has a history of recent nasal surgery. Which clinical condition does the nurse suspect?
1) Epistaxis 2) Rhinosinusitis 3) Allergic rhinitis 4) Acute pharyngitis ANSWER: 1) Epistaxis RATIONALE: Epistaxis or nosebleeds may alter platelet counts. Epistaxis may be observed in clients with upper respiratory tract infections, overuse of decongestant nasal sprays, or nasal surgery.
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care?
1) The disease process and breathing exercises 2) How to control or prevent respiratory infections 3) Using aerosol therapy, especially nebulizers 4) Priorities in carrying out everyday activities ANSWER: 1) The disease process and breathing exercises RATIONALE: Clients need to understand the disease process and how interventions, such as breathing exercises, can improve ventilation.
A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client?
1) Fatigue related to weight loss secondary to COPD 2) Imbalanced nutrition: less than body requirements, related to fatigue 3) Imbalanced nutrition: less than body requirements, related to COPD 4) Ineffective breathing pattern, related to alveolar hypoventilation ANSWER: 2) Imbalanced nutrition: less than body requirements, related to fatigue RATIONALE: The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss.
A nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula?
1) Has an upper respiratory infection. 2) Has many visitors while sitting in a chair. 3) Has a nasogastric tube for gastric decompression. 4) Has dry oral mucous membranes from mouth breathing. ANSWER: 2) Has many visitors while sitting in a chair. RATIONALE: Clients who receive many visitors while sitting in a chair are more mobile and will benefit from a less restrictive form of oxygen administration. The client will be able to talk without the impediment of a mask.
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings?
1) Hypocapnia 2) Hyperkalemia 3) Generalized anemia 4) Respiratory acidosis ANSWER: 4) Respiratory acidosis RATIONALE: The client is experiencing respiratory acidosis. the pH is less than the norm of 7.35 to 7.45, indicating acidosis. The PO2 is less than the norm of 80 to 100 mm Hg. The PCO2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 21 to 28 mEq/L. These results indicate a respiratory etiology.
The son of a 65 year old client said, "My father is suffering from chronic lung disease. He wakes suddenly from sleep and is unable to breathe." What condition does the nurse suspect in the client?
1) Orthopnea 2) Hemoptysis 3) Histoplasmosis 4) Paroxysmal nocturnal dyspnea ANSWER: 4) Paroxysmal nocturnal dyspnea RATIONALE: The symptoms of paroxysmal nocturnal dyspnea (PND), which include waking up suddenly with an inability to breathe, usually develop after the client has been lying down for several hours. PND often occurs in clients with chronic lung disease.
A client with chronic obstructive pulmonary disease (COPD) reports a 5 pound (2.3 kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain?
1) Polycythemia 2) Cor pulmonale 3) Compensated acidosis 4) Left ventricular failure ANSWER: 2) Cor pulmonale RATIONALE: A sudden weight gain is an initial sign of right ventricular failure caused by COPD.
A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include?
1) Purpose of bronchodilators 2) Importance of meticulous oral hygiene 3) Technique use in pursed-lip breathing 4) Methods used to maintain a dust-free environment ANSWER: 2) Importance of meticulous oral hygiene RATIONALE: Microorganisms in the mouth are transferred easily to the tracheobronchial tree and are a source of potential infection; meticulous oral hygiene is essential to reduce the risk of respiratory infection.
A 50 year old client with a 30 year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature of 36.8 º C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during therapy indicates a positive outcome? Select all that apply.
1) Radial pulse: 70 2) Temperature: 37º C 3) Respiratory rate: 14 4) Blood pressure: 110/70 5) Oxygen saturation: 92% ANSWER: 3) Respiratory rate: 14; 4) Blood pressure: 110/70; 5) Oxygen saturation: 92% RATIONALE: The respiratory rate ranges in older adults from 12 to 20 breaths/min and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high blood pressure. Thus, a blood pressure of 110/70 obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95 to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy.
A 65 year old client is found to have dilation of the bronchioles and alveolar ducts. Which suggestions of the nurse would help the client overcome this situation? Select all that apply.
1) Suggest the use of incentive spirometry. 2) Suggest that the client takes an adequate amount of calcium daily. 3) Suggest that the client perform vigorous pulmonary hygiene activities. 4) Suggest that the client maintain an upright position as much as possible. 5) Suggest that the client talk face to face with others as much as possible. ANSWER: 1) Suggest the use of incentive spirometry; 3) Suggest that the client perform vigorous pulmonary hygiene activities; 4) Suggest that the client maintain an upright position as much as possible. RATIONALE: Dilation of the bronchioles and alveolar ducts is a respiratory system change related to aging. Using incentive spirometry may help clients improve functioning of the lungs. This action may help the client take breaths more easily and more comfortably. performing vigorous pulmonary hygiene activities, such as clearing the mucus or other secretions from the airways, help an older adult prevent respiratory infections or complications. The upright position may help in minimizing the mismatching of ventilation perfusion.
A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client?
1) The client may need up to 60% oxygen flow via Venturi mask. 2) The client requires lower levels of oxygen delivery, usually 1-3 L/min via nasal cannula. 3) The client should receive humidified oxygen delivered by a face mask. 4) The client's respiratory treatment plan should have oxygen eliminated from it. ANSWER: 2) The client requires lower levels of oxygen delivery, usually 1-3 L/min via nasal cannula. RATIONALE: Exogenous oxygen is necessary, but it must be delivered in low concentrations. It is not the method of oxygen delivery that is a concern, but rather the concentration of the oxygen. High oxygen concentrations will increase serum oxygen levels and interfere with the stimulus to breathe, which is a lowered oxygen level.
