Adult Health 3 Practice Questions
A male client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannula. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client's respiratory status. Which complication may arise if the client receives a high oxygen concentration? A-Apnea B-Anginal pain C-Respiratory alkalosis D-Metabolic acidosis
A-Apnea Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don't cause metabolic acidosis.
Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? A-Do nothing, because this is an expected finding B-Immediately clamp the chest tube and notify the physician C-Check for an air leak because the bubbling should be intermittent D-Increase the suction pressure so that the bubbling becomes vigorous
A-Do nothing, because this is an expected finding Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? A-Dyspnea B-Bradypnea C-Bradycardia D-Decreased respirations
A-Dyspnea The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.
Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? A-Hypocapnia B- A hyperinflated chest noted on the chest x-ray C-Increased oxygen saturation with exercise D-A widened diaphragm noted on the chest x-ray
B- A hyperinflated chest noted on the chest x-ray Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
On auscultation, which finding suggests a right pneumothorax? A-Bilateral inspiratory and expiratory crackles B-Absence of breaths sound in the right thorax C-Inspiratory wheezes in the right thorax D-Bilateral pleural friction rub
B-Absence of breaths sound in the right thorax In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first? A-Drawing blood for a hematocrit and hemoglobin level B-Applying a dressing over the wound and taping it on three sides C-Preparing a chest tube insertion tray D-Preparing to start an I.V. line
B-Applying a dressing over the wound and taping it on three sides The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A-Inform the physician B-Continue to monitor the client C-Reinforce the occlusive dressing D-Encourage the client to deep-breathe
B-Continue to monitor the client The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.
An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A-A low respiratory rate B-Diminished breath sounds C-The presence of a barrel chest D-A sucking sound at the site of injury
B-Diminished breath sounds This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen? A-Limiting fluid B-Having the client take deep breaths C-Asking the client to spit into the collection container D-Asking the client to obtain the specimen after eating
B-Having the client take deep breaths To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.
The nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? A-It helps prevent early airway collapse B-It increases inspiratory muscle strength C-It decreases use of accessory breathing muscles D-It prolongs the inspiratory phase of respiration
B-It increases inspiratory muscle strength Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A-Pallor B-Low arterial PaO2 C-Elevated arterial PaO2 D-Decreased respiratory rate
B-Low arterial PaO2 The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.
A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? A-Simple mask B-Non-rebreather mask C-Face tent D-Nasal cannula
B-Non-rebreather mask A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.
Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: A-Call the physician B-Place the tube in bottle of sterile water C-Immediately replace the chest tube system D-Place a sterile dressing over the disconnection site
B-Place the tube in bottle of sterile water If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.
The nurse assesses a male client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing? A-Diaphragmatic breathing B-Use of accessory muscles C-Pursed-lip breathing D-Controlled breathing
B-Use of accessory muscles The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.
An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? A-Face tent B-Venturi mask C-Aerosol mask D-Tracheostomy collar
B-Venturi mask The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: A-Pleural effusion B-Pulmonary edema C-Atelectasis D-Oxygen toxicity
C-Atelectasis In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.
Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noticed in the client, should be reported immediately to the physician? A-Dry cough B-Hermaturia C-Bronchospasm D-Blood-streaked sputum
C-Bronchospasm If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must: A-Monitor fluctuations in the water-seal chamber B-Clamp the chest tube once every shift C-Encourage coughing and deep breathing D-Milk the chest tube every 2 hours
C-Encourage coughing and deep breathing When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? A-Restricting fluid intake to 1,000 ml per day B-Enforcing absolute bed rest C-Teaching the patient how to perform controlled coughing D-Administering prescribe sedatives regularly and in large amounts
C-Teaching the patient how to perform controlled coughing Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patient's ability to maintain a patent airway, causing a high risk for infection from pooled secretions.
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A-The system is functioning normally B-The client has a pneumothorax C-The system has an air leak D-The chest tube is obstructed
C-The system has an air leak Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? A-Encouraging the patient to drink three glasses of fluid daily B-Keeping the patient in semi-fowler's position C-Using a high-flow venturi mask to deliver oxygen as prescribe D-Administering a sedative, as prescribe
C-Using a high-flow venturi mask to deliver oxygen as prescribe The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.
Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: A-Dyspnea B-Chest pain C-A bloody, productive cough D-A cough with the expectoration of mucoid sputum
D-A cough with the expectoration of mucoid sputum One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.
A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient? A-Activity intolerance related to fatigue B-Anxiety related to actual threat to health status C-Risk for infection related to retained secretions D-Impaired gas exchange related to airflow obstruction
D-Impaired gas exchange related to airflow obstruction A patient airway and an adequate breathing pattern are the top priority for any patient, making "impaired gas exchange related to airflow obstruction" the most important nursing diagnosis. The other options also may apply to this patient but less important.
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: A-Exhale slowly B-Stay very still C-Inhale and exhale quickly D-Perform the Valsalva maneuver
D-Perform the Valsalva maneuver When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options A, B, and C are incorrect client instructions.
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: A-Promote oxygen intake B-Strengthen the diaphragm C-Strengthen the intercostal muscles D-Promote carbon dioxide elimination
D-Promote carbon dioxide elimination Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? A-pH, 5.0; PaCO2 30 mm Hg B-pH, 7.40; PaCO2 35 mm Hg C-pH, 7.35; PaCO2 40 mm Hg D-pH, 7.25; PaCO2 50 mm Hg
D-pH, 7.25; PaCO2 50 mm Hg In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B and C represent normal ABG values, reflecting normal gas exchange in the lungs.
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? a. 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg b. 32-year-old with ABG results: pH 7.50, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. 40-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. 64-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
a. 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The other patients also should be assessed as quickly as possible, but do not require interventions as quickly as the 20-year-old.
The nurse is aware that the patient is in respiratory failure when the blood gas findings are a PaO2 of _____ mm Hg and a PaCO2 of _____ mm Hg. a. 46; 52 b. 50; 45 c. 52; 42 d. 55; 58
a. 46; 52 Respiratory failure is defined by blood gases that have a PaO2 level below 50 mm Hg and a PaCO2 level equal to or higher than 50 mm Hg.
The nurse has received a change-of-shift report about the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? a. A patient with a respiratory rate of 38 b. A patient with loud expiratory wheezes c. A patient with jugular vein distention and peripheral edema d. A patient who has a cough productive of thick, green mucus
a. A patient with a respiratory rate of 38 A respiratory rate of 38 indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic patient.
Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? a. Pulse oximetry reading of 91% b. Absence of wheezes or crackles c. Decreased use of accessory muscles d. Respiratory rate of 22 breaths/minute
a. Pulse oximetry reading of 91% For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%
a. Weak, nonproductive cough effort The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. The nurse will plan to a. carry out the procedure 3 hours after the patient eats. b. maintain the patient in the lateral position for 20 minutes. c. perform percussion before assisting the patient to the drainage position. d. give the ordered albuterol (Proventil) after the patient has received the therapy.
a. carry out the procedure 3 hours after the patient eats. Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 minutes. Percussion is done while the patient is in the postural drainage position. Bronchodilators are administered before chest physiotherapy.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurses first action should be to a. elevate the head of the bed to 45 to 60 degrees. b. administer the ordered pain medication. c. notify the patients health care provider. d. offer emotional support and reassurance.
a. elevate the head of the bed to 45 to 60 degrees. The patient has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started).
The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 mL of blood in the collection chamber. c. complaint of pain with each deep inspiration. d. subcutaneous emphysema at the insertion site.
b. 400 mL of blood in the collection chamber. The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax.
After the nurse has completed diet teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a body mass index (BMI) of 20, which patient statement indicates that the teaching has been effective? a. I will drink lots of fluids with my meals. b. I will have ice cream as a snack every day. c. I will exercise for 15 minutes before meals. d. I will decrease my intake of meat or poultry.
b. I will have ice cream as a snack every day. High-calorie foods like ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD.
A patient with a chronic cough has a bronchoscopy. Which action will be included in the nursing care plan after the procedure? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours postbronchoscopy. d. Notify the health care provider about blood-tinged mucus.
b. Keep the patient NPO until the gag reflex returns. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowlers position.
After the nurse has finished teaching a patient about pursed lip breathing, which patient action indicates that more teaching is needed? a. The patient inhales slowly through the nose. b. The patient puffs up the cheeks while exhaling. c. The patient practices by blowing through a straw. d. The patients ratio of inhalation to exhalation is 1:3.
b. The patient puffs up the cheeks while exhaling. The patient should relax the facial muscles without puffing the cheeks while doing pursed lip breathing. The other actions by the patient indicate a good understanding of pursed lip breathing.
When teaching the patient with chronic obstructive pulmonary disease (COPD) about exercise, which information should the nurse include? a. Stop exercising if you start to feel short of breath. b. Use the bronchodilator before you start to exercise. c. Breathe in and out through the mouth while you exercise. d. Upper body exercise should be avoided to prevent dyspnea.
b. Use the bronchodilator before you start to exercise. Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.
A patient with emphysema enters the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26. After positioning the patient in high Fowlers, the nurse should: a. attempt to help the patient slow her respirations. b. coach in pursed-lip breathing. c. give oxygen at 5 L/min by nasal cannula. d. reposition patient in orthopneic position.
b. coach in pursed-lip breathing. Coaching in pursed-lip breathing will open the respiratory tree with negative pressure. Oxygen given at such a high concentration will cause an emphysemic patient to stop breathing. High Fowlers position is beneficial and easy to position with minimal equipment.
When a hospitalized patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen, the best action by the nurse is to a. minimize oxygen use to avoid oxygen dependency. b. maintain the pulse oximetry level at 90% or greater. c. administer oxygen according to the patients level of dyspnea. d. avoid administration of oxygen at a rate of more than 2 L/min.
b. maintain the pulse oximetry level at 90% or greater. The best way to determine the appropriate oxygen flow rate is by monitoring the patients oxygenation either by arterial blood gases (ABGs) or pulse oximetry; an oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an oxygen flow rate of 2 L/min may not be adequate. Because oxygen use improves survival rate in patients with COPD, there is not a concern about oxygen dependency. The patients perceived dyspnea level may be affected by other factors (such as anxiety) besides blood oxygen level.
After having the postoperative patient deep-breathe and cough, the nurse should offer: a. a warm drink. b. mouth care. c. oxygen by mask. d. an iced drink.
b. mouth care. Mouth care should be offered after deep breathing and coughing to clear the mouth of unpleasant taste.
When developing a teaching plan to help increase activity tolerance at home for a 70-year-old with severe chronic obstructive pulmonary disease (COPD), the nurse should teach the patient that an appropriate exercise goal is to a. walk until pulse rate exceeds 130. b. walk for a total of 20 minutes daily. c. exercise until shortness of breath occurs. d. limit exercise to activities of daily living (ADLs).
b. walk for a total of 20 minutes daily. The goal for exercise programs for patients with COPD is to increase exercise time gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patients exercise tolerance. A 70-year-old patient should have a pulse rate of 120 or less with exercise (80% of the maximal heart rate of 150).
While caring for a patient with respiratory disease, the nurse observes that the patients SpO2drops from 92% to 88% while the patient is ambulating in the hallway. Which action should the nurse take next? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.
c. Administer the PRN supplemental O2. The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions also are appropriate, but the first action should be to correct the hypoxemia.
A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing action will be most effective? a. Change the oxygen flow rate to the highest prescribed rate. b. Reinforce the ongoing use of pursed lip breathing techniques. c. Educate the patient to use the Flutter airway clearance device. d. Teach the patient about consistent use of inhaled corticosteroids.
c. Educate the patient to use the Flutter airway clearance device. Airway clearance devices assist with moving mucus into larger airways where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not indicated for this patients problem of thick mucous secretions.
Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? a. I will call the doctor if I still feel tired after a week. b. I will need to use home oxygen therapy for 3 months. c. I will continue to do the deep breathing and coughing exercises at home. d. I will schedule two appointments for the pneumonia and influenza vaccines.
c. I will continue to do the deep breathing and coughing exercises at home. Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time.
To evaluate the effectiveness of therapy for a patient with cor pulmonale, the nurse will monitor the patient for a. elevated temperature. b. clubbing of the fingers. c. jugular vein distention. d. complaints of chest pain.
c. jugular vein distention. Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular vein distention. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease (COPD) but are not indicators of cor pulmonale.
Which information will the nurse include in teaching a patient with chronic obstructive pulmonary disease (COPD) who has a new prescription for home oxygen therapy? a. Storage of oxygen tanks will require adequate space in the home. b. Travel opportunities will be limited because of the use of oxygen. c. Oxygen flow should be increased if the patient has more dyspnea. d. Oxygen use can improve the patients prognosis and quality of life.
d. Oxygen use can improve the patients prognosis and quality of life. Research supports the use of home oxygen to improve quality of life and prognosis. Since increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the physician rather than increasing the oxygen flow rate if dyspnea becomes worse. Oxygen can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible by using portable oxygen concentrators.
To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make? a. Lung sounds b. Heart sounds c. Blood pressure d. Peripheral edema
d. Peripheral edema Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distention, and right upper-quadrant abdominal tenderness would be expected. Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor pulmonale.
Which action will the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)? a. Explain reasons for NPO status. b. Administer sedative drug before PFT. c. Assess pulse and BP after the procedure. d. Teach deep inhalation and forceful exhalation.
d. Teach deep inhalation and forceful exhalation. For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT.
A patient with chronic bronchitis has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? a. Titrate oxygen to keep saturation at least 90%. b. Discuss a high-protein, high-calorie diet with the patient. c. Suggest the use of over-the-counter sedative medications. d. Teach the patient how to effectively use pursed lip breathing.
d. Teach the patient how to effectively use pursed lip breathing. Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires oxygen therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.
When the nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD), which information will help most in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patients history indicates a 40 pack-year cigarette history. c. The patient denies having any respiratory problems until the last 6 months. d. The patient complains about a productive cough every winter for 3 months.
d. The patient complains about a productive cough every winter for 3 months. A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.
Which information about a newly admitted patient with chronic obstructive pulmonary disease (COPD) indicates that the nurse should consult with the health care provider before administering the prescribed theophylline? a. The patient has had a recent 10-pound weight gain. b. The patient has a cough productive of green mucus. c. The patient denies any shortness of breath at present. d. The patient takes cimetidine (Tagamet) 150 mg daily.
d. The patient takes cimetidine (Tagamet) 150 mg daily. Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline toxicity. The other patient information would not impact on whether the theophylline should be administered or not.
The nurse cautions each person prior to giving the influenza immunization that they should not take it if they are allergic to: a. strawberries. b. ragweed. c. penicillin. d. eggs.
d. eggs. The influenza vaccine is cultured in chicken embryos, making anyone allergic to eggs probably allergic to the immunization.
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 a. emergency pericardiocentesis. b. stabilization of the chest wall with tape. c. administration of an inhaled bronchodilator. d. insertion of a chest tube with a chest drainage system.
d. insertion of a chest tube with a chest drainage system. The patients 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 patients clinical manifestations are not consistent with these problems.
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. An appropriate intervention for this problem is to a. increase the patients intake of fruits and fruit juices. b. have the patient exercise for 10 minutes before meals. c. assist the patient in choosing foods with a lot of texture. d. offer high calorie snacks between meals and at bedtime.
d. offer high calorie snacks between meals and at bedtime. Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice.
A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for a a. positron emission tomography (PET) scan. b. chest x-ray. c. bronchoscopy. d. spiral computed tomography (CT) scan.
d. spiral computed tomography (CT) scan. Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy is used to inspect for changes in the bronchial tree, not to assess for vascular changes. PET scans are most useful in determining the presence of malignancy.
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the surgeon of a possible pneumothorax. d. take no further action with the collection device.
d. take no further action with the collection device. Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.
When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to a. avoid eating or drinking for several hours before the testing. b. use rescue medications immediately before the tests are done. c. take oral corticosteroids at least 2 hours before the examination. d. withhold bronchodilators for 6 to 12 hours before the examination.
d. withhold bronchodilators for 6 to 12 hours before the examination. Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids also should be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.