Adult Health 1 Practice Test

The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?

"I can use my nasal decongestant spray until the congestion is all gone." The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful?

"I will keep my head elevated for 48 hours to minimize swelling and pain." Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery.

Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis?

"Your urine, sweat, and tears will be orange colored." Orange-colored body secretions are a side effect of rifampin. The other adverse effects are associated with other antituberculosis medications.

Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?

A 23-year-old who is complaining of a sore throat and has a muffled voice The patient's clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.

The nursing assistant reports to the nurse that an African-American client's pulse oximetry reading is 93%. The client has no complaints. Which action by the nurse is most appropriate?

Assess other signs of respiratory adequacy. Normal pulse oximetry readings are 95% to 100%. However, people with dark skin can have readings that are 3% to 5% lower owing to the darker coloration of the nail bed. The nurse should assess other signs of respiratory adequacy because this may be a normal finding for this client.

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Attempt to reinsert the tracheostomy tube with the obturator in place. The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.

The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?

Client has reduced breath sounds; nurse calls physician immediately. A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?

Elevate the head of the bed 30 to 45 degrees. Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)?

Increased anteroposterior chest diameter. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.

A client is prescribed metaproterenol (Alupent) via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverse effects of metaproterenol?

Irregular heartbeats should be reported promptly to the care provider. Metaproterenol (Alupent) may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?

Keep the patient in semi-Fowler's position. The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.

A client tells the nurse that he usually expectorates about 2 ounces of thin, clear, colorless sputum each day, mostly in the morning after getting out of bed. What is the nurse's initial action after gaining this information?

Monitor for an increase in sputum production or a change in color. Sputum production is a normal function of the respiratory tract. Most healthy people produce about 90 mL of sputum/day. This sputum should be thin, clear, and odorless, and should have minimal or no color. The nurse's only action should be to monitor the client for an increase in sputum production or a change in color. It will not be necessary at this time to obtain a specimen for analysis or to prepare for a bronchoscopy.

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?

Put on sterile gloves and use a sterile catheter to suction. Rationale: This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

A client with bacterial pneumonia is to be started on I.V. antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins?

Sputum culture. A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Neither a urinalysis, a chest radiograph, nor a red blood cell count needs to be obtained before initiation of antibiotic therapy for pneumonia.

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy?

Suction the tracheostomy when needed. Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN.

A client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse?

Tachycardia: An increased heart rate may indicate that the client is developing a pneumothorax or hypoxia. Although it is important to note immediately whether the client is experiencing a decreased level of consciousness, increased temperature, or a slowed respiratory rate, none of these is as indicative of a life-threatening complication as tachycardia.

10. A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; Pco2 48; Po2 58; HCO3 26. Which of the following orders should the nurse perform first?

The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.

Which action should the nurse take first when a patient develops a nosebleed?

The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area somewhat, but will not be sufficient to stop bleeding. Cauterization or nasal packing may be needed if pressure to the nares does not stop bleeding, but these are not the first actions to take for nosebleed.

Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions?

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

The nurse is caring for several clients on a respiratory unit. Which client does the nurse see first?

Young adult with an arterial oxygen level of 85% The young adult with an impaired arterial oxygen level should be seen first. A level of 90% to 100% is a normal level for this age-group. The older adult with a pulse oxygen of 96% is within normal limits, as is an adult with a pulse oxygen of 94%. An arterial oxygen level of 94% would also be seen as normal.

The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB

covers the mouth and nose when coughing Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB

When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for

insertion of a chest tube with a chest drainage system. The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems