Ch. 31,33,35

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The nurse is assessing a patient who was extubated several hours ago. Which patient finding warrants notification of the Rapid Response Team?

c. inability to expectorate secretions

Chapter 30

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16. A patient who has well-controlled asthma has what kind of airway changes? A. Chronic, leading to hyperplasia B. Temporary and reversible C. Open alveoli D. Permanent and irreversible

14. The nurse is teaching the patient and family about care of a peritonsillar abscess at home. For what symptoms does the nurse indicate the need for the patient to go to the emergency department (ED) immediately? (Select all that apply.) A. Persistent cough B. Hoarseness C. Stridor D. Drooling E. Nausea and vomiting

C, D

11. An older adult patient experiences an asthma attack that is severe enough to warrant the use of a rescue drug. Which medication is best to use for the acute symptoms? A. Omalizumab (Xolair) B. Fluticasone (Flovent) C. Salmeterol (Severent) D. Albuterol (Proventil)

56. After several weeks of "not feeling well," a patient is seen in the provider's office for possible TB. If TB is present, which assessment findings does the nurse expect to observe? (Select all that apply.) A. Fatigue B. Weight gain C. Night sweats D. Chest soreness E. Low-grade fever

A, C, E

The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases.

55. Which sites are commonly affected by lung cancer metastasis? (Select all that apply.) A. Heart B. Bone C. Liver D. Colon E. Brain

B, C, E

1. An adult patient diagnosed with rhinitis medicamentosa reports chronic nasal congestion. What does the nurse instruct the patient to do? A. Avoid exposure to older adults or immunosuppressed persons when symptoms flare. B. Damp-dust the house and clean the carpets to remove animal dander or mold. C. Discontinue the use of the current nose drops or sprays. D. Identify what triggers the hypersensitivity reaction by keeping a symptom diary.

50. A patient with CF is admitted to the medical-surgical unit for an elective surgery. Which infection control measure is best for this patient? A. It is best to put two patients with CF in the same room. B. Standard precautions including handwashing are sufficient. C. The patient is to be placed on contact isolation. D. Measures that limit close contact between people with CF are needed.

A patient is intubated and has mechanical ventilation with positive end-expiratory pressure (PEEP). Because this patient is at risk for a tension pneumothorax, what is the nurse's priority action?

a. Assess lung sounds every 30 to 60 minutes.

Which conditions are related to acute respiratory distress syndrome (ARDS)?

a. Lung fluid increases. b. A systemic inflammatory response occurs. d. Lung volume is dereased. e. Hypoxemia results.

Which patients on mechanical ventilators are at high risk for barotraumas? (SELECT ALL THAT APPLY)

a. Patient with ARDS b. Patient with undrelying chronic airflow limitation d. PATIENT on PEEP

The nurse is caring for several post-op patients at risk for developing PE. Which interventions does the nurse use to help prevent the development of PE in these patients? (select all that apply.)

a. Start passive and active ROM exercises b. ambulate post-op patients soon after surgery c. use antiembolism devices postoperatively. f. Administer drugs to prevent episodes of Valsalva maneuver.

13.A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/mm3 d. White blood cell (WBC) count: 12,500/mm3

b. Alanine aminotransferase (ALT): 180 U/L

The nurse is reviewing the ABG results for a patient. The latest ABGs show pH 7.48, HCO3- 23 mEq/L, Paco2 25 mm Hg, Pao2 98 mmHg. What is the correct interpretation of these lab findings?

b. Acute respiratory alkalosis w/ hyperventilation

What does the nurse monitor for in a patient with a PE? (Select all that apply.)

b. Cyanosis c. Rapid heart rate (tachycardia) d. Dyspnea f. Crackles in the lung fields

A patient with which condition is a potential candidate for autotransfusion, should the need arise?

b. Hemothorax

What are the characteristics of a mechanical ventilator that is pressure-cycled? 9SELECT ALL THAT APPLY)

b. It is a positive-pressure ventilator. c. It pushes air into the lungs until a present airway pressure is reached e. Tidal volumes (TV's) and inspiratory times are varied

A patient is admitted after a near-drowning and develops ARDS, which is confirmed by the provider. The nurse prepares equipment for which treatment?

b. Mechanical ventilation and ET

20.A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: What action by the nurse takes priority? a. Assess the client for possible items to which he or she is allergic. b. Call the primary care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.

c. Immediately place the client on Airborne Precautions.

10.A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

c. Provide oral care every 4 hours.

Which statement about a micropressure ventilator is true?

d. A computer monitors ventilatory functions, alarms, and patient condition

A patient who is on a mechanical ventilator needs a set volume and set rate delivered because the patient is not able to do the work of breathing. To what mode must the ventilator be set?

d. AC

12. A child is diagnosed with a group B streptococcus throat infection. In teaching the parents about treatment of the infection, what does the nurse instruct the parents? A. Need to complete entire course of penicillin or penicillin-like antibiotics B. Gradual return to activities until there are no physical complaints C. Purpose of a clear liquid diet until infection subsides D. Signs and symptoms of meningitis, which is a common complication

21. A patient with a history of frequent and recurrent episodes of tonsillitis now reports a severe sore throat with pain that radiates behind the ear and difficulty swallowing. The nurse suspects the patient may have a periotonsillar abscess. On physical assessment, which deviated structure supports the nurse's supposition? A. Uvula B. Trachea C. Tongue D. Mucous membranes

31. A patient is diagnosed with pneumonia. During auscultation of the lower lung fields, the nurse hears coarse crackles and identifies the patient problem of impaired oxygenation. What is the underlying physiologic condition associated with the patient's condition? A. Hypoxemia B. Hyperemia C. Hypocapnia D. Hypercapnia

33. A patient with COPD has meal-related dyspnea. To address this issue, which drug does the nurse offer the patient 30 minutes before the meal? A. Albuterol (Ventolin) B. Guaifenesin (Organidin) C. Fluticasone (Flovent) D. Pantoprazole sodium (Protonix)

15. A patient is experiencing an asthma attack and shows an increased respiratory effort. Which arterial blood gas value is more associated with the early phase of the attack? A. PaCO2 of 60 mmHg B. PaCO2 of 30 mmHg C. pH of 7.40 D. PaCO2 of 98 mmHg

17. A patient who had sinus surgery has a surgical incision under the upper lip. The nurse intervenes when a well-intentioned family member performs which action in attempting to make the patient feel better? A. Uses the bed controls to move the patient to a semi-Fowler's position B. Hands the patient a tissue to blow the nose C. Brings the patient a special custard dessert from a nearby restaurant D. Gently helps the patient with oral hygiene during morning care

68. A patient is diagnosed with cor pulmonale secondary to pulmonary hypertension and is receiving an infusion of epoprostenol (Flolan) through a small portable IV pump. What is the critical priority for this patient? A. Strict aseptic technique must be used to prevent sepsis. B. Infusion must not be interrupted, even for a few minutes. C. The patient must have a daily dose of warfarin (Coumadin). D. The patient must be assessed for angina like chest pain and fatigue.

70. The nurse is making home visits to an older adult recovering from a hip fracture and identifies the priority patient problem of risk for respiratory infection. Which condition represents a factor of normal aging that would contribute to this increased risk? A. Inability to force a cough B. Decreased strength of respiratory muscles C. Increased elastic recoil of alveoli D. Increased macrophages in alveoli

10. A patient reporting a "sore throat" also has a temperature of 101.4 F, scarlatiniform rash, and a positive rapid test throat culture. This patient will most likely be treated for which type of bacterial infection? A. Staphylococus B. Penumococcus C. Streptococcus D. Epstein-Barr virus

15. A 35-year-old male patient with no health problems states that he had a flu shot last year and asks if it is necessary to have it again this year. What is the best response by the nurse? A. "No, because once you get a flu shot, it lasts for several years and is effective against many different viruses." B. "Yes, because the immunity against the virus wears off, increasing your chances of getting the flu." C. "Yes, because the vaccine guards against a specific virus and reduces your chances of acquiring flu and is only effective for one year." D. "No, flu shots are only for high-risk patients and you are not considered to be high risk."

18. The nurse is teaching a patient how to interpret peak expiratory flow readings and use this information to manage drug therapy at home. Which statement by the patient indicates a need for additional teaching? A. "If the reading is in the green zone, there is no need to increase the drug therapy." B. "Red is 50% below my 'personal best'; I should try a rescue drug and seek help." C. "If the reading is in the yellow zone, I should increase my use of my inhalers." D. "If frequent yellow readings occur, I should see my provider for a change in medications."

19. A patient with chronic bronchitis often shows signs of hypoxia. Which clinical manifestation is the priority to look out for in this patient? A. Chronic, nonproductive, dry cough B. Clubbing of fingers C. Large amounts of thick mucus D. Barrel chest

41. A family member of a patient with COPD asks the nurse, "What is the purpose of making him cough on a routine basis?" What is the nurse's best response? A. "We have to check the color and consistency of his sputum." B. "We don't want him to feel embarrassed when coughing in public, so we actively encourage it." C. "It improves air exchange by increasing airflow in the larger airways." D. "If he cannot cough, the provider may elect to do a tracheostomy."

42. An older adult patient asks the nurse how often one should receive the pneumococcal vaccine for pneumonia prevention. What is the nurse's best response? A. Every year when the patient is receiving the 'flu shot.' B. The standard vaccination every 3 years. C. It is usually given once, but some older adults may need a second vaccination after 5 years. D. There is no set schedule; it depends on the patient's history and risk factors.

52. A patient reports experiencing mild fatigue and a dry, harsh cough. There is a possibility of exposure to inhalation anthrax, but the patient currently reports feeling much better. What does the nurse advise the patient to do? A. Have a complete blood count to rule out the disease. B. Monitor for and immediately seek attention for respiratory symptoms. C. Consult a provider for diagnostic testing and antibiotic therapy. D. Stay at home, rest, increase fluid intake, and avoid public places.

52. The nurse is caring for a patient with bronchiolitis obliterans organizing pneumonia (BOOP) that has been confirmed by biopsy. What treatment does the nurse expect for this patient? A. A course of 10 to 14 days of antibiotics B. Use of chest physiotherapy to mobilize secretions C. A short course of corticosteroid drug therapy D. Bronchodilation by MDI

68. After being discharged from the hospital, a patient is diagnosed with TB at the outpatient clinic. What is the correct procedure regarding public health policy in this case? A. Contact the infection control nurse at the hospital because the hospital is responsible for follow-up of this case. B. There are no regulations because the patient was diagnosed at the clinic and not during hospitalization. C. Contact the public health nurse so that all individuals who have come in contact with the patient can be screened. D. Have the patient sign a waiver regarding the hospital and clinic's liability for treatment.

73. A patient presents to the walk-in clinic with extremely labored breathing and a history of asthma that is unresponsive to prescribed inhalers or medications. What is the priority nursing action? A. Establish IV access to give emergency medications. B. Obtain the equipment and prepare the patient for intubation. C. Place the patient in a high Fowler's position, and start oxygen. D. Call 911 and report that the patient has probable status asthmaticus.

39. A patient is admitted to the hospital to rule out pneumonia. Which infection control technique does the nurse maintain? A. Strict respiratory isolation and use of a specially designed face mask B. Respiratory isolation and contact isolation for sputum C. Respiratory isolation with a stock surgical mask D. Standard precautions and no respiratory isolation

58. After receiving the subcutaneous Mantoux skin test, a patient with no risk factors returns to the clinic in the required 48 to 72 hours for the test results. Which assessment finding indicates a positive result? A. Test area is red, warm, and tender to touch B. Induration or a hard nodule of any size at the site C. Induration/hardened area measure 5 mm or greater D. Induration/hardened area measure 10 mm or greater

58. The nurse is taking a report on a patient who had a pneumonectomy 4 days ago. Which question is the best to ask during the shift report? A. "Does the provider want us to continue encouraging use of the spirometer?" B. "How much drainage did you see in the Pleur-Evac during your shift?" C. "Do we have to request to 'milk' the patient's chest tube? D. "Does the surgeon want the patient placed on the nonoperative side?"

60. A patient has been compliant with drug therapy for TB and has returned as instructed for follow-up. Which result indicates that the patient is no longer infectious/communicable? A. Negative chest x-ray B. No clinical symptoms C. Negative skin test D. Three negative sputum cultures

60. Upon observation of a chest tube setup, the nurse reports to the provider that there is a leak in the chest tube and system. How has the nurse identified this problem? A. Drainage in the collection chamber has decreased. B. The bubbling in the suction chamber has suddenly increased. C. Fluctuation in the water seal chamber has stopped. D. There was onset of continuous vigorous bubbling in the water seal chamber.

61. A patient diagnosed with TB agrees to take the medication as instructed and to complete the therapy. When does the nurse tell the patient is the best time to take the medication? A. Before breakfast B. After breakfast C. Midday D. Bedtime

67. Which intervention promotes comfort in dyspnea management for a patient with lung cancer? A. Administer morphine only when the patient requests it. B. Place the patient in a supine position with a pillow under the knees and legs C. Encourage coughing and deep-breathing and independent ambulation. D. Provide supplemental oxygen via cannula or mask.

The nurse is caring for the client with congestive heart failure (CHF) in the coronary care unit (CCU). The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? a. Determines the client's physical limitations b. Encourages alternate rest and activity periods c. Monitors and documents heart rate, rhythm, and pulses d. Positions the client to alleviate dyspnea

D: Positioning the client to alleviate dyspnea will help ease air hunger and anxiety. Determining the client's physical limitations and encouraging alternate rest and activity periods are not priorities in this situation. Monitoring of heart rate, rhythm, and pulses is important but is not the priority for this client.

The nurse is reviewing lab results for a patient with a new-onset PE. What is the INR therapeutic range?

2.0-3.0

16. An active 45-year-old school teacher with chronic obstructive pulmonary disease (COPD) taking prednisone asks if it is necessary to get a flu shot. What is the best response by the nurse? A. "Yes, flu shots are highly recommended for patients with chronic illness and/or patients who are receiving immunotherapy." B. "No, flu shots are only recommended for patients 50 years old and older." C. "Yes, it will help minimize the risk of triggering an exacerbation of COPD." D. "No, patients who are active, not living in a nursing home, and not health care providers do not need a flu shot."

29. Patients with asthma are taught self-care activities and treatment modalities according to the "step method." Which symptoms and medication routines relate to step 3? A. Symptoms occur daily; daily use of inhaled corticosteroid, add a long-acting beta agonist. B. Symptoms occur more than once per week; daily use of antiiflammatory inhaler. C. Symptoms occur less than once per week; use of rescue inhalers once per week. D. Frequent exacerbations occur with limited physical activity; increased use of rescue inhalers.

33. A patient is admitted to the hospital with pneumonia. What does the nurse expect the chest x-ray results to reveal? A. Patchy areas of increased density B. Tension pneumothorax C. Thick secretions causing airway obstruction D. Large hyper inflated airways

47. The patient with COPD is undergoing pulmonary rehabilitation by walking. What does the nurse teach this patient about when to increase his or her walking time? A. "You should increase your walking time when your rest periods decrease." B. "You should increase your walking time when your heart rate remains less than 80/minute." C. "You should increase your walking time when you are no longer short of breath." D. "You should increase your walking time when you do not need to use an inhaler."

59. The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient? A. The patient is encouraged to cough and do deep-breathing exercises frequently. B. "Stripping" of the chest tubes is done routinely to prevent obstruction by blood clots. C. Water level in the suction chamber need not be monitored, just the collection chamber. D. Drainage containers are positioned upright or on the bed next to the patient.

24. The nurse is giving discharge instructions to an adult patient diagnosed with the flu. The patient says, "I am generally pretty healthy, but I am concerned because my wife has several chronic health problems. What can I do to protect her from getting my flu?" What does the nurse instruct the patient to do? (Select all that apply.) A. Wash hands thoroughly after sneezing, coughing, or blowing nose. B. Avoid kissing, hugging, close face-to-face proximity, or hand-holding. C. If there is no tissue immediately available, cough or sneeze into your upper sleeve. D. Have the wife wear a respiratory filter mask until coughing stops. E. Use disposable tissues rather than cloth handkerchiefs, and immediately dispose of tissues.

A, B, C, E

65. The patient is receiving isoniazid (INH) to treat TB. Which nursing teaching points are essential when giving this drug? (Select all that apply.) A. Teach the patient not to take medications such as Maalox with this medication. B. Avoid drinking alcoholic beverages. C. Teach the patient that urine will be orange in color. D. Take a multivitamin with B complex. E. If going out in the sun, be sure to wear protective clothing and sunscreen. F. Teach women that this drug reduces the effectiveness of oral contraceptives.

A, B, D

34. The patient with COPD is taking systemic theophylline. What specific precautions must the nurse use when caring for this patient? (Select all that apply.) A. Monitor serum theophylline levels. B. Alert the healthcare provider for any abnormal values. C. Administer the drug using a metered-dose inhaler (MDI). D. Assess the patient for adverse reactions related to a toxic level. E. Monitor the patient's heart rate.

A, B, D, E

47. Which conditions may cause patients to be at risk for aspiration pneumonia? (Select all that apply.) A. Continuous tube feedings B. Bronchoscopy procedure C. Magnetic resonance imaging (MRI) procedure D. Decreased level of consciousness E. Stroke F. Chest tube

A, B, D, E

48. An older adult patient often coughs and chokes while eating or trying to take medication. The patient insists that he is okay, but the nurse identifies the priority patient problem of risk for aspiration. Which nursing interventions are used to prevent aspiration pneumonia? (Select all that apply.) A. Head of bed should always be elevated during feeding. B. Monitor the patient's ability to swallow small bites. C. Give thin liquids to drink in small, frequent amounts. D. Consult a nutritionist and obtain swallowing studies E. Monitor the patient's ability to swallow saliva. F. Place the patient on NPO (nothing by mouth) status until swallowing is normal.

A, B, D, E

6. A patient with chronic obstructive pulmonary disease (COPD) is likely to have which findings on assessment? (Select all that apply.) A. Increased anteroposterior (AP) diameter of the chest B. Sitting in a chair leaning forward with elbows on knees C. Unintentional weight gain D. Decreased appetite E. Unexplained weight loss

A, B, D, E

2. Which are characteristics of asthma? (Select all that apply.) A. Narrowed airway lumen due to inflammation B. Increased eosinophils C. Decreased breathing cycle D. Intermittent bronchospasm E. Loss of elastic recoil F. Stimulation of disease process by allergies

A, B, D, F

The nurse is caring for a client with heart failure. For which symptoms should the nurse assess? Select all that apply. a. Chest discomfort or pain b. Tachycardia c. Expectorates thick, yellow sputum d. Sleeps on back without a pillow e. Shortness of breath with exertion

A, B, E: Decreased tissue perfusion may cause chest pain or discomfort. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Dyspnea results as pulmonary venous congestion ensues. C - Incorrect: Thick, yellow sputum is indicative of infection; clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. D - Incorrect: Orthopnea, the inability to lie flat, occurs in clients with heart failure.

31. In assisting a patient with chronic airflow limitation to relive dyspnea, which sitting positions are beneficial to the patient for breathing? (Select all that apply.) A. On edge of chair, leaning forward with arms folded and resting on a small table B. In a low semi-reclining position with the shoulders back and knees apart C. Forward in a chair with feet spread apart and elbows placed on the knees D. Head slightly flexed, with feet spread apart and shoulders relaxed E. Low semi-Fowler's position with knees elevated

A, C, D

3. Drug therapy with first-generation antihistamines to treat sinusitis is used with caution in the older adult because of which possible side effects? (Select all that apply.) A. Reduced clearance B. Hypotension C. Confusion D. Dry mouth E. Constipation

A, C, D, E

49. The nurse is caring for a patient who has CF. Which assessment findings indicate the need for exacerbation therapy? (Select all that apply.) A. New-onset crackles B. Increased activity tolerance C. Increased frequency of coughing D. Increased chest congestion E. Increased SaO2 F. At least a 10% decrease in FEV1

A, C, D, F

5. To reduce the spread of colds, which teaching points must the nurse include when teaching patients? (Select all that apply.) A. Stay home from work, school, or other places where people gather. B. Seek medical attention at the first sign of an oncoming cold. C. Cover both mouth and nose when coughing or sneezing. D. Always dispose of used tissues properly. E. Thorough handwashing is essential.

A, C, E

55. Which people are at greatest risk for developing TB in the United States? (Select all that apply.) A. An alcoholic homeless man who occasionally stays in a shelter. B. A college student sharing a room in a dormitory C. A person with immune dysfunction or HIV D. A homemaker who does volunteer work at a homeless shelter E. Foreign immigrants (especially those from the Philippines and Mexico)

A, C, E

56. Which of the following may be warnings signs of lung cancer? (Select all that apply.) A. Dyspnea B. Dark yellow-colored sputum C. Persistent cough or change in cough D. Abdominal pain and frequent stools E. Recurring episodes of pleural effusion

A, C, E

71. The nurse is providing discharge instructions to a patient with pulmonary fibrosis and the family. What instructions are appropriate for this patient's diagnosis? (Select all that apply.) A. Using home oxygen B. Maintaining activity level as before C. Preventing respiratory infections D. Limiting fluid intake E. Energy conservation measures

A, C, E

10. A patient with asthma is repeatedly not compliant with the medication regimen, which has resulted in the patient being hospitalized for a severe asthma attack. Which interventions does the nurse suggest to help the patient manage asthma on a daily basis? (Select all that apply.) A. Encourage active participation in the plan of care. B. Help the patient develop a flexible plan of care. C. have the pharmacist establish a plan of care. D. Teach the patient about asthma and its treatment plan. E. Assess symptom severity using a peak flowmeter 1 to 2 times per week.

A, D

1. Which of the following are characteristics of pulmonary emphysema? (Select all that apply.) A. Decreased surface area of alveoli B. Chronic thickening of bronchial walls C. Decreased respiratory rate D. Hypercapnia E. Arterial blood gases (ABGs) show chronic respiratory acidosis F. Increased eosinophils

A, D, E

17. What are the goals of drug therapy in the treatment of asthma? (Select all that apply.) A. Drugs are used to reduce the asthma response. B. Weekly drugs are used to reduce the asthma response. C. Combination drugs are avoided in the treatment of asthma. D. Some patients only require drug therapy during an asthma episode. E. Drugs are used to change airway responsiveness.

A, D, E

28. A patient is seen in the health care provider's office and is diagnosed with community-acquired pneumonia. What are the most common symptoms the patients will have? (Select all that apply.) A. Dyspnea B. Abdominal pain C. Back pain D. Hypoxemia E. Chest discomfort

A, D, E

29. Which diagnostic tests are most likely to be done for a patient suspected of having community-acquired pneumonia? (Select all that apply.) A. Sputum Gram stain B. Pulmonary function test C. Fluorescein bronchoscopy D. Peak flowmeter measurement E. Chest x-ray

A, E

The nurse is caring for a patient on a mechanical ventilator. Which assessments does the nurse perform for this patient? (SELECT ALL THAT APPLY)

A. OBSERVE THE PATIENT'S MOUTH AROUND THE TUBE FOR PRESSURE ULCERS B. AUSCULTATE THE LUNGS FOR CRACKLES, WHEEZES, EQUAL BREATH SOUNDS, AND DECREASED OR ABSENT BREATH SOUNDS C. ASSESS THE PLACEMENT OF THE ET. E. CHECK TO BE SURE ALARMS ARE SET. F. OBSERVE THE PATIENT'S NEED FOR TRACHEAL, ORAL, OR NASAL SUCTIONING EVERY 2 HOURS

A patient has been successfully intubated by the provider, and the nurse and respiratory therapist are securing the tube in place. What does the nurse include in the documentation regarding the intubation procedure? (SELECT ALL.)

A. PRESENCE OF BILATERAL AND EQUAL BREATH SOUNDS B. LEVEL OF THE TUBE C. CHANGES IN T=VITAL SIGNS DURING THE PROCEDURE E. PRESENCE (OR ABSENCE) OF DYSRHYTHMIAS F. PLACEMENT VERIFICATION BY END0TIDAL CARBON DIOXIDE LEVELS

Which are extrapulmonary causes of ventilatory failure?

A. Stroke B. Use of opioid analgesics E. Morbid obesity.

The nurse is providing discharge teaching to the client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates understanding of the teaching? a. "I will call the provider if I have a cough lasting 3 or more days." b. "I will report to the provider weight loss of 2 to 3 pounds in a day." c. "I will try walking for 1 hour each day." d. "I should expect occasional chest pain."

A: Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified. The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.

The nurse caring for a client discusses the importance of restricting sodium in the diet. Which statement made by the client indicates that he needs further teaching? a. "I should avoid grilling hamburgers." b. "I must cut out bacon and canned foods." c. "I shouldn't put the salt shaker on the table anymore." d. "I should avoid lunch meats but may cook my own turkey."

A: Cutting out beef or hamburgers made at home is not necessary; however, fast food hamburgers are to be avoided owing to higher sodium content. Bacon and canned foods are high in sodium, which promotes fluid retention; these are to be avoided. This client does not need further teaching. The client should avoid adding salt to food; he does not need further teaching. This client understands that all lunch meats and processed foods are high in sodium and are to be avoided.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure? a. Ibuprofen (Motrin) b. Hydrochlorothiazide (HydroDIURIL) c. NPH Insulin d. Levothyroxine (Synthroid)

A: Long-term use of NSAIDs, such as ibuprofen (Motrin), causes fluid and sodium retention. A diuretic may be used in the treatment of heart failure and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause heart failure. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism; it does not cause heart failure.

After receiving change-of-shift report about these four clients, which client should the nurse assess first? a. The 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset, frequent premature ventricular complexes b. The 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% c. The 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths d. The 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, rate 104

A: This client's premature ventricular complexes may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity should be done and the physician notified about the dysrhythmia. Option B: This client is stable. Option C: This type of pain is expected in pericarditis. Option D: Tachycardia is expected in this client because rejection will cause signs of decreased cardiac output, including tachycardia.

The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes cigarettes daily d. Older man who has had a myocardial infarction

ANS: A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.

A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."

ANS: A Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.

A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention? a. Assess respiratory status. b. Monitor electrolyte levels. c. Administer intravenous fluids. d. Insert a Foley catheter.

ANS: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously.

A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.

An older adult client with heart failure states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response? a. "Would you like to talk about this more?" b. "You're lucky to have such a devoted daughter." c. "You must feel as though you are a burden." d. "Would you like an antidepressant medication?"

ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly.

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."

ANS: A Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority? a. Echocardiography b. Chest x-ray c. T4 and thyroid-stimulating hormone (TSH) d. Arterial blood gas

ANS: A Echocardiography is considered the best tool for the diagnosis of heart failure. A chest x-ray probably will be done, and if the client has dyspnea, an arterial blood gas will be drawn, but the echocardiogram is the priority. T4 and TSH might be ordered to assess for a contributing cause of heart failure.

The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate

ANS: A Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. Dysphagia, sacral edema, and an irregular heart rate are not related to pulmonary edema.

A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication? a. Insert a separate IV access. b. Prepare a test bolus dose. c. Prepare the piggyback line. d. Administer furosemide (Lasix) first.

ANS: A Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin. A test bolus is not needed, nor is Lasix. Because the medication should be given through a separate IV, it is not necessary to prepare a piggyback line.

A nurse assesses a client who is recovering from a myocardial infarction. The client's pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the client's chart as the only action.

ANS: A Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this client's readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider.

A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? a. Place the client in a high Fowler's position. b. Perform nasotracheal suctioning of the client. c. Auscultate the client's heart and lung sounds. d. Place the client on a 1000 mL fluid restriction.

ANS: A Placing a client in a high Fowler's position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client's heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed.

The nurse is caring for a client with severe heart failure. What is the best position in which to place this client? a. High Fowler's, pillows under arms b. Semi-Fowler's, with legs elevated c. High Fowler's, with legs elevated d. Semi-Fowler's, on the left side

ANS: A Placing the client in high Fowler's position, with pillows under the arms, allows for maximum chest expansion.

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

ANS: A The aortic valve is auscultated in the second intercostal space just to the right of the sternum.

A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client? a. "Please come into the clinic for an evaluation." b. "Increase your fluid intake during waking hours." c. "Use an over-the-counter cough suppressant." d. "Sleep on two pillows to facilitate postnasal drainage."

ANS: A The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible.

The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation

ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism.

A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action? a. Administer the Vasotec. b. Recheck the blood pressure. c. Hold the Vasotec. d. Notify the health care provider.

ANS: A The nurse should administer the medication. Generally, the health care provider will maintain the client's blood pressure between 90 and 110 mm Hg.

The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's best intervention? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

ANS: A When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

ANS: A, B, C If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter are not required for the procedure and would only increase the client's risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. S3/S4 summation gallop f. Cough worsens at night

ANS: A, B, E, F Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle.

The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply.) a. Hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria

ANS: A, B, E, F The hematocrit is low (should be 42.6%), indicating a dilutional ratio of red blood cells (RBCs) to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart.

A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL

ANS: A, C, E A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade

ANS: A, C, E Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke and myocardial infarction are complications of left-sided heart catheterizations.

The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client? a. Administer this medication before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level and check for symptoms of hypokalemia.

ANS: B Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension.

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching? a. "The best way to lose weight is a high-protein, low-carbohydrate diet." b. "You should balance weight loss with consuming necessary nutrients." c. "A nutritionist will provide you with information about your new diet." d. "If you exercise more frequently, you won't need to change your diet."

ANS: B Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education? a. "I will be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by the dentist in 2 weeks." c. "I will avoid eating foods high in vitamin K, like spinach." d. "I will use an electric razor instead of a straight razor to shave."

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics.

The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"

ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level.

The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction? a. "Walk until you become short of breath and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."

ANS: B Gathering all supplies needed for a chore at one time decreases the amount of energy needed.

A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? a. Increase in stroke volume b. Decrease in tissue perfusion c. Increase in oxygen saturation d. Decrease in arterial vasoconstriction

ANS: B In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. Stroke volume and oxygen saturation do not increase with a low ejection fraction.

The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention? a. Insert an indwelling urinary catheter. b. Monitor the client's blood pressure. c. Place the nitroglycerin under the client's tongue. d. Monitor the client's serum glucose level.

ANS: B Intravenous nitroglycerin and morphine will decrease the client's blood pressure, so it is important to monitor closely for hypotension. Intravenous medications are not administered under the tongue. Although the client may need an indwelling urinary catheter to monitor output, it is not the priority. The client's glucose levels should not be affected by these medications.

The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."

ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse's best response? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

ANS: B The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction.

The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans.

ANS: B The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left.

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.

ANS: B The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.) a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the client's medications.

ANS: B The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.

A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client's discharge instructions? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."

ANS: B These agents cause immune suppression, leaving the client more vulnerable to infection.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day." c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."

ANS: B Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

ANS: B, C, E Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

ANS: B, D, E Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure.

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor

ANS: B, D, E In the first few hours postprocedure, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The client's blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours.

The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity? a. Decrease in oxygen saturation from 98% to 95% b. Respiratory rate change from 22 to 28 breaths/min c. Systolic blood pressure change from 136 to 96 mm Hg d. Increase in heart rate from 86 to 100 beats/min

ANS: C A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

ANS: C A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the client's fluid status. Neurologic changes would take priority.

The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority? a. Rapid position changes can create shear and friction forces, which can tear out internal vascular sutures. b. The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure. c. The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes. d. The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.

ANS: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period.

A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." How should the nurse respond? a. "Chili is high in fat and calories; it would be a good idea to stop eating it." b. "The provider has prescribed an antacid for you to take every morning." c. "What do you understand about what happened to you?" d. "When did you start experiencing this indigestion?"

ANS: C Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain.

The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? a. "I have been drinking more water than usual." b. "I have been awakened by the need to urinate at night." c. "I have to stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client? a. Bounding arterial pulse b. Slow, faint arterial pulse c. Narrowed pulse pressure d. Elevated systolic pressure

ANS: C In aortic stenosis, the client presents with narrowed pulse pressure when blood pressure (BP) is assessed.

A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A decrease in blood pressure and urine output b. An increase in creatinine and extremity edema c. An increase in heart rate and respiratory rate d. A decrease in respirations and oxygen saturation

ANS: C In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings.

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

ANS: C In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as "left pedal pulse of +1/4."

ANS: C Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client's problem.

A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d. Administer 1 mg of atropine.

ANS: C Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.

The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include? a. "Take your digoxin at the same time every day." b. "You should begin an aerobic exercise program." c. "You should report episodes of dizziness or fainting." d. "You may have only two alcoholic drinks daily."

ANS: C The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM.

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma b. A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy

ANS: C The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease.

A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." How should the nurse respond? a. "This is a routine surgery and the risk of death is very low." b. "Would you like to speak with a chaplain prior to surgery?" c. "Tell me more about your concerns about the surgery." d. "What support systems do you have to assist you?"

ANS: C The nurse should discuss the client's feelings and concerns related to the surgery. The nurse should not provide false hope or push the client's concerns off on the chaplain. The nurse should address support systems after addressing the client's current issue.

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

ANS: D All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the client's chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Client's level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

ANS: D Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 beats/min to 80 beats/min

ANS: D Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.

A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.

The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.

A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? a. Cough b. Headache c. Pulse of 62 beats/min d. Potassium of 2.9 mEq/L

ANS: D Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headache may occur with any medication and is not a serious side effect. Bradycardia is not likely to occur with this medication.

A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble sleeping at night." How should the nurse respond? a. "I will consult the provider to prescribe a sleep study to determine the problem." b. "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." c. "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." d. "Use pillows to elevate your head and chest while you are sleeping."

ANS: D The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." What is the nurse's best response? a. "Would you like to speak with a priest or chaplain?" b. "I will consult a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future.

A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? a. Place the client in a high Fowler's position. b. Begin cardiopulmonary resuscitation (CPR). c. Promote rest and minimize activities. d. Administer loop diuretics as prescribed.

ANS: D The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler's position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.

The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about? a. Family history of coronary artery disease b. Recent travel to Third World countries c. Pet ownership, especially cats with litter boxes d. History of a systemic infection within the past month

ANS: D The clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. Assessing for coronary artery disease, recent travel, or pet ownership is not related to endocarditis.

The client who just started taking isosorbide dinitrate (Isordil) reports a headache. What is the nurse's best action? a. Titrate oxygen to relieve headache. b. Hold the next dose of Isordil. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

ANS: D The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen.

14. A patient who is allergic to dogs experiences a sudden "asthma attack." Which assessment findings does the nurse expect for this patient? A. Slow, deep, pursed-lip respirations B. Breathlessness and difficulty completing sentences C. Clubbing of the fingers and cyanosis of the nailbeds d. Bradycardia and irregular pulse

20. The nurse is taking a history of a patient with chronic pulmonary disease. The patient reports often sleeping in a chair that allows his head to be elevated rather than sleeping in a chair that allows his head to be elevated rather than sleeping in a bed. The patient's behavior is a strategy to deal with which condition? A. Paroxysmal nocturnal dyspnea B. Orthopnea C. Tachypnea D. Cheyne-Stokes respirations

22. A parent calls the ED about her child who reports a severe sore throat and refuses to drink fluids or to take liquid pain medication. What is the most important question for the nurse to ask in order to determine the need to seek immediate medical attention? A. "Does the child seem to be refusing fluids and medications because of the sore throat." B. "Is the child drooling or do you hear stridor, a raspy rough sound when the child breathes?" C. "When did the symptoms start and how long have you been encouraging fluids?" D. "Is the throat red or do you see any white patches in the back of the throat?"

24. Which statement is true about the relationship of smoking cessation to the pathophysiology of COPD? A. Smoking cessation completely reverses the damage to the lungs. B. Smoking cessation slows the rate of disease progression. C. Smoking cessation is an important therapy for asthma but not for COPD. D. Smoking cessation reverses the effects on the airways but not the lungs.

25. A patient has a history of COPD but is admitted for a surgical procedure that is unrelated to the respiratory system. To prevent any complications related to the patient's COPD, what action does the nurse take? A. Assess the patient's respiratory system every 8 hours. B. Monitor for signs and symptoms of pneumonia. C. Give high-flow oxygen to maintain pulse oximetry readings. D. Instruct the patient to use a tissue if coughing or sneezing.

26. Which patient is at highest risk for developing pneumonia? A. Any hospitalized patient between the ages of 18 and 65 years B. 32-year-old trauma patient on a mechanical ventilator C. Disabled 54-year-old with osteoporosis; discharged to home D. Any patient who has not received the vaccine for pneumonia

27. Which statement best describes pneumonia? A. An infection of just the "windpipe" because the lungs are "clear" of any problems B. A serious inflammation of the bronchioles from various causes C. Only an infection of the lungs with mild to severe effects on breathing D. An inflammation resulting from lung damage caused by long-term smoking

28. A patient with respiratory difficulty has completed a pulmonary function test before starting any treatment. The peak expiratory flow (PEF) is 15% to 20% below what is expected for this adult patient's age, gender, and size. The nurse anticipates this patient will need additional information about which topic? A. Further diagnostic tests to confirm pulmonary hypertension B. How to manage asthma medications and identify triggers C. Smoking cessation and its relationship to COPD D. How to manage the acute episode of respiratory infection

35. A patient is receiving ipratropium (Atrovent) and reports nausea, blurred vision, headache, and inability to sleep. What action does the nurse take? A. Administer a PRN medication for nausea and a milk PRN sedative. B. Report these symptoms to the provider as signs of overdose. C. Obtain a provider's request for an ipratropium level. D. Tell the patient that these side effects are normal and not to worry.

38. The nurse is teaching a patient with chronic airflow limitation about his medications. What is the correct sequence for administering aerosol treatment? A. Bronchodilator should be taken 5 to 10 minutes after the steroid. B. Bronchodilator should be taken at least 5 minutes before other inhaled drugs. C. Bronchodilator should be taken immediately after the steroid. D. Bronchodilator and steroid are two different classes of drugs, so sequence is irrelevant.

41. The nurse has identified the priority patient problem of ineffective airway clearance with bronchospasm for a patient with pneumonia. The patient has no previous history of chronic respiration disorders. The nurse obtains an order for which nursing intervention? A. Increased liters of humidified oxygen via facemask B. Scheduled and PRN (as-needed) aerosol C. Handheld bronchodilator inhaler as needed D. Corticosteroid via inhaler or IV to reduce the inflammation

43. The nurse is caring for a patient with chronic bronchitis, and notes the following clinical findings: fatigue, dependent edema, distended neck veins, and cyanotic lips. What condition is the patient exhibiting? A. COPD B. Cor pulmonale C. Asthma D. Lung cancer

45. A patient has been treated for pneumonia and the nurse is preparing discharge instructions. The patient is capable of performing self-care and is anxious to return to his job at the construction site. Which instructions does the nurse give to this patient? A. "You are not contagious to others, so you can return to work as soon as you like." B. "You will continue to feel tired and will fatigue easily for the next several weeks." C. "Try to drink 4 quarts of water per day, especially if you are very physically active." D. "You should be able to return to work full-time in 2 weeks when your energy returns."

49. Which condition causes a patient to have the greatest risk for community-acquired pneumonia? A. Tube feedings B. History of tobacco use C. Poor nutritional status D. Altered mental status

5. The nurse is presenting a community education lecture about respiratory disorders. Which statement by a participant indicates a correct understanding of the information? A. "Bronchitis is a genetic disease that affects many organs." B. "In bronchial asthma, an airway obstruction can be caused by inflammation." C. "In chronic bronchitis, the tissue damage is only temporary and reversible." D. "Smoking cessation reverses the tissue damage caused by emphysema."

51. The nurse is working for a manufacturing company and is responsible for routine employee health issues. Which primary prevention is most important for those employees at high risk for occupational pulmonary disease? A. Screen all employees by use of chest x-ray films twice a year. B. Advise employees not to smoke, and to use masks and ventilation equipment. C. Perform pulmonary function tests once a year on all employees. D. Refer at-risk employees to a social worker for information about pensions.

53. A patient with human immunodeficiency virus (HIV) is admitted to the hospital with a temperature of 99.6 F, and reports of bloody sputum, night sweats, feeling of tiredness, and shortness of breath. What are these assessment findings consistent with? A. Penumocystis jiroveci pneumonia (PJP) B. Tuberculosis C. Superinfection as a result of low CD4 count D. Severe bronchitis

62. A patient has an HIV infection, but the TB skin test shows an induration of less than 10 mm and no clinical symptoms of TB are present. Which medication does the patient receive for a period of 12 months to prevent TB? A. Bacille Calmette-Guerin (BCG) vaccine B. Isoniazid (INH) C. Ethambutol D. Streptomycin

63. The nurse has determined that a patient with COPD has the priority problem of impaired oxygenation related to reduced airway size, ventilator muscle fatigue, and excessive mucus production. Which action is best to delegate to the unlicensed assistive personnel (UAP)? A. Observe the patient for fatigue, shortness of breath, or change of breathing pattern during activities of daily living (ADLs). B. Report a respiratory rate of greater than 24/min at rest or 30/min after ambulating to the nurses' station. C. Encourage the patient to cough up sputum, and examine the color, consistency, and amount. D. Record and monitor the patient's intake and output, and give fluids to keep the secretions thin.

64. A patient diagnosed with TB has been receiving treatment for 3 weeks and has clinically shown improvement. The family asks the nurse if the patient is still infectious. What is the nurse's reply? A. "The patient is still infectious until the entire treatment is completed." B. "The patient is not infectious but needs to continue treatment for at least 6 months." C. "The patient is infectious until there is a negative chest x-ray." D. "The patient may or may not be infectious; a purified protein derivative test (PPD) must be done."

64. A patient is receiving a chemotherapy agent for lung cancer. The nurse anticipates that the patient is likely to have which common side effect? A. Diarrhea B. Nausea C. Flatulence D. Constipation

66. A patient with suspected TB is admitted to the hospital. Along with a private room, which nursing intervention is appropriate related to isolation procedures? A. Respiratory isolation and contact isolation for sputum only B. Strict respiratory isolation and use of specially designed face masks C. Respiratory isolation with surgical masks until diagnosis is confirmed D. No respiratory isolation necessary until diagnosis is confirmed

7. An older adult patient residing in a long-term care facility demonstrates new onset of coughing and sneezing with rhinorrhea after his grandchildren came to visit him. He denies pain or fever. Which infection control procedures does the nurse instruct the LPN to initiate in order to protect other residents? A. Initiate the use of standard precautions when caring for the patient. B. Place the patient on droplet precautions for the first 2 to 3 days. C. Use gown and gloves when entering the room and perform hand hygiene D. Instruct the patient to wash his hands after coughing or sneezing.

8. The nurse is assessing an older adult who has been diagnosed with bacterial pharyngitis. Which assessment finding is typically associated with this medical diagnosis, but may not be present in the older adult patient? A. Cough and rash B. High fever and elevated white blood cell (WBC) count C. Pain with speaking or swallowing D. Erythema of tonsils with yellow exudate

9. The nurse teaches a patient with asthma to monitor for which problem while exercising? A. Increased peak expiratory flow rates B. Wheezing from bronchospasm C. Swelling in the feet and ankles D. Respiratory muscle fatigue

19. A patient with COPD needs instruction in measures to prevent pneumonia. What information does the nurse include? (Select all that apply.) A. Avoid going outside. B. Clean all respiratory equipment you have at home. C. Avoid indoor pollutants such as dust and aerosols. D. Get plenty of rest and sleep daily. E. Limit alcoholic beverages to 4 to 5 per week.

B, C, D

54. Which statements about the precautions of caring for a hospitalized patient with tuberculosis (TB) are true? (Select all that apply.) A. Health care workers must wear a mask that covers the face and mouth. B. Negative airflow rooms are required for these patients. C. Health care workers must wear an N95 or high-efficiency particulate air (HEPA) mask. D. Gown and gloves are included in appropriate barrier protection. E. Strict contact precautions must be maintained.

B, C, D

Which priority problems may be considered for the client with heart failure? Select all that apply. a. Decreased fluid volume related to compromised regulatory mechanism b. Impaired Physical Mobility related to limited cardiovascular endurance c. Impaired Gas Exchange related to ventilation-perfusion imbalance d. Potential for pulmonary edema e. Risk for Ineffective renal Perfusion related to hypervolemia

B, C, D, E: Owing to intra-alveolar edema and poor cardiac output, the client is fatigued, has limited endurance, and may develop hypoxemia. Owing to limited cardiac reserve, the client is at risk for pulmonary edema. The client with heart failure has poor cardiac output, reduced blood flow to the kidney, and accumulation of pulmonary and peripheral fluid.

51. The nurse is preparing a community information packet about "bird flu." What information does the nurse include for public dissemination? (Select all that apply.) A. In the event of an outbreak, do not eat any cooked or uncooked poultry products. B. Prepare a minimum of 2 weeks supply of food, water, and routine prescription drugs. C. Listen to public health announcements and early warning signs for disease outbreaks. D. Avoid traveling to areas where there has been a suspected outbreak of disease. E. Obtain a supply of antiviral drugs such as oseltamivir (Tamiflu). F. In the event of an outbreak, avoid going to public areas such as churches or schools.

B, C, D, F

12. Which are main purposes of asthma treatment? (Select all that apply.) A. Avoid secondhand smoke B. Improve airflow C. Relieve symptoms D. Improve exercise tolerance E. Prevent asthma episodes

B, C, E

48. A patient is undergoing diagnostic testing for possible cystic fibrosis (CF). Which nonpulmonary assessment findings does the nurse expect to observe in a patient with CF? (Select all that apply.) A. Peripheral edema B. Abdominal distention C. Steatorrhea D. Constipation E. Gastroesophageal reflux

B, C, E

69. Patients who are at high risk for TB would be asked which questions upon assessment? (Select all that apply.) A. "What does your diet normally consist of?" B. "Do you have an immune dysfunction or HIV?" C. "Do you use alcohol or inject recreational drugs?" D. "Where do you live in the United States?" E. "Do you work in a crowded area such as a prison or mental health facility?"

B, C, E

The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. a. Hypokalemia b. Sinus bradycardia c. Fatigue d. Serum digoxin level of 1.5 e. Anorexia

B, C, E: Digoxin toxicity may be manifested by bradycardia, fatigue, and/or anorexia. A - Incorrect: Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. D - Incorrect: This represents a therapeutic value that is between 0.8 and 2.0.

Ventilatory failure is the result of what processes? (Select all that apply.)

B. Defect in the respiratory control center of the brain C. Physical problem of the lungs d Poor function of the diaphragm e. Physical problem of the chest wall

The client begins therapy with lisinopril (Prinivil, Zestril). What should the nurse consider at the start of therapy with this medication? a. The client's ability to understand medication teaching b. The risk for hypotension c. The potential for bradycardia d. Liver function tests (LFTs)

B: Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, understanding of medication teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action should the nurse take first? a. Assess the client for peripheral edema. b. Listen to the client's posterior breath sounds. c. Notify the physician about the client's weight gain. d. Remind the client about dietary sodium restrictions.

B: Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds. Assessment of edema may be delayed while the nurse focuses on breathing and breath sounds. After a full assessment, the nurse should notify the physician. Defer this action until physiologic stability is attained; then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

The nurse recognizes that which medication when given in heart failure may improve morbidity and mortality? a. Dobutamine (Dobutrex) b. Carvedilol (Coreg) c. Digoxin (Lanoxin) d. Bumetamide (Bumex)

B: Beta-adrenergic blockers reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; they improve morbidity, mortality, and quality of life. Dobutamine and digoxin are inotropic agents used in acute heart failure; they do not improve mortality. Bumetamide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? a. Ejection fraction is 25%. b. Client states that she is able to sleep on one pillow. c. Client was hospitalized five times last year with pulmonary edema. d. Client reports that she experiences palpitations.

B: Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. An ejection fraction of 25% is well below the normal ejection fraction of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.

The client who has been admitted for the third time this year for cardiac failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? a. Calls the family to lift the client's spirits b. Considers further assessment for depression c. Sedates the client to decrease myocardial oxygen demand d. Tells the client that things will get better

B: This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done. Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope and ignores his feelings.

Which of these clients is best to assign to an LPN/LVN working on the telemetry unit? a. A client with heart failure who is receiving dobutamine (Dobutrex) b. A client with restrictive cardiomyopathy who uses oxygen for exertional dyspnea c. A client with pericarditis who has a paradoxical pulse and distended jugular veins d. A client with rheumatic fever who has a new systolic murmur

B: This client, who needs oxygen only with exertion, is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. Option A: This client is receiving an intravenous inotropic agent, which requires monitoring by the professional nurse. Option C: This client is displaying signs of cardiac tamponade and requires immediate life-saving intervention. Option D: A new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the professional nurse.

20. The nurse is taking a history on a patient who presents with symptoms of pharyngitis: sore throat with dry sensation, pain on swallowing, and low-grade fever. The patient mentions plans to take an overseas trip. Which immunization does the nurse suggest the patient should have, if not already received, before leaving? A. Tetanus toxoid B. Hepatitis B C. Diphtheria D. Yellow fever

22. A patient has COPD with chronic difficult breathing. In planning this patient's care, what condition must the nurse acknowledge is present in this patient? A. Decreased need for calories and protein requirements since dyspnea causes activity intolerance B. COPD has no effect on calorie and protein needs, meal tolerance, satiety, appetite, and weight C. Increased metabolism and the need for additional calories and protein supplements D. Anabolic state, which creates conditions for building body strength and muscle mass

23. In a long-term care facility for older adults and immunocompromised patients, one employee and several patients have been diagnosed with influenza (flu). What does the supervising nurse do to decrease the risk of infection to other patients? A. Ask employees who have flu to stay at home for at least 24 hours. B. Place any patient with a sore throat, cough, or rhinorrhea into isolation for 1 to 2 weeks. C. Ask employees with flu symptoms to stay at home for up to 5 days after onset of symptoms. D. Recommend that all patients and employees be immediately vaccinated for flu.

25. The patient developed flu symptoms less than 24 hours ago. Which drug therapy does the nurse expect the health care provider to order at this time? A. Penicillin therapy B. Amantadine (Symmetrel) C. Oseltamivir (Tamiflu) D. IV steroid therapy

26. The nurse is instructing a patient regarding complications of COPD. Which statement by the patient indicates the need for additional teaching? A. "I have to be careful because I am susceptible to respiratory infections." B. "I could develop heart failure, which could be fatal if untreated." C. "My COPD is serious, but it can be reversed if I follow my doctor's orders." D. "The lack of oxygen could cause my heart to beat in an irregular pattern."

32. The nurse is developing a teaching plan for a patient with chronic airflow limitation using the priority patient problem of insufficient knowledge related to energy conservation. What does the nurse advise the patient to avoid? A. Performing activities at a relaxed pace throughout the day with rest periods B. Working on activities that require using arms at chest level or lower C. Eating three large meals per day D. Talking and performing activities separately

32. Which patient is least likely to be at risk for developing pneumonia? A. Patient with a 5-year history of smoking B. Renal transplant patient C. Postoperative patient with a bedside commode D. Postoperative patient with a hip replacement

34. What nursing intervention may help to prevent the complication of pneumonia for a surgical patient? A. Monitoring chest x-rays and WBC counts for early signs of infection B. Monitoring lung sounds every shift and encouraging fluids C. Teaching coughing, deep-breathing exercises, and use of incentive spirometry D. Encouraging hand hygiene among all caregivers, patients, and visitors

36. A patient hospitalized for pneumonia has the priority patient problem of ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness. What nursing intervention helps to correct this problem? A. Administer oxygen to prevent hypoxemia and atelectasis B. Push fluids to greater than 3000 mL/day to ensure adequate hydration. C. Administer bronchodilator therapy in a timely manner to decrease bronchospasm. D. Maintain semi-Fowler's position to facilitate breathing and prevent further fatigue.

36. A patient with asthma has been prescribed a fluticasone (Flovent) inhaler. What is the purpose of this drug for the patient? A. Relaxes the smooth muscles of the airway B. Acts as a bronchodilator in severe episodes C. Reduces obstruction of airways by decreasing inflammation D. Reduces the histamine effect of the triggering agent

37. A patient is admitted to the hospital for treatment of pneumonia. Which nursing assessment finding best indicates that the patient is responding to antibiotics? A. Wheezing, oxygen at 2 L/min, respiratory rate 26, no shortness of breath or chills B. Temperature 99 F, lung sounds clear, pulse oximetry on 2 L/min at 98%, cough with yellow sputum C. Cough, clear sputum, temperature 99 F, pulse oximetry at 96% on room air D. Feeling tired, respiratory rate 28 on 2 L/min of oxygen, audible breath sounds

39. A patient has been prescribed cromolyn sodium (Intal) for the treatment of asthma. Which statement by the patient indicates a correct understanding of this drug? A. "It opens my airways and provides short-term relief." B. "It is the medication that should be used 30 minutes before exercise." C. "It is not intended for use during acute episodes of asthma attacks." D. "It is a steroid medication, so there are severe side effects."

4. The nurse is caring for an older adult patient with a history of chronic asthma. Which problem related to aging can influence the care and treatment of this patient? A. Asthma usually resolves with age, so the condition is less severe in older adult patients. B. It is more difficult to teach older adult patients about asthma than to teach younger patients. C. With aging, the beta-adrenergic drugs do not work as quickly or strongly. D. Older adult patients have difficulty manipulating handheld inhalers.

40. After the nurse has instructed a patient with COPD in the proper coughing technique, which action the next day by the patient indicates the need for additional teaching or intervention? A. Coughing upon rising in the morning B. Coughing before meals C. Coughing after meals D. Coughing at bedtime

44. A patient is admitted with asthma. Which assessment findings are most likely to indicate that the patient's asthma condition is deteriorating and progressing toward respiratory failure? A. Crackles, rhonchi, and productive cough with yellow sputum B. Tachypnea; thick, tenacious sputum; and hemoptysis C. Audible breath sounds, wheezing, and use of accessory muscles D. Respiratory alkalosis; slow, shallow respiratory rate

46. The nurse assesses a patient and finds a dusky appearance with bluish mucous membranes and production of lots of mucus. What illness does the nurse suspect? A. Asthma B. Emphysema C. Chronic bronchitis D. Acute bronchitis

53. A patient has prolonged occupational exposure to petroleum distillates and subsequently developed a chronic lung disease. This patient is advised to seek frequent health examinations because there is high risk for developing which respiratory disease condition? A. Tuberculosis B. Cystic fibrosis C. Lung cancer D. Pulmonary hypertension

57. Which statement is true about radiation therapy for lung cancer patients? A. It is given daily in "cycles" over the course of several months. B. It causes hair loss, nausea, and vomiting for the duration of treatment. C. It causes dry skin at the radiation site, fatigue, and changes in appetite with nausea. D. It is the best method of treatment for systemic metastatic disease.

59. A patient has a positive skin test result for TB. What explanation does the nurse give to the patient? A. "There is active disease, but you are not yet infectious to others." B. "There is active disease and you need immediate treatment." C. "You have been infected but this does not mean active disease is present." D. "A repeat skin test is necessary because the test could give a false-positive result."

61. The provider's prescriptions indicate an increase in the suction to -20cm for a patient with a chest tube. To implement this, the nurse performs which intervention? A. Increases the wall suction to the medium setting, and observes gentle bubbling in the suction chamber. B. Adds water to the suction and drainage chambers to the level of -20cm C. Stops the suction, adds sterile water to level of -20cm to the water seal chamber, and resumes the wall suction D. has the patient cough and deep-breathe, and monitors level of fluctuation to achieve -20cm

62. A patient is fearful that she might develop lung cancer because her father and grandfather died of cancer. She seeks advice about how to modify lifestyle factors that contribute to cancer. How does the nurse advise the patient? A. Not to worry about air pollution unless there is hydrocarbon exposure. B. Quit her job if she has continuous exposure to lead or other heavy metals C. Avoid situations where she would be exposed to "secondhand" smoke D. Not to be concerned because there are no genetic factors associated with lung cancer

65. A patient is having pain resulting from bone metastases caused by lung cancer. What is the most effective intervention for relieving the patient's pain? A. Support the patient through chemotherapy. B. Handle and move the patient very gently. C. Administer analgesics around the clock. D. Reposition the patient, and use distraction.

66. A patient has a chest tube in place. What does the water in the water seal chamber do when the system is functioning correctly? A. Bubbles vigorously and continuously B. Bubbles gently and continuously C. Fluctuates with the patient's respirations D. Stops fluctuation, and bubbling is not observed

67. A patient is admitted to the hospital to rule out TB. What type of mask does the nurse wear when caring for this patient? A. Surgical facemask B. Surgical facemask with eye shield C. HEPA respirator mask D. Any type of mask that covers the nose and mouth

A patient in the hospital being treated for a PE is receiving a continuous infusion of heparin. When the nurse comes to take vital signs, the patient has blood on the front of his chest and nose, and is holding a tissue saturated with blood to his nose. What is the first priority action the nurse must take?

C. Stop the heparin IV infusion.

The nurse's young neighbor who smokes is going on an overseas flight. The neighbor knows he is at risk for DVT and PE, and asks the nurse for advice. What does the nurse suggest?

C. drink water and get up q hour for at least 5min

Which assessment finding is considered an early sign of ARDS?

C. intercostal and suprasternal retractions

A patient recently received anticoagulant therapy for complications of PE after knee surgery. The patient is now in a rehab facility and receiving warfarin. What i the nursing responsibility related to Coumadin?

C. teaching the patient about foods high in vit K

In monitoring the diagnostic test of a client admitted with heart failure (HF), which finding is consistent with this diagnosis? a. Serum potassium level of 3.2 mEq/L b. Ejection fraction of 60% c. B-type natriuretic peptide (BNP) of 760 ng/dL d. Chest x-ray report showing right middle lobe consolidation

C: BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia may occur in response to diuretic therapy for heart failure but may also occur with other conditions; it is not specific to heart failure. Consolidation on chest x-ray may indicate pneumonia.

Which of these nursing actions should the nurse delegate to a nursing assistant working on the medical unit? a. Determine the usual alcohol intake for a client with cardiomyopathy. b. Monitor the pain level for a client with acute pericarditis. c. Obtain daily weights for several clients with class IV heart failure. d. Check for peripheral edema in a client with endocarditis.

C: Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments; do not delegate this activity.

Which intervention will best assist the client with acute pulmonary edema in reducing anxiety and dyspnea? a. Monitor pulse oximetry and cardiac rate and rhythm. b. Reassure the client that his distress can be relieved with proper intervention. c. Place the client in high Fowler's position with the legs down. d. Ask a family member to remain with the client.

C: High Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities but will not prevent them. Option B may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved. Option D may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.

The client, a college athlete who has collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? a. "How does this make you feel?" b. "This can be caused by taking performance-enhancing drugs." c. "This may be caused by a genetic trait." d. "Just imagine how bad it would be if you weren't in good shape."

C: Hypertrophic cardiomyopathy is often transmitted as a single-gene autosomal dominant trait.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? a. Client ambulates around the nursing unit with a walker. b. The nurse monitors the client's pulse and blood pressure frequently. c. The nurse obtains a bedside commode before administering furosemide. d. The nurse returns the client to bed when he becomes tachycardic.

C: Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. On the day of admission, the client is experiencing dyspnea, fatigue, and weakness; this activity will increase oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.

When caring for a client who has undergone a partial left ventriculectomy, which of these new-onset clinical manifestations indicates the need for immediate action by the nurse? a. Chest pain with movement b. Fatigue after ambulation c. Muffled heart sounds d. Bi-basilar fine crackles

C: Muffled heart sounds may be a clinical manifestation of bleeding into the pericardial space; the nurse should assess the client for possible decreased cardiac output and should notify the surgeon. Surgery will result in pain with mobility; pain should be treated but not until physiologic stability is ensured. This procedure was performed for heart failure; this client has had surgery as well and will need some time to recover his energy. Although the nurse should strive to prevent atelectasis or dependent crackles, this common after chest surgery. This client should be gotten out of bed and shown how to use an incentive spirometer.

The nurse is assessing the client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? a. Friction rub auscultated at the left lower sternal border b. Pain aggravated by breathing, coughing, and swallowing c. Splinter hemorrhages d. Thickening of the endocardium

C: Splinter hemorrhages are indicative of infective endocarditis. Friction rub in the left lower sternal border is a sign of chronic constrictive pericarditis. Pain aggravated by breathing, coughing, and swallowing is indicative of signs and symptoms of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, pink, frothy sputum, and crackles throughout the lung fields. Which prescription should the nurse carry out first? a. Enalapril b. Heparin c. Furosemide d. I & O

C: The client is displaying typical signs of acute pulmonary edema, secondary to fluid-filled alveoli and pulmonary congestion; a diuretic will promote fluid loss. Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis (DVT) secondary to immobility but will not reduce fluid excess. Although all clients with congestive heart failure (CHF) should have I & O maintained, this is not a priority; removing fluid volume and treating dyspnea are matters of priority.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? a. Auscultation of crackles b. Pedal edema c. Weight loss of 6 pounds since the last visit d. Reports sucking on ice chips all day for dry mouth

C: Weight loss in this client indicates effective fluid restriction and diuretic drug therapy. Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. This indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.

11. A patient reporting soreness in the throat is diagnosed with "strep throat." To prevent complications such as rheumatic heart disease, this patient should receive which intervention? A. Humidification of the air B. Saline gargles 4 to 6 times a day C. Increased fluid intake of 3 to 4 L/day D. Oral antibiotics such as penicillin

2. The nurse notes that an older patient has a disorder that indicates drug therapy that the health care provider just prescribed for symptomatic relief of allergic rhinitis must be used with caution. Which disorder does the nurse report to the health care provider as a possible precaution for drug therapy? A. Sleep apnea B. Valvular heart disease C. Meniere's disease D. Urinary retention

21. A patient has chronic bronchitis. The nurse plans interventions for inadequate oxygenation based on which set of clinical manifestations? A. Chronic cough, thin secretions, and chronic infection B. Respiratory alkalosis, decreased PaCO2, and increased PaO2 C. Areas of chest tenderness and sputum production (often with hemoptysis) D. Large amounts of thick secretions and repeated infections

27. What is the purpose of pulmonary function testing? A. Determines the oxygen liter flow rates required by the patient B. Measures blood gas levels before bronchodilators are administered C. Evaluates the movement of oxygenated blood from the lung to the heart D. Distinguishes airway disease from restrictive lung disease

30. The nurse is reviewing laboratory results for a patient who has pneumonia. Which laboratory value does the nurse expect to see for this patient? A. Decreased hemoglobin B. Increased red blood cells (RBCs) C. Decreased neutrophils D. Increased white blood cells (WBCs)

30. What principle guides the nurse when providing oxygen therapy for a patient with COPD? A. The patient depends on a high serum carbon dioxide level to stimulate the drive to breathe. B. The patient requires a low serum oxygen level for the stimulus to breathe to work. C. The patient who receives oxygen therapy at a high flow rate is at risk for a respiratory arrest. D. The patient should receive oxygen therapy at rates to reduce hypoxia and bring SpO2 levels up between 88% and 92%.

37. What is the advantage of using the aerosol route for administering short-acting beta2 agonists? A. Achieves a rapid and effective anti-inflammatory action. B. Reduces risk for fungal infections C. Increases patient compliance because it is easy to use D. Provides rapid therapy with fewer systemic side effects

38. The nurse is reviewing the laboratory results for an older adult patient with pneumonia. Which laboratory value frequently seen in patients with pneumonia may not be seen in this patient? A. RBC 4.0 to 5.0 B. Hgb 12 to 16 C. Hct 36 to 48 D. WBC 12 to 18

8. The nurse is taking a medical history on a new patient who has come to the office for a check up. The patient states that he was supposed to take a medication called montelukast (Singulair), but that he never got the prescription filled. What is the best response by the nurse? A. "When did you first get diagnosed with a respiratory disorder?" B. "Why didn't you get the prescription filled?" C. "Tell me how you feel about your decision to not fill the prescription." D. "Tell me about how your asthma has been recently?"

Although the client with cardiac failure is asymptomatic, the nurse suspects noncompliance with prescribed home therapy. Which laboratory test confirms the nurse's suspicions? a. B-type natriuretic peptide (BNP) 90 pg/mL b. Serum electrolytes c. Hemoglobin and hematocrit d. Digoxin level of 0.2 ng/dL

D: A therapeutic digoxin level is 0.8 to 2.0 ng/dL. A level of 0.2 ng/dL indicates that the client has not been taking his digoxin as prescribed. A BNP test is a cardiac failure diagnostic tool but is not the best indicator of decreased compliance. Electrolytes are not an early indicator of decreased cardiac compliance. Hemoglobin and hematocrit are not early indicators of decreased cardiac compliance.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8 Pulse: 48 and irregular Respirations: 20 Potassium level: 3.2 mEq/L What action does the nurse take? a. Give digoxin; reassess the heart rate in 30 minutes. b. Give the digoxin; document assessment findings in the medical record. c. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. d. Hold the digoxin, and obtain a prescription for a potassium supplement.

D: Digoxin causes bradycardia; hypokalemia potentiates digitalis. The nurse seeks to correct this situation through collaboration with the provider. Digoxin causes bradycardia, so should be held. Digoxin is given to treat heart failure and atrial fibrillation, an irregular heart rate. Regardless of mental status, the drug should be held. Hypokalemia potentiates digitalis toxicity. Lasix decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid excess at this time.

A client admitted for heart failure has a priority problem of Excess Fluid Volume related to compromised regulatory mechanisms. Which of these assessment data obtained the day after admission is the best indicator that the treatment has been effective? a. The client has a diuresis of 400 mL in 24 hours. b. The client's blood pressure is 122/84 mm Hg. c. The client has an apical pulse of 82 beats/min. d. The client's weight decreases by 2.5 kg.

D: The best indicator of fluid volume loss is daily weight; because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid. Option A: This volume of urine represents oliguria, not the needed response of diuresis. Option B: Although this is a normal finding, alone it is not significant for relief of fluid volume excess. Option C: Although this is a normal finding, alone it is not significant to determine whether fluid excess is relieved.

6.A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"

a. "Breathing so quickly can be dehydrating."

1.A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

a. 22-year-old client with asthma c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

21.A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.

a. Administer oxygen at 4 liters per nasal cannula.

2.A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin)

11.The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 minutes d. Pulse oximetry obtained on all clients

a. Antibiotics started before admission

15.A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.

a. Ask the spouse to explain the fear of visiting in further detail.

4.A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours

a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed

8.A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

a. Educating the client on adherence to the treatment regimen

The charge nurse in the intensive care unit is reviewing the patient census and caseload to identify staffing needs and potential transfers. Which patient might take the longest time to wan from a ventilator?

a. 54-year-old man with metastatic colon cancer who has been intubated for 6 days.

The nurse notices that a patient has a gradual increase in peak inspiratory pressure over the last several days. Waht is the best nursing intervention for this patient?

a. Assess for a reason such as ARDS or pneumnoia.

The nurse is caring for a patient on a mechanical ventilator. Waht does the nurse monitor to assess for them most likely cardiac problem associated with this therapy?

a. Check blood pressure.

A patient in a motor vehicle accident (MVA) was unrestrained and appears to have hit the front dashboard. Teh patient has severe respiratory distress, inspiratory stridor, and extensive subcutaneous emphysema. The ED physician identifies tracheobronchial trauma. Which procedure does the nurse immediately prepare for?

a. Cricothyroidotomy

The nursing student is assisting in the care of a critically ill patient on a ventilator. Which action by the student nurse requires intervention by the supervising nurse?

a. Deflates the cuff on the ET tube to check placement.

A patient has a history of COPD and had to be intubated for respiratory failure. The patient is currently on a mechanical ventilator. The nurse obtains an order for which type of dietary therapy for this patient?

a. High-fat nutritional supplement

What is the cardiac problem that can occur from mechanical ventilation?

a. Hypotension

What are the characteristics of a mechanical ventilator that is time-cycled? (SELECT ALL THAT APPLY)

a. It needs an artificial airway such as a tracheostomy or ET. b. It is a positive-airway pressure c. Its tdidal volumes are variable. d. Preset inspiration and expiration rate can be set w/ possibel variation fo tidal volume.

The nurse is caring for a patient with acute hypoxemia. Which nursing interventions are best for the care of this patient? (Select all that apply. )

a. Minimal self-care c. Upright position d. Oxygen therapy f. Prescribed metered-dose inhalers

The high-pressure alarm of a patient's mechanical ventilator goes off. What are the potential causes for this? (select all that apply.)

a. Mucus plug . Pt is fighting the ventilator d. Bronchospasm e. Patient is coughing

A patient in respiratory failure is diagnosed with a flail chest. After the patient is intubated, which treatment does the nurse expect to be implemented?

a. PEEP

The nurse is caring for a patient with a post-operative complication of PE. The patient has been receiving treatment for several days. Which factors are indicators of adequate perfusion in the patient? (Select All That Apply.)

a. Pulse ox 95% d. Absence of pallor e. Mental status at patient's baseline

A patient demonstrates chest pain, dyspnea, dry cough, and change in LOC. The nurse suspects PE & notifies the HCP who orders an ABG. In the early stages of PE, what would ABG results probably indicate?

a. Respiratory alkalosis

The nurse hears an alarm go off on a mechanical ventilator that signals the ventilator is not able to give the patient a breath. What are the possible reasons that would make this alarm go off? (SELECT ALL THAT apply.)

a. The tubing has become disconnected. d. The patient has become disconnected from the ventilator e. the patient needs to be suctioned.

The nurse is assessing a patient who sustained significant chest trauma during a motor vehicle accident. What significant assessment finding suggests tension pneumothorax?

a. Tracheal deviation to the unaffected side

Which are the risk factors for pulmonary embolism (PE) and deep vein thrombosis (DVT)? select all that apply

a. Trauma c. Heart failure e. Cancer (particularly lung or prostate)

The nurse is caring for several patients on the medical-surgical unit who are experiencing acute respiratory problems. Which conditions may eventually require a patient to be intubated? (SELECT ALL THAT APPLY.)

a. Trouble maintaining a patent airway because of mucosal swelling c. copious secretions and lacking muscular strength to cough e. increasing fat9gue because of the work of breathing

Which conditions define respiratory failure? (select all that apply)

a. Ventilatory failure c. Oxygenation failure e. Combination of ventilatory and oxygenation

Which clinical manifestations can occur from cardiac problems due to mechanical ventilation? (Select All That Apply.)...

a. decreased cardiac output d. fluid retention

What are the characteristics of a noninvasive pressure support (Bi-PAP_)? (SELECT ALL THAT APPLY....)

a. it provides noninvasive pressure support ventilation by nasal mask or facemask c. it is most often used for patients with sleep apnea. e. It may be used for patients with respiratory muscle fatigue.

7.An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."

b. "Older people often have vague symptoms, so an x-ray is essential."

19.A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a. Ask the client what foods cause trouble swallowing. b. Assess the client for pain when swallowing. c. Determine if the client can swallow saliva. d. Palpate the client's jaw while swallowing.

b. Assess the client for pain when swallowing.

5.The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Cohort the "clients" in the same area of the unit. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.

b. Cohort the "clients" in the same area of the unit.

17.A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.

b. Facilitate polymerase chain reaction testing.

14.A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a. Collect a sputum sample for culture by deep suctioning. b. Inform the client that antibiotics will be needed for 60 days. c. Place the client on Airborne Precautions immediately. d. Tell the client that directly observed therapy is needed.

b. Inform the client that antibiotics will be needed for 60 days.

3.A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3

b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds

3.Which teaching point is most important for the client with bacterial pharyngitis? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.

b. Take all antibiotics as directed.

Acute respiratory failure is classified by which critical values of PaCO2? (select all that apply.

b. 52 mm Hg c. < 60 mm Hg e. > 50 mm Hg with a pH value of < 7.3

Which finding might delay weaning a patient from mechanical ventilation support?

b. Arterial PO2=70 mm Hg on a 40% Fio@

THE nurse is caring for a patient who has just been extubated. waht interventions does the nurse use in caring for this patient? (Select All That Apply.).

b. Assess the ventilatory pattern for manifestations of respiratory distress. d. Instruct the patient to take deep breaths every 30 mins e. Encourage use of an incentive spirometer every 2 horus. f. Advise the patient to limit speaking right after extubation.

The nurse is caring for a patient on a mechanical ventilator. during the shift, the nurse hears the patient talking to himself. What does the nurse do next?

b. Check the inflation of the pilot balloon

The low-pressure alarm of a patient's mechanical ventilator goes off. What are potential causes for this? (SELECT ALL THAT APPLY.)

b. Cuff leak in the endotracheal or tracheostomy tube c. Patient has stopped breathing e. Leak in the circuit

What is the most common site of origin for a clot to occur, causing a PE?

b. Deep veins of the legs and pelvis

The nurse is performing patient teaching for a patient who whill be taking anticoagulants at home. What does the nurse include in the instructions? (select all that apply.)

b. Do not take aspirin or any aspirin-containing products. c. Do not participate in activities that will cause bumps, scratches, or scrapes. e. Eat warm, cool, or cold foos to avoid burning your mouth. f. If you must blow your nose, do so gently without blocking either nasal passage.

The nurse is assessing a patient with a hemothorax. When the nurse performs percussion of the chest on the affected side, what type of sound is expected?

b. Dull

An older adult patient arrives in the ED after falling off a roof. The nurse observes "sucking inward" of the loose chest area during inspiration and a "puffing out" of the same area during expiration. ABG results show severe hypoxemia and hypercarbia. Which procedure does the nurse prepare for>?

b. ET intubation

The nurse receives report on a patient with ARDS who has been intubated for 6 days and has progressive hypoxemia that responds poorly to high levels of oxygen. This patient is in which phase of ARDS case managemet?

b. Fibroproliferative phase

The nurse assisting with emergency intubation for a patient in severe respiratory disress. Although the provider is experienced, the procedure is difficult cuz the pt has severe kyphosis. At what point does the nurse intervene?

b. First intubation attempt lats longer than 30 seconds.

A 19-year-old patient was seen in the ED after a motorcycle accident for multiple rib fractures that resulted in free-floating ribs, paradoxical breathing, and inadequate oxygenation. What is this condition called?

b. Flail chest

A pt is being treated with heparin therapy for a PE. The patient has the potential for bleeding with the administration of heparin. What does the nurse monitor in relation to the heparin therapy?

b. PTT values for greater than 2.5 times the control and/or the patient for bleeding

The nursing student is assisting in the care of a patient on a mechanical ventilator. Which action by the student contributes to the prevention of ventilator-assisted pneumonia?

b. Performs oral care every 2 hours.

What causes the potential cardiac problems that can result from mechanical ventilation?

b. Positive pressure increases in the chest.

The nurse suspects a patient has a PE and notifies the provider who orders an ABG. the provider is en route to the facility. The nurse anticipates and prepares the patient for which additional diagnostic test?

b. Pulmonary angiography

The provider orders heparin therapy for a patient with a relatively small PE. The patient states, "I didnt tell the doctor my complete medical hx." Which condition may affect the provider's decision to immediately start heparin therapy?

b. Recent cerebral hemorrhage

A patient in the critical care unit requires an emergency ET intubation. The nurse immediately obtains and prepares which supplies to perform this procedure? (SELECT ALL THAT APPLY.)

b. Resuscitation Ambu bag c. Source for 100% oxygen d. Suction e. Airway equipment box (laryngoscope) f. Oral airway

The nurse is caring for several postoperative patients with high risk for a PE. All of these patients have preexisting chronic respiratory problems. What is a unique assessment finding for a clot in the lung?

b. Sudden dry cough

An older adult patient on anticoagulation therapy for a PE is somewhat confused and requires assistance with Adls. Which instruction specific to this therapy does the nurse give to the UAP?

b. Use a lift sheet when moving or turning the patient in bed.

A patient with ARDS is currently in the exudatiive management stage. What is the focus of the nursing assessment?

b. note early changes in dyspena and tachypnea

12.A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a. "I need to take extra vitamin C while on INH." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."

c. "I will take this medication on an empty stomach."

2.A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. "Ice packs may help with the facial pain." b. "Limit fluids to dry out your sinuses." c. "Try warm, moist heat packs on your face." d. "We will schedule you for a computed tomography scan this week."

c. "Try warm, moist heat packs on your face."

1.A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor-Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

c. Fexofenadine (Allegra)

A patient in the ED required emergency intubation for status asthmaticus. Immediately after the insertion of the ET tube, how does the nurse and/or physician verify correct placement?

c. Check end-tidal Co2 level.

A patient reports pain with inspiration after falling off a skateboard. The provider makes the diagnosis of rib fracture. The nurse prepares to do patient teaching for which treatment?

c. Coughing and deep-breathing

A patient on a ventilator is biting and chewing at the ET tube. Which nursing intervention is used for ET management?

c. Insert an oral airway

The nurse hears in shift report that a patient has been agitated and pulling at the ET. Soft restraints ahve recently been ordered and placed, but the patient continues to move his head and chew at the tube. What does the nurse do to ensure proper placement of the ET tub>?

c. Mark the tube where it touches the patient's teeth

4.A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

d. Teach the client to sneeze in the upper sleeve.

16.A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

d. Visiting Nurses for directly observed therapy

A patient with a massive PE has hypotension and shock, and is receiving IV crystalloids. However, the patient's CO is not improving. The nurse anticipates an order for which drug?

d. Dobutamine (Dobutrex)

A pt with PE is receiving anticoagulant therapy. Which assessment related to the therapy does the nurse perform?

d. Examine skin every 2 hrs for evidence of bleeding

The patient is to be extubated. What action does the nurse perform first?

d. Explain the procedure

The nurse is caring for a patient who was recently extubated. What is an expected assessment finding for this patient?

d. Hoarseness

On arrival to the ED, the patient develops extreme respiratory distress and the provider identifies a tension pneuomothorax. The nurse prepares to assist with which initial urgent procedure?

d. Insertion of a large-bore needle into the second intercostal space on the affected side

A patient is being extubated and the nurse has emergency equipment at the bedside. whch intervention is implemented during extubation?

d. Instruct the patient to cough after tube is removed

Upon diagnosis of a PE, the nurse expects to perform which therapeutic intervention for the patient?

d. Parenteral anti-coagulant therapy

The provider instructs the nurse to watch for and report signs and symptoms of improvement so the patient can be weaned from the ventilator. Which assessment finding indicates the patient is ready to be weaned?

d. Pt is receiving only 1-2 mechanical bspm

A patient sustained a chest injury resulting from a motor vehicle accident. The patient is asymptomatic at first, but slowly develops decreased breath sounds, crackleds, wheezing, and blood in the sputum. The mechanism of injury and physical findings are consistent with which condition?

d. Pulmonary contusion

A patient is admitted to the trauma unit following a front-end motor vehicle collision. The patient is currently asymptomatic, but the provider advises the nurse that the patient has a high risk for pulmonary contusion. What does the nure carefully monitor for?

d. decreased breath sounds

The nurse is performing a check of the ventilator equipment. What is included during the equiptment check?

c. Note the prescribed and actual settings.

A patient is following up on a postoperative complication of PE. The patient must have blood drawn to determine the therapeutic range for Coumadin. Which lab test determines this therapeutic range?

c. PT and INR

A postoperative patient reports sudden onset of shortness of breath and pleuritic chest pain. Assessment findings include diaphoresis, hypotension, crackles in the left lower lobe, and pulse oximetry of 85%. What does the nurse suspect has occurred with this patient?

c. Pulmonary embolism

The nurse is caring for several patients at risk for DVT and PE. Which condition causes the patient to be a candidate for placement of a vena cava filter?

c. Recurrent bleeding while receiving anticoagulants

The nurse is caring for a patient at risk for pulmonary contusion. Why is this a potentially lethal chest injury?

c. Respiratory failure develops over time

A patient with a tracheostomy who is on a mechanical ventilator is beginning to take spontaneous breaths at his own rate and tv between set ventilator breaths. Which mode is the ventilator on?

c. SIMV (synchronized intermittent ventilation.)

After receiving IV heparin anticoagulant therapy, patients are generally not discharged from the hospital without a prescription and instructions for which drug?

c. Warfarin (Coumadin)

What is the most common cause of embolism?

c. blood clot

9.A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a. "Are any family members also ill?" b. "Have you traveled recently?" c. "How long have you been ill?" d. "What is your occupation?"

d. "What is your occupation?"

18.A client has the diagnosis of "valley fever" accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on? a. Intravenous amphotericin B b. Long-term anti-inflammatories c. No specific treatment d. Oral fluconazole (Diflucan)

d. Oral fluconazole (Diflucan)

35. The nurse is conducting an in-service for the hospital staff about practices that help prevent pneumonia among at-risk patients. Which nursing intervention is encouraged as standard practice? A. Administering vaccines to patients at risk B. Implementing isolation for debilitated patients C. Restricting foods from home in immunosuppressed patients D. Decontaminating respiratory therapy equipment weekly

40. A critical concern for a patient returning to the unit after a surgical procedure is related to impaired oxygenation caused by inadequate ventilation. Which arterial blood gas value and assessment finding indicates to the nurse that oxygen and incentive spirometry must be administered? A. PaO2 is 90 mmHg with crackles. B. PaO2 is 90 mmHg with wheezing. C. PCO2 is 38 mmHg with clear lung sounds. D. PCO2 is 45 mmHg with atelectasis

42. A patient with a history of bronchitis for more than 20 years is hospitalized. With this patient's history, what is a potential complication? A. Right-sided heart failure B. Left-sided heart failure C. Renal disease D. Stroke

50. In the event of a new severe acute respiratory syndrome (SARS) outbreak, what is the nurse's primary role? A. Immediately report new cases of SARS to the Centers for Disease Control and Prevention (CDC). B. Administer oxygen, standard antibiotics, and supportive therapies to patients. C. Prevent the spread of infection to other employees and patients. D. Initiate and strictly enforce contact isolation procedures.

18. The nursing is giving discharge instructions to a patient diagnosed with a viral pharyngitis. Which statement by the patient indicates the need for further teaching? A. "I should try to rest, increase my fluid intake, and get a humidifier for the house." B. "I will wait for my test results, then I can get a prescription for antibiotics." C. "Over-the-counter analgesics, like Tylenol or ibuprofen, can be used for pain." D. "I should gargle several times a day with warm salt water and use throat lozenges."

A client with heart failure has furosemide (Lasix). Which finding would concern the nurse with this new prescription? a. Serum sodium level of 135 mEq/L b. Serum potassium level of 2.8 mEq/L c. Serum creatinine of 1.0 mg/dL d. Serum magnesium level of 1.9 mEq/L

B: Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy.

A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regularly gallop rhythm d. Coarse crackles in bilateral lung bases

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not relate

43. The nurse is providing discharge instructions about pneumonia to a patient and family. Which discharge information must the nurse be sure to include? A. Complete antibiotics as prescribed, rest, drink fluids, and minimize contact with crowds. B. Take all antibiotics as ordered, resume diet and all activities as before hospitalization. C. No restrictions regarding activities, diet, and rest because the patient is fully recovered when discharged. D. Continue antibiotics only until no further signs of pneumonia are present; avoid exposing immunosuppressed individuals.

44. A patient is admitted to the hospital with cough, purulent sputum production, temperature of 37.9 C, and reports of shortness of breath. Which intervention does the nurse provide first? A. Set up oxygen equipment and administer oxygen. B. Instruct the patient about the importance of keeping the oxygen delivery device on. C. Monitor the effectiveness of oxygen therapy (pulse oximetry, ABGs) as appropriate. D. Monitor the patient's anxiety related to the need for oxygen delivery.

45. A patient has returned several times to the clinic for treatment of respiratory problems. Which action does the nurse perform first? A. Obtain a history of the patient's previous problems and response to therapy. B. Ask the patient to describe his compliance with the prescribed therapies. C. Obtain a request for diagnostic testing, including a tuberculosis and human immunodeficiency virus (HIV) evaluation. D. Listen to the patient's lungs, obtain a pulse oximetry reading, and count the respiratory rate.

46. Which complication of pneumonia creates pain that increases on inspiration because of inflammation of the parietal pleura? A. Pleuritic chest pain B. Pulmonary emboli C. Pleural effusion D. Meningitis

54. The nurse has completed a community presentation about lung cancer. Which statement from a participant demonstrates an understanding of the information presented? A. "The primary prevention for reducing the risk of lung cancer is to stop smoking and avoid secondhand smoke." B. "The overall 5-year survival rate for all patients with lung cancer is 85%." C. "The death rate for lung cancer is less than prostate, breast, and colon cancer combined." D. "Cures are most likely for patients who undergo treatment for stage III disease."

57. Which test result indicates a patient has clinically active TB? A. Induration of 12 mm and positive sputum B. Positive chest x-ray for TB C. Positive chest x-ray and clinical symptoms D. Sputum tests positive for blood

6. A patient reports throat soreness and dryness, throat pain, pain on swallowing (odynophagia), and difficulty swallowing. Which disorder does the nurse suspect? A. Pharyngitis B. Tonsillitis C. Rhinosinusitis D. Pneumonia

63. The nurse is teaching a patient about the combination drug therapy that is used in the treatment of TB. Which patient statement indicates the nurse's instruction was effective? A. "I will take three drugs: isoniazid, rifampin, and pyrazinamide, then ethambutol may be added later." B. "Combining the drugs in one pill is a convenient way for me to take all the medications." C. "The isoniazid combines with the TB bacteria. I can take the rifampin and pyrazinamide if I continue to have symptoms." D. "Combining the medications means to take the isoniazid, rifampin, and pyrazinamide all at the same time."

69. A patient has developed pulmonary hypertension. What is the goal of drug therapy for this patient? A. Dilate pulmonary vessels and prevent clot formation. B. Decrease pain and make the patient comfortable. C. Improve or maintain gas exchange. D. Maintain and manage pulmonary exacerbation.

7. The nurse is helping a patient learn about managing her asthma. What does the nurse instruct the patient to do? A. Keep a symptom diary to identify what triggers the asthma attacks. B. Make an appointment with an allergist for allergy therapy. C. Take a low dose of aspirin every day for the anti-inflammatory action. D. Drinks large amounts of clear fluid to keep mucus thin and watery.

70. A patient is newly diagnosed with sarcoidosis. Which statement by the patient indicates an understanding of the disease? A. "Corticosteroids are the main type of therapy for sarcoidosis." B. "Sarcoidosis is a type of lung cancer that is treatable if diagnosed early." C. "My condition can be treated with antibiotics." D. "Sarcoidosis is a type of pneumonia that is highly contagious."

72. A patient with a history of asthma enters the emergency department with severe dyspnea, accessory muscle involvement, neck vein distention, and severe inspiratory/expiratory wheezing. The nurse is prepared to assist the provider with which emergency procedure if the patient does not respond to initial interventions? A. Intubation B. Needle thoracentesis C. Chest tube insertion D. Pleurodesis

74. The nurse is instructing a patient to use a flutter-valve mucus clearance device. What should the patient be taught to do? A. Inhale deeply and exhale forcefully through the device. B. Use an inhalation technique that is similar to the handheld inhaler. C. Use pursed-lip breathing before and after usage. D. Exhale slowly through the nose, and then inhale by sniffing.

23. In obtaining a history for a patient with chronic airflow limitation, which risk factors are related to potentially causing or triggering the disease process? (Select all that apply.) A. Cigarette smoking B. Occupational and air pollution C. Genetic tendencies D. Smokeless tobacco E. Occupation

A, B, C, E

3. The nurse is caring for an older adult patient with a chronic respiratory disorder. Which interventions are best to use in caring for this patient? (Select all that apply.) A. Provide rest periods between activities such as bathing, meals, and ambulation. B. Place the patient in a supine position after meals to allow fore rest. C. Schedule drug administration around routine activities to increase adherence to drug therapy. D. Arrange chairs in strategic locations to allow the patient to walk and rest. E. Teach the patient to avoid getting the pneumococcal vaccine. F. Encourage the patient to have an annual flu vaccination.

A, C, D, F

13. Which patients are at risk for developing health-care acquired pneumonia? (Select all that apply.) A. Confused patient B. Patient with atrial fibrillation who is alert and oriented C. Patient with Gram-negative colonization of the mouth D. Patient with hyperthyroid disease E. Malnourished patient

A, C, E

4. A patient comes to the walk-in clinic reporting seasonal nasal congestion; sneezing; rhinorrhea; and itchy, watery eyes. The nurse identifies that the patient most likely has rhinitis and should also be assessed for sinusitis. Which manifestations does the nurse assess in a patient with rhinosinusitis? (Select all that apply.) A. Pain over the right cheek radiating to the teeth. B. Tenderness to percussion over the sinuses. C. Generalized musculoskeletal achiness. D. General facial pain when bending forward. E. Referred pain to the temple or back of the head.

A, B, D, E

9. Which factors can contribute to acute pharyngitis? (Select all that apply.) A. Viruses B. Coughing C. Irritants D. Bacteria E. Alcohol

A, C, D, E

13. For a patient that is a nonsmoker, which classic assessment finding of chronic airflow limitation is particularly important in diagnosing asthma? A. Cyanosis B. Dyspnea C. Audible wheezing D. Tachypnea

Which patient has the greatest risk for developing ARDS?

a. 74-year-old who aspirates a tube feeding

A pt with PE asks for an explanation of heparin therapy. what is the nurse's best response?

d. "it increases the time it takes for blood to clot, therefore preventing further clotting and improving blood flow."

Ch. 31,33,35

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