Exam 1

A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize? A. Provide emotional support to the patient and family. B. Schedule a visit to the patient's primary physician within 24 hours. C. Notify the physician that the patient needs a referral to a psychiatrist. D. Place a referral for a social worker to visit the patient.

A. Provide emotional support to the patient and family. Rationale: The recovery process may take longer than the patient had expected, and providing support to the patient is an important task for the home care nurse. It is not necessary, based on this scenario, to schedule a visit with the physician within 24 hours, or to get a referral to a psychiatrist or a social worker.

The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A. Between 10 and 15 mm Hg B. Between 15 and 20 mm Hg C. Between 20 and 25 mm Hg D. Between 25 and 30 mm Hg

B. Between 15 and 20 mm Hg Rationale: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg.

A client is to be discharged home on oxygen therapy. What information does the nurse teach the client? A. "Carry the H cylinder tank on short trips." B. "Only use the E tank when stationary." C. "The D or C cylinder can be carried." D. "Roll the tank gently when transporting."

C. "The D or C cylinder can be carried." Rationale: The D and C cylinders are small enough to be carried. The H cylinder cannot be carried. The E tank can be transported. The tanks should not be rolled and should be carried only in a stand or a rack.

Which instructions would the nurse include when teaching self-care strategies to a patient with acute pharyngitis? Select all that apply. A. Drink citrus juices. B. Restrict fluid intake. C. Gargle with warm salt water. D. Suck on popsicles or hard candies. E. Use a cool mist vaporizer or humidifier.

C. Gargle with warm salt water. D. Suck on popsicles or hard candies. E. Use a cool mist vaporizer or humidifier.

The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO2 is the client receiving? A. 24% B. 28% C. 36% D. 40%

D. 40% Rationale: A nasal cannula can provide oxygen at 0.5 to 6 L/min, corresponding to an FiO2 range of 25% to 40%. At 5 L/min, the client is receiving 40% oxygen.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem should the nurse assign as the priority? A. Fatigue B. Hyperthermia C. Impaired mobility D. Impaired gas exchange

D. Impaired gas exchange Rationale: All these problems are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and severe pleuritic chest pain. Which prescribed medication should the nurse give FIRST? A. Codeine B. Guaifenesin C. Acetaminophen (Tylenol) D. Piperacillin/tazobactam (Zosyn)

D. Piperacillin/tazobactam (Zosyn) Rationale: Early initiation of antibiotic therapy has been shown to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A. 20 cm H2O B. 15 cm H2O C. 10 cm H2O D. 5 cm H2O

A. 20 cm H2O Rationale: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? Select all that apply. A. Age B. Blood pressure C. Respiratory rate D. O2 saturation E. Presence of confusion F. Blood urea nitrogen (BUN) level

A. Age B. Blood pressure C. Respiratory rate E. Presence of confusion F. Blood urea nitrogen (BUN) level Rationale: Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). The other information is also essential to assess but are not used for CURB-65 scoring.

A client has begun therapy with theophylline. The nurse should plan to teach the client to limit the intake of which items while taking this medication? A. Coffee, cola, and chocolate B. Oysters, lobster, and shrimp C. Melons, oranges, and pineapple D. Cottage cheese, cream cheese, and dairy creamers

A. Coffee, cola, and chocolate Rationale: Theophylline is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate.

A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse? A. Constant, nonproductive coughing B. Blood-tinged sputum C. Rhonchi in upper lobes D. Dry mucous membranes

A. Constant, nonproductive coughing Rationale: Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough, substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is not an emergent problem. Dry mucous membranes should be lubricated, and the client's hydration status can be checked.

Which topics will the nurse include in discharge teaching for a patient who has had a complete laryngectomy? Select all that apply. A. How to obtain a Medic Alert bracelet B. Care of the stoma or laryngectomy tube C. Ways to hide the stoma with a scarf or shirt D. Use of a smartphone with a text-to-speech app E. Ways to decrease aspiration risk when swallowing.

A. How to obtain a Medic Alert bracelet B. Care of the stoma or laryngectomy tube C. Ways to hide the stoma with a scarf or shirt D. Use of a smartphone with a text-to-speech app

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. A. Post thoracotomy B. Spontaneous pneumothorax C. Need for postural drainage D. Chest trauma resulting in pneumothorax E. Pleurisy

A. Post thoracotomy B. Spontaneous pneumothorax D. Chest trauma resulting in pneumothorax Rationale: Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system.

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? A. Weak cough effort B. Profuse green sputum C. Respiratory rate of 28 breaths/min D. Resting pulse oximetry (SpO2) of 85%

A. Weak cough effort Rationale: The weak cough effort indicates that the patient is unable to clear the airway effectively. The other data suggest problems with gas exchange and breathing pattern.

Before removing a PICC, the nurse should give what instructions to the patient? A. "Take several quick breaths to oxygenate." B. "Take a deep breath and hold it." C. "Inhale quickly when the catheter is being removed." D. "Breathe normally during the removal process."

B. "Take a deep breath and hold it." Rationale: When removing a PICC, the nurse should instruct the patient to take a deep breath and hold it or exhale; this action prevents complications associated with air emboli. Breathing normally, inhaling, or taking several quick breaths does not maintain the ventilatory air pressure needed to avoid potential complications.

Which action should the nurse take first when a patient develops epistaxis? A. Pack the affected nare tightly with an epistaxis balloon. B. Apply squeezing pressure to the nostrils for 10 minutes. C. Obtain silver nitrate that may be needed for cauterization. D. Instill a vasoconstrictor medication into the affected nare.

B. Apply squeezing pressure to the nostrils for 10 minutes. Rationale: Application of cold packs may decrease blood flow to the area but will not be sufficient to stop bleeding. Cauterization, nasal packing, and vasoconstrictors are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? A. Chest x-ray via stretcher B. Blood cultures from two sites C. Ciprofloxacin (Cipro) 400 mg IV D. Acetaminophen (Tylenol) suppository

B. Blood cultures from two sites Rationale: Initiating antibiotic therapy rapidly is essential, but it is important to obtain the cultures before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

Which information will be most important for the nurse to communicate to the health care provider about an older patient who has influenza? A. Fever of 100.4° F (38° C) B. Diffuse crackles in the lungs C. Sore throat and frequent cough D. Myalgia and persistent headache

B. Diffuse crackles in the lungs Rationale: The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter pain relievers and increased fluid intake.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity? A. Bradycardia and frontal headache B. Dyspnea and substernal pain C. Peripheral cyanosis and restlessness D. Hypotension and tachycardia

B. Dyspnea and substernal pain Rationale: Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.

The nurse is discussing techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? A. Palpation and clubbing B. Percussion and vibration C. Hyperoxygenation and suctioning D. Administer a bronchodilator and monitor peak flow

B. Percussion and vibration Rationale: Chest physiotherapy of percussion and vibration helps to loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus move from smaller airways to larger ones to support expectoration of the mucus. Options A, C, and D are not actions that will loosen secretions.

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure? A. Beclomethasone first and then the salmeterol B. Salmeterol first and then the becolmethasone C. Alternating a single puff of each, beginning with the salmeterol D. Alternating a single puff of each, beginning with the beclomethasone

B. Salmeterol first and then the becolmethasone Rationale: Salmeterol is an adrenergic type of bronchodilator and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? A. Teach about the reason for the blood tests. B. Schedule an appointment for a chest x-ray. C. Teach the patient about providing specimens for 3 consecutive days. D. Instruct the patient to collect several separate sputum specimens today.

C. Teach the patient about providing specimens for 3 consecutive days. Rationale: Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used to test for tuberculosis. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.

Which statement by the student nurse indicates a need for further instruction about airway obstruction? A. "Airway obstruction can be either partial or complete." B. "Endotracheal intubation may be performed to reestablish the airway." C."Ventilation should be provided after 10 minutes of complete airway obstruction." D." Airway obstruction may be caused by aspiration of food contents into the windpipe."

C."Ventilation should be provided after 10 minutes of complete airway obstruction." Rationale: Complete airway obstruction should be corrected within 3 to 5 minutes because a delay can lead to permanent brain damage or death. p. 487

Which nursing action would be of highest priority when suctioning a patient with a tracheostomy? A. Auscultating lung sounds after suctioning is complete. B. Giving anti-anxiety medications 30 minutes before suctioning C. Instilling 5 mL of normal saline into the tracheostomy tube before suctioning. D. Assessing the patient's oxygen saturation before, during, and after suctioning

D. Assessing the patient's oxygen saturation before, during, and after suctioning

Which action would the nurse take for a patient with acute pharyngitis whose laboratory reports indicate the presence of a candidiasis infection? A. Suggest that the patient avoid aspirin. B. Teach the patient to drink lemon juice. C. Instruct the patient to avoid cold beverages. D. Educate the patient to gargle with warm salt water.

D. Educate the patient to gargle with warm salt water. Rationale: Gargling with warm salt water helps in relieving swelling and discomfort in the throat. The patient may have aspirin or ibuprofen as needed for pain. Lemon is a citrus fruit and would result in more throat irritation. Warm and cold fluids can reduce throat pain for patients with pharyngitis related to Candida. p. 487

The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan? A. Administration of inhaled corticosteroids B. Assessment of neurologic status C. Turning and coughing D. Signs of pulmonary infection

D. Signs of pulmonary infection Rationale: The nurse teaches the patient and family about the ventilator, suctioning, tracheostomy care, signs of pulmonary infection, cuff inflation and deflation, and assessment of vital signs. Neurologic assessment and turning and coughing are less important than signs and symptoms of infection. Inhaled corticosteroids may or may not be prescribed.

While palpating the skin around a patient's CVAD insertions site, the nurse elicits a crackling sound. What might this finding indicate? A. Catheter occlusion B. Infection C. Skin erosion D. Subcutaneous emphysema

D. Subcutaneous emphysema Rationale: A crackling sound or sensation probably indicates subcutaneous emphysema as a manifestation of pneumothorax, hemothorax, air embolism, or hydrothorax. A crackling or popping sound does not indicate catheter occlusion and is not associated with infection or with skin erosion.

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this? A. Maintaining a patent airway B. Preventing the need for suctioning C. Maintaining the sterility of the patient's airway D. Increasing the patient's lung compliance

A. Maintaining a patent airway Rationale: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a patient with an endotracheal or a tracheostomy tube. The other answers are incorrect.

The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client? A. Teach him postural drainage. B. Teach him how to perform huffing. C. Teach him to use a mini-nebulizer. D. Teach him how to use a metered dose inhaler.

B. Teach him how to perform huffing. Rationale: The technique of "huffing" may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.

The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis? A. Asthma B. Pneumonia C. Lung cancer D. COPD

D. COPD Rationale: Breathing retraining is especially indicated in patients with COPD and dyspnea. Breathing retraining may be indicated in patients with other lung pathologies, but not to the extent indicated in patients with COPD.

A patient tells the nurse he had the bacilli Calmette-Guérin (BCG) vaccination as a child because his mother had tuberculosis. How should the nurse expect this patient to be screened for tuberculosis? A. tine test B. Mantoux test C. Tine and Mantoux tests D. chest x-ray

D. Chest x-ray Rationale: Periodic chest x-rays may be required for screening purposes. After vaccination with BCG, a positive reaction to tuberculin testing is common.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? A. Slow, deep respirations B. Rapid, deep respirations C. Paradoxical respirations D. Pain, especially with inspiration

D. Pain, especially with inspiration Rationale: Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest. Test-Taking Strategy: Focus on the subject, findings associated with a rib fracture. Focusing on the anatomical location of the injury will direct you to the correct option.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? A. Sitting up in bed B. Side-lying in bed C. Sitting in a recliner chair D. Sitting up and leaning on an overbed table

D. Sitting up and leaning on an overbed table Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is MOST important to communicate to the health care provider? A. The Mantoux test had an induration of 7 mm. B. The chest x-ray showed infiltrates in the lower lobes. C. The patient has a cough that is productive of blood-tinged mucus. D. The patient is being treated with antiretrovirals for HIV infection.

D. The patient is being treated with antiretrovirals for HIV infection. Rationale: Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

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Which statement made by the student nurse indicates that education regarding tracheostomy tubes has been effective? A. "A patient may be able to speak with a tracheostomy tube." B. "A patient cannot eat and drink while using a tracheostomy tube." C. "There is more discomfort to the patient who uses a tracheostomy tube than an endotracheal tube." D. "There is more risk of damage to the vocal cords with a tracheostomy tube than with an endotracheal tube."

A. "A patient may be able to speak with a tracheostomy tube." Rationale: Patients who use a tracheostomy tube may be able to learn to speak with the tube in place. Patients with tracheostomy tubes can eat. Because a tracheostomy tube will move around less and does not have to go through the oropharynx, it will be more comfortable than an endotracheal tube. Because the tracheostomy tube moves around less within the trachea, there will be less risk of vocal cord damage. p. 488

The nurse is removing a PICC from a patient being treated for glaucoma. Which instruction should the nurse give this patient? A. "Hold your breath but do not bear down." B. "Lie on your right side during the procedure." C. "Raise the catheter site above the heart during the procedure." D. "Wear protective goggles during the procedure."

A. "Hold your breath but do not bear down." Rationale: A patient with glaucoma should avoid the Valsalva response and should not bear down during PICC removal; instead, she should hold her breath to reduce the risk of venous air embolus. The patient should also be placed in the Trendelenburg position or the left lateral decubitus position (not the right side) and instructed to keep the arm with the PICC below the level of the heart. There is no need for the patient to wear protective goggles.

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient reports hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask? A. "How much alcohol do you drink in an average week?" B. "Do you have a family history of head or neck cancer?" C. "Have you had frequent streptococcal throat infections?" D. "Do you use antihistamines for upper airway congestion?"

A. "How much alcohol do you drink in an average week?" Rationale: Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Patients with streptococcal throat infections will also have pain and a fever.

The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the the therapy. Which statement by the client indicates an understanding of the instructions? A. "I must take the medication exactly as prescribed." B. "Once I start the medication, I will no longer be contagious." C. "I will not get any colds or infections while taking this medication." D. "This medication has minimal side effects and I can return to normal activities."

A. "I must take the medication exactly as prescribed." Rationale: Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza and clients are usually contagious for up 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate a change in activities, especially when driving or operating machinery if dizziness occurs.

After the nurse provides discharge teaching for a patient who has a new laryngectomy, which patient statement reflects an adequate understanding of the care of the laryngectomy? A. "I will cover my stoma if I cough." B. "I can swim as long as I don't get my neck wet." C. "I will remove the tube once a week for cleaning." D. "I will clean the area around the stoma with alcohol."

A. "I will cover my stoma if I cough." Rationale: The patient should cover the stoma when coughing to avoid the spread of mucous droplets to others. Swimming is contraindicated when a laryngectomy is present because of the likelihood of aspiration. The laryngectomy tube should be removed daily for cleaning. Alcohol would be drying to the skin around the stoma; the area around the stoma is cleaned with a moist cloth. p. 498

Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx? A. "I will need to buy a water bottle to carry with me." B. "I should not use any lotions on my neck and throat." C. "Until the radiation is complete, I may have diarrhea." D. "Alcohol-based mouthwashes will help clean my mouth."

A. "I will need to buy a water bottle to carry with me." Rationale: Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

The nurse teaches a client about the effects of diphenhydramine, which has been prescribed as a cough suppressant. The nurse determines that the client needs further instruction if the client makes which statement? A. "I will take the medication on an empty stomach." B. "I won't drink alcohol while taking this medication." C. "I won't do activities that require mental alertness while taking this medication." D. "I will use sugarless gum, candy, or oral rinses to decrease dryness in my mouth."

A. "I will take the medication on an empty stomach." Rationale: Diphenhydramine has several uses, including as an antihistamine, antitussive, antidyskinetic, and sedative hypnotic. Instructions for use including taking with food or milk to decrease gastrointestinal upset and using oral rinses, sugarless gum, or hard candy to minimize dry mouth. Because the medication causes drowsiness, the client should avoid use of alcohol or central nervous system depressants, operating a car, or engaging in other activities requiring mental awareness during use.

The nurse is teaching a client about his fenestrated tracheostomy tube. Which statement by the client indicates an accurate understanding of the tube? A. "I'm glad I will still be able to talk with this tube in place." B. "It is great that this tube does not have to be cleaned regularly." C. "This tube will not get dislodged because it never needs suctioning." D. "Because I can't swallow, I will need another tube for eating."

A. "I'm glad I will still be able to talk with this tube in place." Rationale: The client can speak with a fenestrated tube, which has a hole in it and allows air to flow over the vocal cords. The tube still needs to be cleaned and suctioned. The tube may become dislodged, and the client is able to swallow.

A nurse is teaching a student nurse about the type of dressing to place on the insertion site after removing a PICC. Which statement would indicate the student nurse understood the information? A. "Place petroleum-based ointment and cover it with an occlusive sterile gauze dressing immediately on the site." B. "Put a dry sterile gauze over the site and tape it on three sides." C. "Use a transparent semipermeable dressing and change it every seven days." D. "Using a sterile swab, put some antibiotic cream over the side, and then cover it with gauze dressing."

A. "Place petroleum-based ointment and cover it with an occlusive sterile gauze dressing immediately on the site." Rationale: A dressing with petroleum-based ointment minimizes the risk of a venous air embolism. Dry gauze should not be used because it allows air to communicate with the removal site. A transparent semipermeable dressing may be placed over the sterile gauze with petroleum-based ointment, but it should not be used directly on the site. Antibiotic cream should not be used because it may be permeable to air entering the site and cause an embolism.

When planning health care teaching to prevent or detect early head and neck cancer, which people would be the priority to target? Select all that apply. A. 65-year-old man who has used chewing tobacco most of his life B. 45-year-old rancher who uses snuff to stay awake while driving his herds of cattle C. 21-year-old college student who drinks beer on weekends with his fraternity brothers D. 78-year-old woman who has been drinking liquor since her husband died 15 years ago E. 22-year-old woman who has been diagnosed with human papilloma virus of the cervix

A. 65-year-old man who has used chewing tobacco most of his life B. 45-year-old rancher who uses snuff to stay awake while driving his herds of cattle D. 78-year-old woman who has been drinking liquor since her husband died 15 years ago E. 22-year-old woman who has been diagnosed with human papilloma virus of the cervix

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination? (Select all that apply.) A. A 76-yr-old nursing home resident B. A 36-yr-old female patient who is pregnant C. A 42-yr-old patient who has a 15 pack-year smoking history D. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis E. A 24-yr-old patient who has allergies to penicillin and cephalosporins

A. A 76-yr-old nursing home resident B. A 36-yr-old female patient who is pregnant D. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis Rationale: Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old patient increases the risk for infection. Current guidelines suggest that healthy individuals between 6 months and age 49 years receive intranasal immunization with live, attenuated influenza vaccine.

Which patient in the ear, nose, and throat clinic should the nurse assess first? A. A patient who reports having a sore throat and has a muffled voice. B. A patient with a history of a total laryngectomy whose stoma is red. C. A patient who has a "scratchy throat" and a positive rapid strep antigen test. D. A patient who is receiving radiation for throat cancer and has severe fatigue.

A. A patient who reports having a sore throat and has a muffled voice. Rationale: A muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. A tracheal stoma is normally red. Strep throat and fatigue do not indicate life-threatening problems.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. A. Activities should be resumed gradually. B. Avoid contact with other individuals, except family members, for at least 6 months. C. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. D. Respiratory isolation is not necessary because family members already have been exposed. E. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. F. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

A. Activities should be resumed gradually. C. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. D. Respiratory isolation is not necessary because family members already have been exposed. E. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues in plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment. Test-Taking Strategy: Focus on the subject, home care instructions for tuberculosis. Knowledge regarding the pathophysiology, transmission, and treatment of tuberculosis is needed to answer this question. Read each option carefully to answer correctly.

How can the nurse best minimize a patient's risk for infection during tracheostomy care? A. Adhere to sterile technique when appropriate. B. Frequently assess for signs of local or systemic infection. C. Monitor for indications that tracheostomy care is needed. D. Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.

A. Adhere to sterile technique when appropriate. Rationale: Adherence to sterile technique is the most important factor in minimizing the patient's risk for infection during tracheostomy care. Proper assessment is important but will not reduce the patient's risk for infection during tracheostomy care. Monitoring the patient for indications that tracheostomy care is needed will not reduce the patient's risk for infection. Although the NAP would be instructed to report changes in tracheal drainage, such notification will not minimize the patient's risk for infection.

When the nursing supervisor is observing a newly hired nurse during suctioning of a tracheostomy patient, which action by the new nurse would require intervention? A. Apply suction while inserting the catheter B. Limiting the suction time to 10 seconds or less C. Providing preoxygenation for a minimum of 30 seconds before the procedure D. Assessing the patient's SpO2 and heart rate and rhythm during the procedure.

A. Apply suction while inserting the catheter Rationale: Suction is not applied while inserting the catheter because this will cause unnecessary trauma to the tracheal mucosa; suction is applied as the catheter is being withdrawn. Suction time should be limited to 10 to 15 seconds or less to help decrease discomfort and minimize hypoxemia. Preoxygenation prior to suctioning helps prevent hypoxemia during and after suctioning. Because hypoxemia is a complication of suctioning, it is imperative that the nurse monitor indicators of oxygenation status, such as SpO2, heart rate, and heart rhythm, during the procedure. p. 491

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? A. Auscultate for breath sounds. B. Administer as-needed morphine. C. Have the patient cough forcefully. D. Notify the patient's health care provider.

A. Auscultate for breath sounds. Rationale: The patient's statement indicates that pleurisy or a pleural effusion may have developed, and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

Which nursing actions are included when providing tracheostomy care to a patient? Select all that apply. A. Auscultating lung sounds B. Removing soiled dressing C. Limiting care to once daily D. Explaining the procedure to the patient E. Assisting the patient to the Sims' position

A. Auscultating lung sounds B. Removing soiled dressing D. Explaining the procedure to the patient Rationale: Before starting tracheostomy care, the nurse will auscultate for lung sounds to check for the presence of rhonchi or coarse crackles; if they are present, the nurse can encourage the patient to cough up secretions or suction the tracheostomy. Removal of the soiled dressing and replacement with a clean dressing is included in tracheostomy care. Before starting the procedure, the nurse will explain the procedure to the patient to reduce anxiety. Tracheostomy care is provided at least three times daily but may be needed more frequently depending on amount and type of secretions. The patient should be in the semi-Fowler's position during tracheostomy care to improve breathing and decrease aspiration risk. p. 491

What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has gauze dressing? A. Change the dressing every 48 hours. B. Apply sterile gloves to remove the original dressing. C. Cleanse the catheter and insertion site with sterile saline. D. Label the dressing with the date and time of application and the nurse's initials.

A. Change the dressing every 48 hours. Rationale: A gauze dressing on a CVAD should be changed every 48 hours and as needed. Doing so will reduce the patient's risk for infection. It is not necessary to wear sterile gloves to remove the soiled dressing. Cleansing the site with sterile saline will not minimize the patient's risk for infection. Labeling the dressing will not minimize the patient's risk for infection.

Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment? A. Chest auscultation B. Pulmonary function testing C. Chest percussion D. Thoracic palpation

A. Chest auscultation Rationale: Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy. Percussion and palpation are less likely to provide clinically meaningful data for the nurse. PFTs are normally beyond the scope of the nurse and are not necessary immediately before postural drainage.

A patient arrives in the emergency department with a possible nasal fracture after being hit by a baseball. Which finding by the nurse is most important to report to the health care provider? A. Clear nasal drainage B. Report of nasal pain C. Bilateral nose swelling and bruising D. Inability to breathe through the nose

A. Clear nasal drainage Rationale: Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate complications.

Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning? A. Comparing presuctioning and postsuctioning respiratory assessment data B. Confirming that the patient's pulse oximetry value is >90% C. Asking the patient to report any symptoms of dyspnea D. Assessing the patient's skin for signs of cyanosis

A. Comparing presuctioning and postsuctioning respiratory assessment data Rationale: Comparing presuctioning and postsuctioning assessment data allows the nurse to compare the patient's postintervention respiratory status against his or her baseline to see if it has improved. Pulse oximetry readings depend on the patient's health status. A value of >90% does not indicate that suctioning was effective, since it is unknown whether this value represents an improvement over the patient's baseline. The patient might require suctioning even without symptoms of dyspnea or evidence of cyanosis.

The BEST method for determining the risk for aspiration in a patient with a tracheostomy is to A. Consult a speech therapist for swallowing assessment. B. Have the patient drink plain water and assess for coughing. C. Ask the patient to rate the perceived degree of swallowing difficulty. D. Assess for sputum changes 48 hours after the patient drinks small amount of blue dye.

A. Consult a speech therapist for swallowing assessment.

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session? (Select all that apply.) A. Decongestants can be used to relieve swelling. B. Avoid blowing the nose to decrease the nosebleed risk. C. Taking a hot shower will increase sinus drainage and decrease pain. D. Saline nasal spray can be made at home and used to wash out secretions. E. You will be more comfortable if you keep your head in an upright position.

A. Decongestants can be used to relieve swelling. C. Taking a hot shower will increase sinus drainage and decrease pain. D. Saline nasal spray can be made at home and used to wash out secretions. E. You will be more comfortable if you keep your head in an upright position. Rationale: The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Document the amount of drainage every 8 hours. B. Obtain samples of drainage for culture from the system. C. Assess patient pain level associated with the chest tube. D. Check the water-seal chamber for the correct fluid level.

A. Document the amount of drainage every 8 hours. Rationale: UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? A. Dyspnea B. Headache C. Weight gain D. Hypothermia

A. Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The Infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. A. Dyspnea B. Headache C. Night sweats D. A bloody, protective cough E. A cough with the expectoration of mucoid sputum

A. Dyspnea C. Night sweats D. A bloody, protective cough E. A cough with the expectoration of mucoid sputum Rationale: Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations.

Which patient data will the nurse monitor when suctioning a patient who has a tracheostomy tube? Select all that apply. A. Heart rate B. Temperature C. Glucose level D. BP E. Oxygen saturation

A. Heart rate E. Oxygen saturation Rationale: Because tachycardia and bradycardia may occur as a result of oxygenation changes during suctioning, the heart rate is obtained before and after suctioning. Hypoxemia may occur during suctioning, and oxygen saturation is frequently monitored throughout the suctioning procedure. Temperature is not affected by suctioning and would not be monitored when suctioning. Glucose levels will not be affected by suctioning. Although BP would be expected to increase during the suctioning procedure as part of the stress response, it is not necessary to monitor BP while suctioning. p. 491

When a tracheostomy is planned for a patient who has had an endotracheal tube (ET) for several weeks, which information will the nurse include when teaching about the advantages of tracheostomy over ET? Select all that apply. A. Improves removal of secretions B. Helps resolve subcutaneous crepitus C. Prevents narrowing of the trachea D. Bypasses an airway obstruction E. Allows for better oral hygiene

A. Improves removal of secretions D. Bypasses an airway obstruction E. Allows for better oral hygiene Rationale: A tracheostomy allows for better removal of respiratory secretions, bypasses airway obstructions, and improves oral hygiene. Subcutaneous emphysema is a complication of tracheostomy that may occur if air leaks under the skin from the patient's airway. Narrowing of the trachea (tracheal stenosis) may occur after tracheostomy if scarring of the trachea occurs. pp. 488, 490

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? A. Increased tactile fremitus B. Dry, nonproductive cough C. Hyperresonance to percussion D. A grating sound on auscultation

A. Increased tactile fremitus Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

A patient who had a Mantoux test for tuberculosis two days ago has a 2 mm area of erythema at the site of the test. The nurse concludes that this patient's response A. Is negative. B. Is positive for tuberculosis. C. should be followed up with a tine test. D. is unable to determine the presence of tuberculosis.

A. Is negative. Rationale: Intradermal PPD or Mantoux test is read within 48 to 72 hours, the peak reaction period, and recorded as the diameter of induration (raised area, not erythema) in millimeters. The area on the patient is erythematous, not an induration. No follow up is needed, as this patient's response is by definition a negative one. A 2 mm area of erythema at the site of the test is negative for tuberculosis. A 2 mm area of erythema at the site of the test is not an indication of the need for a tine test. A 2 mm area of erythema at the site of the test is negative for tuberculosis.

Which actions would the nurse take when performing suctioning of a patient's tracheostomy tube? Select all that apply. A. Limit suction time to 10 to 15 seconds. B. Insert the catheter until it meets resistance. C. Avoid rinsing catheter between suction passes. D. Apply suction continuously while withdrawing the catheter. E. Continue to perform suction passes until the airway is completely clear.

A. Limit suction time to 10 to 15 seconds. D. Apply suction continuously while withdrawing the catheter. Rationale: A long suction time can cause hypoxemia and trauma to the airways; therefore the suction time should be limited to 10 to 15 seconds at a time. The nurse will suction continuously while withdrawing the catheter. Because inserting the catheter until it meets resistance can cause trauma and bleeding of the carina, the catheter should be inserted only until the patient coughs. The catheter should be rinsed with sterile water between suction passes. If the airway is not clear after three suction passes, the nurse will allow the patient time to rest before any further suctioning attempts. p. 491

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? A. Mask B. Gown C. Gloves D. Eye protection

A. Mask Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options B, C, and D are not necessary.

The nurse assesses a client with a new tracheotomy, and the tracheostomy tube is pulsating in synchrony with the client's heartbeat. Which is the nurse's priority action? A. Notify the health care provider immediately. B. Stabilize the tube by reapplying the ties. C. Change the inner cannula of the tube. D. Increase the inflation pressure of the cuff.

A. Notify the health care provider immediately. Rationale: If a tracheostomy tube is pulsating with the client's heart rate, this could indicate proximity to the innominate artery and may cause erosion of the artery if left in this position. The provider should be notified immediately. Reapplying the ties, changing the inner cannula, and increasing the inflation pressure of the cuff are all interventions that will not solve the immediate problem of proximity of the tube to the innominate artery.

When a patient is diagnosed with acute bacterial pharyngitis, which prescribed medication would the nurse question? A. Nystatin B. Ibuprofen C. Penicillin G D. Acetaminophen

A. Nystatin Rationale: Nystatin is an antifungal medication that is used to treat fungal pharyngitis, most typically caused by Candida. Penicillin is the preferred treatment for bacterial pharyngitis. Ibuprofen and acetaminophen are recommended for pain and fever relief. p. 487

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a PRIORITY to communicate to the health care provider? A. O2 saturation is 88%. B. Blood pressure is 155/90 mm Hg. C. Respiratory rate is 24 breaths/min when lying flat. D. Pain level is 5 (on 0 to 10 scale) with a deep breath.

A. O2 saturation is 88%. Rationale: O2 saturation should improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? A. Observe for distended neck veins. B. Auscultate for crackles in the lungs. C. Palpate for heaves or thrills over the heart. D. Monitor for elevated white blood cell count.

A. Observe for distended neck veins. Rationale: Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.

Which action will the nurse take when caring for a patient with pharyngitis? A. Offer a drink of water. B. Suggest that the patient sip hot tea. C. Offer hydrogen peroxide for gargling. D. Encourage the patient to drink orange juice.

A. Offer a drink of water. Rationale: Offering a drink of water is correct because cool, bland liquids, such as water, will not irritate the pharynx. Drinking warm or cold liquid is recommended, but consuming hot tea will irritate the pharynx and cause pain. Gargling with warm salt water can alleviate the symptoms of acute pharyngitis, but hydrogen peroxide will irritate pharyngeal tissues. Citrus juices are acidic and will be irritating and painful. p. 487

After oropharyngeal suctioning, what does the nurse do with the supplies? A. Place the Yankauer catheter in a clean, dry area. B. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle. C. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle. D. Place dirty gloves in the biohazard receptacle in the patient's room.

A. Place the Yankaeur catheter in a clean, dry area. Rationale: Placing the Yankauer catheter in a clean, dry area will protect it until it is needed again. Supplies are not disposed of in the trash, and the Yankauer tube can be used again. The supplies need not be placed in a biohazard bag.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? A. Positive B. Negative C. Inconclusive D. Need for repeat testing

A. Positive Rationale: The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options B, C, and D are incorrect interpretations.

Which interventions help to prevent aspiration during eating for a client with a tracheostomy? (Select all that apply.) A. Provide close supervision for the client during eating and drinking. B. Add liquids to foods to make them thinner and easier to swallow. C. Inflate the tracheostomy cuff tube to maximum pressure before starting. D. Let the client indicate readiness for another bite when being fed. E. Have the client tuck the chin down and forward while swallowing. F. Instruct the client to dry swallow to clear food particles from the throat. G. Place the client in a semi-Fowler's position for an hour after eating.

A. Provide close supervision for the client during eating and drinking. D. Let the client indicate readiness for another bite when being fed. E. Have the client tuck the chin down and forward while swallowing. F. Instruct the client to dry swallow to clear food particles from the throat. Rationale: The client with a tracheostomy will require close supervision, even if the client is feeding himself or herself. Do not rush the client. Allow him or her to indicate when ready for another bite. Teaching interventions should include instructing the client to tuck the chin down and forward while swallowing to encourage food to move down smoothly. Dry swallowing helps remove food residue. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further without a physician's order; if possible, the cuff should be deflated during eating. Placing the client in a semi-Fowler's position after the meal will not prevent aspiration.

The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? A. Pulmonary function studies B. Exercise tolerance tests C. Arterial blood gas values D. Chest x-ray

A. Pulmonary function studies Rationale: Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the patient who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities.

The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order? A. Removal from the ventilator, tube, and then oxygen B. Removal from oxygen, ventilator, and then tube C. Removal of the tube, oxygen, and then ventilator D. Removal from oxygen, tube, and then ventilator

A. Removal from the ventilator, tube, and then oxygen Rationale: The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.

A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with labored respirations. Which action does the nurse perform first? A. Remove bedding from around the adaptor opening. B. Listen to lung sounds and obtain a respiratory rate. C. Call respiratory therapy to check oxygen saturation. D. Notify the provider or Rapid Response Team immediately.

A. Remove bedding from around the adaptor opening. Rationale: The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would effectively change the FiO2. The nurse should ensure that the holes remain unobstructed. Other options are appropriate but are not the first choice, because this simple step may be what solves the problem.

Which health promotion information should the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) A. Resources for support in smoking cessation B. Reasons for annual sputum cytology testing C. Erlotinib (Tarceva) therapy to prevent tumor risk D. Computed tomography (CT) screening for cancer E. Importance of obtaining a yearly influenza vaccination

A. Resources for support in smoking cessation D. Computed tomography (CT) screening for cancer E. Importance of obtaining a yearly influenza vaccination Rationale: Because smoking is the major cause of lung cancer, an important role for the nurse is teaching patients about the benefits of and means of smoking cessation. Screening for using low-dose CT is recommended for high-risk patients Encourage those at risk for pneumonia (e.g., those who smoke) to obtain both influenza and pneumococcal vaccines. Sputum cytology is a diagnostic test but does not prevent cancer or disease. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? A. Right pneumothorax B. Pulmonary embolism C. Displaced endotracheal tube D. Acute respiratory distress syndrome

A. Right pneumothorax Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi. Test-Taking Strategy: Note the strategic word, immediately. Focus on the symptoms presented in the question and note the relationship between right upper lobe and right pneumothorax in the correct option.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side and adverse effects of the medication should the nurse monitor? Select all that apply. A. Signs of hepatitis B. Flulike syndrome C. Low neutrophil count D. Vitamin B6 deficiency E. Ocular pain or blurred vision F. Tingling and numbness of the fingers

A. Signs of hepatitis B. Flulike syndrome C. Low neutrophil count E. Ocular pain or blurred vision Rationale: Rifabutin may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side and adverse effects include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange-colored body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flulike syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid.

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A. Stable vital signs and ABGs B. Pulse oximetry above 80% and stable vital signs C. Stable nutritional status and ABGs D. Normal orientation and level of consciousness

A. Stable vital signs and ABGs Rationale: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Patients who are weaned may or may not have full level of consciousness.

When a patient's heart rate falls from 80 to 60 beats/minute during suctioning, which action will the nurse take? A. Stop suctioning B. Apply continuous suction. C. Apply rapid intermittent suction. D. Start rotating the suction catheter.

A. Stop suctioning Rationale: A drop in the heart rate during suctioning indicates a possible vagal response. If the heart rate drops or increases by 20 beats per minute while suctioning through a tracheostomy tube, suctioning should be stopped immediately. Continuous suctioning will result in worsening bradycardia. Rapid intermittent suctioning will lead to more bradycardia. Rotation of the suction catheter may stimulate the vagus nerve and lead to bradycardia. p. 491

Which information will the nurse include when teaching a patient who has had a complete laryngectomy about transesophageal puncture (TEP)? A. TEP offers good speech quality. B. TEP will take a long time to learn. C. TEP generates mechanical voice quality. D. TEP uses a hand-held device to generate speech.

A. TEP offers good speech quality. Rationale: TEP provides a fistula between the esophagus and trachea with a one-way valved prosthesis that allows patients a good voice quality with minimal training. Esophageal speech takes a long time to learn and has a poorer voice quality. A mechanical voice quality is associated with the use of an electrolarynx. A one-way valve in the tracheoesophageal fistula allows speech with a TEP. p. 496

An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize? A. The importance of adhering closely to the prescribed medication regimen B. The fact that the disease is a lifelong, chronic condition that will affect ADLs C. The fact that TB is self-limiting, but can take up to 2 years to resolve D. The need to work closely with the occupational and physical therapists

A. The importance of adhering closely to the prescribed medication regimen Rationale: Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.

The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse? A. The oxygen saturation is 89%. B. The nose appears red and swollen. C. The patient reports level 8 (0 to 10 scale) pain. D. The patient's temperature is 100.1° F (37.8° C).

A. The oxygen saturation is 89%. Rationale: Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data indicate a need for nursing action but not as immediately as the low O2 saturation.

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A. To remove air from the pleural space B. To drain copious sputum secretions C. To monitor bleeding around the lungs D. To assist with mechanical ventilation

A. To remove air from the pleural space Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

A patient diagnosed with active tuberculosis is in a negative pressure room for respiratory airborne isolation. How long should the nurse maintain the patient in this type of isolation? A. Until sputum specimens for acid-fast bacilli are negative B. Until the Mantoux test (PPD) converts from positive to negative C. Until the patient has orders for discharge D. Until the chest x-ray is normal

A. Until sputum specimens for acid-fast bacilli are negative Rationale: The patient should remain in isolation until sputum cultures have tested negative. Until that time and in spite of treatment, there is no certainty that the patient is not infectious. A positive PPD indicates that an individual has been exposed to tuberculosis and has developed antibodies, so the PPD will not convert back to negative. The patient should not be discharged without evidence that he or she is no longer infectious. The chest x-ray validates the amount of lung involvement; the patient may experience chronic changes, such as nodules.

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated? A. Use a hand-held manometer to measure cuff pressure. B. Review the health record for the prescribed cuff pressure. C. Suction the patient through a fenestrated inner cannula to clear secretions. D. Insert the decannulation plug before removing the nonfenestrated inner cannula.

A. Use a hand-held manometer to measure cuff pressure. Rationale: Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.

Which action will the nurse include when changing a tracheostomy dressing? A. Use an unlined gauze. B. Cut the gauze before using it. C. Change the dressing once every two days. D. Use sterile gloves to remove the used dressing.

A. Use an unlined gauze. Rationale: A dressing designed to be used for a tracheostomy or with an unlined gauze should be used to reduce the risk of inhalation or aspiration of loose threads or threads winding around the tracheostomy tube. Cutting the gauze will lead to loose threads and increase the risk for inhalation of the threads by the patient. The stoma should be cleaned and the dressing changed as needed, but at least every eight hours. Clean gloves may be used to remove the soiled dressing, although sterile gloves are used to replace the dressing after tracheostomy care. p. 491

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB and has never had a positive TB skin test before. Which information should the occupational health nurse plan to teach the staff nurse? A. Use and side effects of isoniazid B. Standard four-drug therapy for TB C. Need for annual repeat TB skin testing D. Bacille Calmette-Guérin (BCG) vaccine

A. Use and side effects of isoniazid Rationale: The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for those who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD? A. Use sterile technique throughout the process. B. Apply a stabilization device if the initial sutures are no longer intact. C. Apply a mask to the patient during the procedure. D. Change the transparent dressing every 48 hours.

A. Use sterile technique throughout the process. Rationale: Using sterile technique throughout the dressing application will minimize the patient's risk for infection. Applying a stabilization device will not reduce the patient's risk for infection. A mask need not be applied to the patient when changing a CVAD. Transparent dressings are changed every 5 to 7 days and as needed.

Which rationales are used to explain the need for humidification of air for a patient who has a tracheostomy? Select all that apply. A. Warm secretions B. Moisturizes secretions C. Decreases risk for stoma infection D. Prevents formation of mucous plugs E. Aids in the prevention of tracheal necrosis

A. Warms secretions B. Moisturizes secretions D. Prevents formation of mucous plugs Rationale: Humidification of inspired air after laryngectomy helps to compensate for the loss of the upper airway mechanisms that warm and moisturize inspired air and helps prevent thick secretions that may lead to mucous plugs. Stoma infection is a concern after laryngectomy but is prevented by frequent stoma cleaning and care, not by humidification. Tracheal necrosis occurs when blood flow to the tracheal capillaries is reduced by overinflation of tracheostomy tube cuff and is not caused by lack of humidification of inspired air. p. 490

An older adult is receiving standard multidrug therapy for tuberculosis (TB). Which finding should the nurse report to the health care provider? A. Yellow-tinged sclera B. Orange-colored sputum C. Thickening of the fingernails D. Difficulty hearing high-pitched voices

A. Yellow-tinged sclera Rationale: Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) A. Obtain the O2 saturation. B. Check the patient's pulse rate. C. Document the change in status. D. Notify the health care provider.

ANS: A, B, D, C Rationale: Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) A. The patient is in a side-lying position with the head of the bed flat. B. The patient is coughing blood-tinged secretions from the tracheostomy. C. c. The nasogastric (NG) tube is disconnected from suction and clamped off. D. The wound drain in the neck incision contains 200 mL of bloody drainage.

ANS:A, B, D, C Rationale: The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse? A. "Are you ready to talk with family members about dying?" B. "Can you tell me what makes you think you will die so soon?" C. "Do you think that an antidepressant medication would be helpful?" D. "Would you like to talk to the hospital chaplain about your feelings?"

B. "Can you tell me what makes you think you will die so soon?" Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? A. "I will drink lots of juices and other fluids to stay well hydrated." B. "I can use nasal decongestant spray until the congestion is gone." C. "I can take acetaminophen (Tylenol) to treat my sinus discomfort." D. "I will watch for changes in nasal secretions or the sputum that I cough up."

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

The nurse provides discharge instructions for a patient after a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? A. "I can participate in fitness activities except swimming." B. "I must keep the stoma covered with an occlusive dressing." C. "I need to have smoke and carbon monoxide detectors installed." D. "I will wear a Medic-Alert bracelet to identify me as a neck breather."

B. "I must keep the stoma covered with an occlusive dressing." Rationale: An occlusive dressing will completely block the patient's airway. The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? A. "I will call my health care provider if I still feel tired after a week." B. "I will continue to do deep breathing and coughing exercises at home." C. "I will schedule two appointments for the pneumonia and influenza vaccines." D. "I will cancel my follow-up chest x-ray appointment if I feel better next week."

B. "I will continue to do deep breathing and coughing exercises at home." Rationale: Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

A family member has been taught to provide oral care to a client with a tracheostomy. Which statement by the family member indicates an accurate understanding of the correct way to provide mouth care? A. "I can use glycerin swabs." B. "I'll use water and a toothette." C. "I can use hydrogen peroxide." D. "It is okay to use mouthwash."

B. "I'll use water and a toothette." Rationale: The best choice for mouth care is water and a toothette because these are the least irritating. Glycerin swabs, hydrogen peroxide, and mouthwash all are too irritating to the mucous membranes of the mouth.

Which statement made by the student nurse demonstrates understanding regarding the care of the patient's tracheostomy tube? A. "The extra tracheostomy tube will be kept at the nurses' station." B. "The obturator should be removed after tube insertion." C. "The outer cannula will be inserted into the obturator." D. "The tracheostomy cuff is inflated when the patient needs to speak."

B. "The obturator should be removed after tube insertion." Rationale: The obturator is an accessory that guides the outer cannula and prevents scraping of the tracheal walls while the tracheostomy tube is being inserted and is removed immediately after tracheostomy tube insertion to allow airflow to the patient through the tube. A sterile extra tracheostomy tube is kept at the patient's bedside in case of accidental decannulation so that immediate reinsertion of the tracheostomy can be accomplished. The obturator is inserted into the outer cannula to facilitate insertion of the tracheostomy tube. The tracheostomy cuff is deflated when a patient needs to speak to allow air to pass over the vocal cords. pp. 490, 492

A client is being discharged with a tracheostomy and voices concern about his appearance. What discharge teaching will assist the client with maintaining a positive body image? A. "Tell people how sick you were when they ask about the tracheostomy." B. "Your clothing can help hide the tracheostomy so it is not as noticeable." C. "You can put a bandage around your tracheostomy so no one will see it." D. "You have to ignore comments that people make about your appearance."

B. "Your clothing can help hide the tracheostomy so it is not as noticeable." Rationale: The client may have an alteration in body image because of the tracheostomy stoma. Encourage the client to wear loose-fitting shirts and collars to help hide the appearance of the stoma. Clients should not be encouraged to tell people about their illness, because they should not be made to "justify" their appearance. You should not bandage the tracheostomy, because airflow would be impaired. Ignoring comments will not help the client's self-image.

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? A. 5 seconds B. 10 seconds C 30 seconds D. 60 seconds

B. 10 seconds Rationale: Hypoxemia can be caused by prolonged suctioning which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must pre-oxygenate the client before suctioning and limit the suctioning pass to 10 seconds. Test-Taking Strategy: Focus on the subject, the procedure for suctioning. Recall that during suctioning, the client's airway is blocked; therefore, you should be able to eliminate options C and D easily. From the remaining options, eliminate option A because of the short time frame. Five seconds does not seem reasonable to achieve removal of secretions.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? A. A 77-yr-old patient with tuberculosis (TB) who has four medications due B. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath C. A 35-yr-old patient with pneumonia who has a temperature of 100.2° F (37.8° C) D. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled

B. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath Rationale: Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

A patient who is taking rifampin (Rifadin) as part of his treatment for tuberculosis asks about making an appointment for a urologist because his urine is "bright orange." What should the nurse realize this patient is experiencing? A. A secondary urinary tract infection B. A common side effect of rifampin therapy C. The onset of a kidney stone D. Early renal failure

B. A common side effect of rifampin therapy Rationale: Rifampin (Rifadin) causes body fluids, including sweat, urine, saliva, and tears, to turn red-orange. This is not harmful. Bright orange urine is not a symptom for urinary tract infection. Bright orange urine does not indicate early renal failure.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease Which findings would the nurse expect to note on assessment of this client? Select all that apply. A. A low arterial PCo2 level B. A hyperinflated chest noted on the chest x-ray C. Decreased oxygen saturation with mild exercise D. A widened diaphragm noted on the chest x-ray E. Pulmonary function tests that demonstrate increased vital capacity

B. A hyperinflated chest noted on the chest x-ray C. Decreased oxygen saturation with mild exercise Rationale: Clinical manifestations of chronic obnstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity. Test-Taking Strategy: Focus on the subject, manifestations of COPD. Think about the pathophysiology associated with this disorder. Remember that hypercapnia, a hyperinflated chest, a flat diaphragm, oxygen desaturation on exercise, and decreased vital capacity are manifestations.

What would the critical care nurse recognize as a condition that may indicate a patient's need to have a tracheostomy? A. A patient has a respiratory rate of 10 breaths per minute. B. A patient requires permanent ventilation. C. A patient exhibits symptoms of dyspnea. D. A patient has respiratory acidosis.

B. A patient requires permanent ventilation. Rationale: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? A. The patient is offered a tissue from the box at the bedside. B. A surgical face mask is applied before visiting the patient. C. A snack is brought to the patient from the unit refrigerator. D. Hand washing is performed before entering the patient's room.

B. A surgical face mask is applied before visiting the patient. Rationale: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? A. Clamp the chest tube in two places. B. Administer the prescribed morphine. C. Milk the chest tube to remove any clots. D. Assist the patient with incentive spirometry.

B. Administer the prescribed morphine. Rationale: Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

Which assessment has the highest priority when the nurse is caring for a patient who is three hours postoperative laryngectomy? A. Patient pain B. Airway patency C. Incisional drainage D. BP and heart rate

B. Airway patency Rationale: Because postoperative swelling may compress the trachea, assessing for airway patency has the highest priority after laryngectomy. Assessment and management of postoperative pain are also important but not as high of a priority as maintaining airway patency. There are large blood vessels in the neck, and frequency assessment of incisional drainage is essential, but changes in respiratory status have a higher priority. BP and heart rate will be frequently monitored but are not as important as assessment for respiratory compromise. p. 497

A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do first? A. Notify the health care provider B. Assess the client's pulse oximetry C. Document the observation. D. Raise the head of the bed.

B. Assess the client's pulse oximetry Rationale: Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more oxygen. Although you would want to notify the provider of the change in the client's condition, the best action is first to assess pulse oximetry and then to increase the oxygen. You would not just document the assessment finding without intervening. Raising the head of the bed would not help the client oxygenate better.

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A. Fluid intake for the last 24 hours B. Baseline arterial blood gas (ABG) levels C. Prior outcomes of weaning D. Electrocardiogram (ECG) results

B. Baseline arterial blood gas (ABG) levels Rationale: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patient's record, and the nurse can refer to them before the weaning process begins.

The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patient's high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response? A. CPAP allows a higher percentage of oxygen to be safely used. B. CPAP allows a lower percentage of oxygen to be used with a similar effect. C. CPAP allows for greater humidification of the oxygen that is administered. D. CPAP allows for the elimination of bacterial growth in oxygen delivery systems.

B. CPAP allows a lower percentage of oxygen to be used with a similar effect. Rationale: Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive end-expiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent microatelectasis, thus allowing a lower percentage of oxygen to be used. Oxygen is moistened by passing through a humidification system. Changing the tubing on the oxygen therapy equipment is the best technique for controlling bacterial growth.

Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? A. Cleaning the stoma with hydrogen peroxide and drying thoroughly B. Cleaning and assessing the skin around the stoma C. Assessing temperature and reporting skin breakdown immediately D. Allowing the patient to re-oxygenate after each tracheal suctioning

B. Cleaning and assessing the skin around the stoma Rationale: Frequently cleaning and assessing the skin in the tracheostomy area will reduce the patient's risk for skin breakdown. Hydrogen peroxide is not used to cleanse the stoma and could injure the patient's skin. Assessing for signs of infection and reporting skin breakdown will not reduce the patient's risk for injury. Re-oxygenating after suctioning will not reduce the patient's risk for skin breakdown.

How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? A. Asking the patient about symptoms of respiratory difficulty. B. Comparing respiratory assessment data from before and after the suctioning procedure. C. Confirming that the patient's pulse oximetry value is >90%. D. Auscultating the patient's chest after suctioning.

B. Comparing respiratory assessment data from before and after the suctioning procedure. Rationale: Comparing presuctioning and postsuctioning assessment data will provide the best measure of the procedure's efficacy. The patient may have needed suctioning without experiencing respiratory difficulty. The patient's normal pulse oximetry value may not be >90%. The nurse might be able to auscultate clear breath sounds; however, this information must be evaluated in light of presuctioning and postsuctioning assessment data to evaluate the procedure's efficacy.

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? A. Adjust the dial on the wall regulator. B. Continue to monitor the collection device. C. Document the presence of a large air leak. D. Notify the surgeon of a possible pneumothorax.

B. Continue to monitor the collection device. Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? A. Correct use of a ventilator B. Correct use of incentive spirometry C. Correct use of a mini-nebulizer D. Correct technique for rhythmic breathing

B. Correct use of incentive spirometry Rationale: Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use. You do not teach a patient the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.

The nursing student is performing tracheostomy care on a client. Which action by the student leads the supervising nurse to intervene? A. Using folded gauze dressings on both sides of the stoma B. Cutting a slit in a gauze 4 × 4 pad to fit around the stoma C. Applying new tracheostomy ties before removing old ones D. Tying the twill tape in a square knot on the side of the neck

B. Cutting a slit in a gauze 4 × 4 pad to fit around the stoma Rationale: Tracheostomy dressings should be made from gauze pads with a manufactured slit in them that fits around the tube. If none are available, use two gauze pads folded in half placed on either side of the tube. Cutting a piece of gauze could result in entry of tiny shreds of the gauze the tracheostomy. The other interventions are appropriate.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? A. A low respiratory rate B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injury

B. Diminished breath sounds Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury. Test-Taking Strategy: Focus on the subject, a blunt chest injury. Noting the word blunt will assist in eliminating option D, which describes a sucking chest wound injury. Knowing that in a respiratory injury increased respirations will occur will assist you in eliminating option A. Option C can be eliminated because a barrel chest is a characteristic finding in a client with chronic obstructive pulmonary disease.

Which technique would the nurse use to change a patient's tracheostomy ties? A. Use a slipknot. B. Ensure that two fingers fit snugly under the tie. C. Knot the ends of the tie in the eyelets on the faceplate. D. Ask the patient to hold his or her breath while the ties are changed.

B. Ensure that two fingers fit snugly under the tie. Rationale: When the tie is secure, two fingers should fit snugly under it. A slipknot could become untied. Use a square knot on tracheostomy ties. The ends of the ties are not knotted at the eyelets on the faceplate. Doing so would make it difficult to change the ties when they become soiled. The patient is not asked to hold his or her breath during tracheostomy care.

Which tracheostomy tube has openings on the surface of the cannula to permit airflow? A. Talking tracheostomy tube B. Fenestrated tracheostomy tube' C. Tracheostomy tube with foam-filled cuff D. Tracheostomy tube with cuff and pilot balloon

B. Fenestrated tracheostomy tube Rationale: A fenestrated tube has openings on the surface of the outer cannula that permit air to flow over the vocal cords. Talking tracheostomy tubes allow speech by connecting a port to compressed air, which flows over the vocal cords. Tracheostomy tubes with foam-filled cuffs do not allow speech because the cuff self-inflates and is not deflated. A tracheostomy with a cuff and pilot balloon does not have any openings to allow airflow, but patients can speak when the cuff is deflated and the inner cannula removed. p. 489

A patient diagnosed with tuberculosis is prescribed ethambutol (EMB). Prior to initiating this medication, what should the nurse instruct the patient? A. Avoid this medication if allergic to eggs. B. Have a baseline visual exam. C. Have an influenza (flu) vaccination. D. Have a baseline ECG

B. Have a baseline visual exam. Rationale: Before starting on ethambutol (EMB), a baseline visual examination is indicated. Eye exams also may be scheduled during the course of treatment. This medication can cause optic neuritis. Assessment of an allergy to eggs is not warranted prior to the implementation of this medication. Administration of a flu vaccine is not warranted prior to the implementation of this medication. An ECG is not warranted prior to the implementation of this medication.

Which nursing action indicates good understanding of the postoperative care of the patient who has had a complete laryngectomy? A. Keeping the neck extended for the first few postoperative days B. Helping the patient use a smartphone text-to-speech application C. Repositining the nasogastric tube to relieve abdominal distention D. Avoiding tracheal suctioning during the early postoperative period.

B. Helping the patient use a smartphone text-to-speech application

When a patient with a newly inserted tracheostomy suddenly coughs and expels the tracheostomy tube, which action will the nurse take first? A. Suction the tracheostomy opening. B. Hold the stoma open with a sterile hemostat. C. Use a bag-valve-mask to ventilate the patient. D. Attempt to reinsert a new sterile tracheostomy tube.

B. Hold the stoma open with a sterile hemostat. Rationale: The initial action will be to use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. Suctioning is not indicated at this point because the priority is to keep the stoma open to allow air movement. Bag-valve-mask ventilation may be needed if the patient develops respiratory distress, but this is not the initial action. The nurse will get help to reinsert a sterile tracheostomy tube after ensuring that the airway is kept open with the sterile hemostat. pp. 490-491

The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? A. How to milk the chest tubing B. How to splint the incision when coughing C. How to take prophylactic antibiotics correctly D. How to manage the need for fluid restriction

B. How to splint the incision when coughing Rationale: Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel. The patient is not taught how to milk the chest tubing because this is performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is not indicated following thoracotomy.

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? A. Using oral antihistamines for 2 weeks before the allergy season may prevent reactions. B. Identifying and avoiding environmental triggers are the best way to prevent symptoms. C. Frequent hand washing is the primary way to prevent spreading the condition to others. D. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.

B. Identifying and avoiding environmental triggers are the best way to prevent symptoms. Rationale: The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinopharyngitis (common cold) can be prevented by washing hands, but allergic rhinitis cannot.

A client receiving high-flow oxygen has new crackles and diminished breath sounds since the last assessment 1 hour ago. Which action by the nurse is most appropriate? A. Call respiratory therapy and request a bronchodilator treatment. B. Instruct the client to use the spirometer and to cough and deep breathe. C. Consult with the health care provider and request an order for diuretics. D. Ensure that the ordered FiO2 is what is being provided.

B. Instruct the client to use the spirometer and to cough and deep breathe. Rationale: A client who is receiving high rates of oxygen is at risk for absorption atelectasis, in which the normal nitrogen in the air becomes diluted and the alveoli collapse. Hallmarks of this condition include new onset of crackles and diminished breath sounds. Spirometer use, coughing, and deep-breathing exercises would help to re-expand the alveoli. None of the other options are appropriate choices.

What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? A. Complete the suctioning process in 20 seconds or less. B. Keep the oxygen mask near the patient's face during the suctioning procedure. C. Encourage the patient to take several deep breaths before suctioning begins. D. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning.

B. Keep the oxygen mask near the patient's face during the suctioning procedure. Rationale: Keeping the oxygen mask near the patient's face during the intervention ensures that oxygen therapy will not be interrupted. Although the intervention should be completed in a timely manner, doing so in less than 20 seconds is not a priority. Encouraging the patient to breathe deeply before the suctioning is not a specific intervention related to oropharyngeal suctioning. The flow rate can be increased before suctioning, but doing so is not a priority intervention.

Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? A. Having a spare oxygen mask at the patient's bedside B. Keeping an obturator and a tracheostomy tube at the patient's bedside C. Reviewing the agency's policy regarding tracheostomy care D. Instructing the family to call immediately if the patient has difficulty breathing

B. Keeping an obturator and a tracheostomy tube at the patient's bedside Rationale: eeping an obturator and a tracheostomy tube of the correct size at the patient's bedside is the best way to plan for an emergency involving a tracheostomy, such as tube dislodgement. Having a spare oxygen mask at the bedside does not constitute adequate emergency planning for a patient with a tracheostomy. Reviewing the agency's policy is important, but does not by itself constitute effective emergency planning for a patient with a tracheostomy. Instructing the family to call for help if the patient has difficulty breathing is appropriate, but does not by itself constitute effective emergency planning for a patient with a tracheostomy.

Which action by the student nurse indicates understanding regarding routine tracheostomy care? A. Cleaning around the stoma once every 24 hours B. Maintaining tracheostomy cuff pressure of 20 mm Hg C. Using a one-person technique to change tracheostomy tapes D. Cutting a gauze square to make a new tracheostomy dressing

B. Maintaining tracheostomy cuff pressure of 20 mm Hg Rationale: Cuff inflation pressure is maintained at 15 to 22 mm Hg to maximize ventilation while avoiding compression of tracheal capillaries and the risk for tracheal necrosis. The area around the stoma should be cleaned at least once every 8 hours. A two-person technique is recommended when changing tracheostomy tapes to prevent dislodgment of the tracheostomy tube during the procedure. A premade tracheostomy dressing is used to avoid inhalation of threads from cut gauze. pp. 489, 491

The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patient's needs? A. Non-rebreathing mask B. Nasal cannula C. Simple mask D. Partial-rebreathing mask

B. Nasal cannula Rationale: A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The patient's respiratory status does not require a partial- or non-rebreathing mask.

Which action would the nurse include when suctioning a patient's tracheostomy tube? A. Suction for five minutes at a time. B. Oxygenate for 30 seconds after suctioning. C. Adjust the suction pressure to 140 to 150 mm Hg. D. Insert the suction catheter until meeting resistance.

B. Oxygenate for 30 seconds after suctioning. Rationale: The nurse should supply oxygen for 30 seconds after suctioning and before starting the next suction to prevent hypoxemia. To avoid hypoxemia, suctioning should be performed for a short period, such as for 10 to 15 seconds. Suction pressures should not exceed 125 mm Hg with the tubing occluded. To avoid trauma to the carina, the suction catheter should be inserted only until the patient coughs. p. 491

The nurse is concerned that a patient's central venous access device (CVAD) may have become dislodged. How might the nurse assess for this complication? A. Check for blood return. B. Palpate the skin for coiling. C. Listen for gurgling sounds. D. Assess for pain at the site.

B. Palpate the skin for coiling. Rationale: The nurse would check for coiling, which can occur if the CVAD becomes dislodged. Blood return is checked to assess for an occlusion. Gurgling sounds could indicate catheter migration or pinch-off syndrome. Catheter dislodgement is not associated with pain at the insertion site.

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? A. Surgical mask and gloves B. Particulate respirator, gown, and gloves C. Particulate respirator and protective eyewear D. Surgical mask, gown, and protective eyewear

B. Particulate respirator, gown, and gloves Rationale: The nurse who is in contact with a client with TB should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.

Patient A Type of tube: Tracheostomy tube with cuff and pilot balloon Action: Maintain a cuff pressure of less than or equal to 20 mm Hg. Patient B Type of tube: Fenestrated tracheostomy tube Action: Insert decannulation plug in tracheostomy tube before deflating the cuff. Patient C Type of tube: Talking tracheostomy tube Action: Disconnect flow when patient does not want to speak. Patient D Type of tube: Tracheostomy tube with foam-filled cuff Action: Before insertion, withdraw all air from the cuff using a 20 mL syringe and cap pilot balloon. Which patient with a tracheostomy requires a change in the plan of care? A. Patient A B. Patient B C. Patient C D. Patient D

B. Patient B Rationale: While caring for patients who are using fenestrated tracheostomy tubes, such as Patient B, the nurse should never insert a decannulation plug into the tracheostomy tube until the cuff is deflated because it will obstruct airflow and can cause respiratory arrest. For Patient A, who has tracheostomy tubes with cuff and pilot balloon, a cuff pressure of 15 to 22 mm Hg should be maintained. Patient C, who has a talking tracheostomy tube, will need compressed air or oxygen connected to the second port in order to speak. Because a continuous supply of air to the second port will cause mucosal dryness, the compressed air will be discontinued when it is not needed for patient speech. Air from the foam-filled cuff of a tracheostomy tube should be withdrawn and the port should be capped to prevent the reentry of air fro Patient D during tracheostomy insertion. p. 489

When caring for a patient who has a CVAD, which sign may indicate infection at the insertion site? A. Occlusion alarm sounds on infusion pump B. Patient's oral temperature gradually increases C. Patient's neck veins become distended D. The nurse cannot achieve blood return

B. Patient's oral temperature gradually increases Rationale: A progressive elevation in the patient's temperature may indicate an infection. The sounding of an occlusion alarm is more likely an indication of an occlusion. Neck vein distention is more likely an indication of catheter migration. Inability to achieve blood return is more likely an indication of an occlusion.

Which interprofessional action will the clinic nurse plan to take after assessing a patient with a scratchy throat, severe pain, and enlargement of the anterior cervical lymph node? A. Schedule a chest x-ray. B. Perform a rapid antigen-detection test. C. Prepare for needle aspiration of the lymph node. D. Transfer the patient to the emergency department.

B. Perform a rapid antigen-detection test. Rationale: The patient's clinical manifestations suggest possible acute streptococcal pharyngitis, and the nurse will anticipate swabbing the throat and doing a rapid antigen-detection test. A chest x-ray is not indicated because the patient does not have any indication of respiratory distress or abnormal lung sounds. Because an enlarged anterior cervical lymph node is expected in an upper respiratory infection, no needle aspiration or biopsy of the enlarged node is indicated. The patient's assessment does not indicate any emergent problems, and no transfer to the emergency department is indicated. p. 487

A client has been brought in by the rescue squad to the emergency department. The client is having an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is severely short of breath. On arrival, the client is on 15 L/min of oxygen via rebreather mask. Which action by the nurse takes priority? A. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula. B. Perform a thorough respiratory assessment and attach pulse oximetry. C. Call the laboratory to obtain arterial blood gases as soon as possible. D. Obtain a stat chest x-ray, then slowly wean the client's oxygen down.

B. Perform a thorough respiratory assessment and attach pulse oximetry. Rationale: Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO2 levels, such as those seen in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and can cause respiratory arrest. However, hypoxemia is a greater threat to an acutely ill client than is the potential for oxygen-induced hypoventilation, and clients should be given the amount of oxygen they require. The nurse should perform a thorough respiratory assessment and should monitor the client for signs of this problem, rather than automatically reducing oxygen delivery. Blood gases and a chest x-ray will also be obtained, but they do not take priority over assessing and monitoring the client.

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem? A. Hypercalcemia B. Peripheral neuritis C. Small blood vessel spasm D. Impaired peripheral circulation

B. Peripheral neuritis Rationale: Isoniazid is an anti-tubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B6) intake. Options A, C, and D are not associated with the information in the question.

A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for 24 hours. Which action by the nurse is most appropriate? A. Collect all materials needed for suturing the stoma shut. B. Place a dry dressing over the stoma and tape it securely. C. Assess the client for air leaking around the tube. D. Select a smaller tracheostomy tube to be inserted.

B. Place a dry dressing over the stoma and tape it securely. Rationale: The tube will be able to be removed after the client has tolerated capping of it for 24 hours. Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be sutured. It will heal on its own with a small scar. Airflow should be adequate around the capped tube. The physician will not likely insert the next smallest size tube but instead will remove the existing tube.

Which action should the nurse plan to prevent aspiration in a high-risk patient? A. Turn and reposition an immobile patient at least every 2 hours. B. Place a patient with altered consciousness in a side-lying position. C. Insert a nasogastric tube for feeding a patient with high-calorie needs. D. Monitor respiratory symptoms in a patient who is immunosuppressed.

B. Place a patient with altered consciousness in a side-lying position. Rationale: With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with decreased level of consciousness are placed in side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.

The nurse is preparing to receive a postoperative client who just had a tracheostomy. Which action by the nurse takes priority? A. Obtain report from the postanesthesia care unit. B. Place a second tracheostomy tube and obturator at the bedside. C. Review orders for postoperative pain medications. D. Order supplies for tracheostomy care for 24 hours.

B. Place a second tracheostomy tube and obturator at the bedside. Rationale: The nurse must ensure that a second tracheostomy tube with obturator is available at the bedside in case of accidental decannulation, because tube dislodgment in the first 72 hours is an emergency. Obtaining report and understanding pain medication orders are important for any postoperative client, but for the tracheostomy client, having the extra material on hand is critical. Obtaining supplies for tracheostomy care is not as high a priority as the other three.

Which action would the nurse perform when preparing to suction a patient's oropharynx? A. Apply sterile gloves. B . Place the patient in a semi-Fowler's or sitting position. C. Remove the nasal cannula. D. Flush the suction catheter with 200 mL of warm tap water.

B. Place the patient in a semi-Fowler's or sitting position. Rationale: A semi-Fowler's or sitting position would facilitate this intervention. This intervention would be performed using clean, not sterile, technique. The nasal cannula can remain in place to deliver oxygen during the intervention. Sterile water or sterile normal saline is preferred to tap water, and a quantity of only 100 mL is needed.

While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? A. Notify the physician immediately. B. Place the patient in a semi-Fowler's position. C. Use a bag-valve-mask (BVM) and begin rescue breathing for the patient. D. Instill 10 mL of normal saline into the tracheostomy tube to loosen secretions. E. Continue patient assessment, including O2 saturation, respiratory rate, and breath sounds.

B. Place the patient in a semi-Fowler's position. E. Continue patient assessment, including O2 saturation, respiratory rate, and breath sounds.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? A. Listening to the patient's lung sounds several times during the shift B. Placing the patient on droplet precautions in a private hospital room C. Monitoring patient serology results to identify the infecting organism D. Titrating the O2 flowrate as prescribed to keep the O2 saturation over 90%

B. Placing the patient on droplet precautions in a private hospital room Rationale: Fungal infections are not transmitted from person to person. Therefore, no isolation procedures are necessary. The other actions by the new nurse are appropriate.

As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? A. Complete the catheter insertion in 5 seconds or less. B. Remove the catheter. C. Encourage the patient to take several deep breaths to minimize the nausea. D. Stop advancing the catheter, and allow the patient to rest for several minutes.

B. Remove the catheter. Rationale: Gagging and nausea indicate that the catheter has probably entered the esophagus and must be removed. Attempting to complete the insertion could increase the gagging and nausea. Deep breathing is not the appropriate response to nausea when it occurs during insertion of a nasotracheal catheter. The catheter is probably in the esophagus and must be removed. Advancing the catheter after a period of rest will simply lead to more gagging and nausea.

How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A. Lower the patient's head during the dressing change. B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. C. Apply skin protectant while the stabilization device is off. D. Cleanse the insertion site quickly and gently in concentric circles.

B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. Rationale: The old dressing should be removed in the direction of catheter insertion. Positioning the patient with his or her head lower will not reduce the risk of dislodging the catheter during a dressing change. Skin protectant should be applied before placing a new catheter stabilization device. However, doing so will not reduce the risk of dislodging the catheter. The site should be cleansed using a back-and-forth motion vertically and horizontally for at least 30 seconds. However, following this technique will not reduce the risk of dislodging the catheter.

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action? A. Use alcohol in small amounts only. B. Report yellow eyes or skin immediately. C. Increase intake of Swiss or aged cheeses. D. Avoid vitamin supplements during therapy.

B. Report yellow eyes or skin immediately. Rationale: Isoniazid is hepatotoxic, and therefore the client is taught to report signs and symptoms of hepatitis immediately, which include yellow skin and sclera. For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or lightheadedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B6) during the course of isoniazid therapy.

To determine whether a patient with a tracheostomy has swallowing dysfunction, which action by the nurse is best? A. Offer the patient sips of water. B. Request a speech therapy consult. C. Ask the patient about swallowing ability. D. Have the charge nurse assess the patient.

B. Request a speech therapy consult. Rationale: A speech therapist has the education and scope of practice to perform swallowing studies on the patient. Offering sips of water will help the nurse assess for swallowing dysfunction but may lead to aspiration. The patient clearly should have input in the assessment of swallowing ability but does bot have the education or experience to determine whether there is swallowing dysfunction. An experienced nurse may be able to recognize clinical swallowing difficulty but is not as well educated in determining the causes and management of swallowing dysfunction as the speech therapist. p. 497

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/VN) caring for a patient with a permanent tracheostomy? A. Assess the patient's risk for aspiration. B. Suction the tracheostomy when directed. C. Teach the patient to provide tracheostomy self-care. D. Determine the need for tracheostomy tube replacement.

B. Suction the tracheostomy when directed. Rationale: Suctioning of a stable patient can be delegated to LPNs/VNs. The RN should perform patient assessment and patient teaching.

Which task can the RN delegate to properly trained unlicensed assistive personnel (UAP) when caring for a stable patient who has a tracheostomy? A. Assessing the need for suctioning B. Suctioning the patient's oropharynx C. Assessing the patient's swallowing ability D. Maintaining appropriate cuff inflation pressure.

B. Suctioning the patient's oropharynx Rationale: If the UAP has been trained in correct techniquie, the UAP may suction the patient's oropharynx as part of oral care. Assessing the need for suctioning requires clinical judgment and will be done by RNs or licensed practical nurses who have the education and scope of practice to safely perform assessments. Because the inability to swallow may result in aspiration, swallowing assessment is a complex skill that requires the education and scope of practice of an RN. Maintaining appropriate cuff inflation pressure is a complex skill requiring RN education and scope of practice because inappropriate cuff pressure may result in tracheal necrosis or increased aspiration risk. p. 493

A client is being discharged home with a tracheostomy. Which action does the nurse teach the client to decrease the risk for aspiration while eating? A. Swallow quickly. B. Thicken all liquids. C. RInse all food with water. D. Chew food completely.

B. Thicken all liquids. Rationale: Thickening liquids may assist the client in swallowing and may help prevent aspiration. Swallowing quickly will not decrease the risk of aspiration and may actually put the client at greater risk. It is not recommended that the client drink water to wash down food. Chewing food completely will help prevent choking but will not decrease aspiration risk.

When preparing to suction a patient's oral cavity, why would the nurse first suction a small amount of sterile water through the cateter? A. To moisten the exterior of the plastic catheter B. To ensure that the catheter's suction is functioning properly C. To minimize friction as the catheter moves within the oral cavity D. To avoid startling the patient with the sound created by the suction

B. To ensure the catheter's suction is functioning properly. Rationale: A small amount of sterile water is suctioned through the catheter to ensure that the suction equipment is working properly. Moistening the exterior of the catheter is not the reason for suctioning a small amount of water through the catheter. Minimizing friction is not the reason for suctioning a small amount of water through the catheter. Sterile water is not suctioned through the catheter in order to avoid startling the patient with the sound of the suctioning. The nurse can prepare the patient for the sound by telling him or her that the suction may be noisy and by indicating when the suction is about to be turned on.

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? A. Teach the patient about the use of expectorants. B. Use a swab to obtain a sample for a rapid strep antigen test. C. Discuss the need to rinse the mouth out after using any inhalers. D. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

B. Use a swab to obtain a sample for a rapid strep antigen test. Rationale: The patient's clinical manifestations are consistent with streptococcal pharyngitis, and the nurse will anticipate the need for a rapid strep antigen test or cultures (or both). Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing out the mouth after inhaler use may prevent fungal oral infections, but the patient's assessment data are not consistent with a fungal infection. NSAIDS are often prescribed for pain and fever relief with pharyngitis.

A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse takes priority? A. Auscultate breath sounds bilaterally. B. Ventilate with a resuscitation bag and mask. C. Call a code or the Rapid Response Team. D. Insert a new obturator into the neck.

B. Ventilate with a resuscitation bag and mask. Rationale: Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation bag and face mask while another nurse calls for help. Although auscultation of breath sounds is important, the client's airway must be opened and ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? A. Face tent B. Venturi mask C. Aerosol mask D. Tracheostomy collar

B. Venturi mask Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease, because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy for cancer would include______________. Select all that apply. A. Encouraging regular exercise such as swimming. B. Washing around the stoma daily with a moist washcloth. C. Encouraging participation in post-laryngectomy support group. D. Providing pictures and "hands-on" instruction for tracheostomy care. E. Teaching how to hold breath and trying to gag to promote swallowing reflex.

B. Washing around the stoma daily with a moist washcloth. C. Encouraging participation in post-laryngectomy support group. D. Providing pictures and "hands-on" instruction for tracheostomy care.

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? A. Every 2 hours when the patient is awake B. When adventitious breath sounds are auscultated C. When there is a need to prevent the patient from coughing D. When the nurse needs to stimulate the cough reflex

B. When adventitious breath sounds are auscultated Rationale: It is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.

A patient is prescribed isoniazid (INH) and rifampin for treatment of tuberculosis. Which adverse effects should the nurse instruct the patient to report to the healthcare provider? Select all that apply. A. Fever B. Yellow tint to the skin C. Episodic pain in the upper-left quadrant D. Diarrhea E. Change in stool color

B. Yellow tint to the skin E. Change in stool color Rationale: INH and rifampin can cause hepatitis. Jaundice could indicate hepatitis. A change in stool color could be an indication of hepatitis. A fever would not indicate hepatitis. The pain from hepatitis is on the upper-right quadrant, not the left. Diarrhea would not indicate hepatitis.

A patient who is on isoniazid (INH) for pulmonary tuberculosis tells the nurse he doesn't like taking the medication because it makes his "fingers burn." The nurse concludes that the patient is experiencing which effect? A. A common side effect of isoniazid (INH) that will go away after completing the medication B. a common side effect of isoniazid (INH) that can be treated with pyridoxine C. a long-term complication of isoniazid (INH) that has no treatment D. a common complication of isoniazid (INH) that can be treated with vitamin B12 injections

B. a common side effect of isoniazid (INH) that can be treated with pyridoxine Rationale: Peripheral neuropathy numbness, tingling, or a burning sensation of the extremities may occur with isoniazid (INH). Pyridoxine or vitamin B6 often is prescribed to prevent this adverse effect. This is correct but pyridoxine or vitamin B6 often is prescribed to prevent this adverse effect. This adverse effect is treatable. Pyridoxine or vitamin B6 often is prescribed to prevent this adverse effect.

A nurse is providing a patient with instructions about PICC removal. The nurse knows the patient understood the post-procedure instructions when he makes which of the following statements? A. "I can get out of bed and go to the bathroom after you take the catheter out." B. "I have to stay in bed for the next 4 hours." C. "I have to stay in bed for 30 minutes after you can take the catheter out." D. "I have to lie flat in bed for the next hour."

C. "I have to stay in bed for 30 minutes after you can take the catheter out."

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a CVAD? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site is painful or swollen."

C. "Let me know immediately if the patient's dressing becomes damp." Rationale: The task of reporting the need for a dressing change may be delegated to NAP. Assessment of a CVAD may not be delegated to NAP. No aspect of insertion site care or dressing application may be delegated to NAP. Patient education may not be delegated to NAP.

Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site becomes painful or swollen."

C. "Let me know immediately if the patient's dressing becomes damp." Rationale: The task of reporting the need for a dressing change may be delegated to NAP. No aspect of CVAD assessment or patient education may be delegated to NAP. No aspect of CVAD insertion or dressing application may be delegated to NAP.

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? A. "I will take the bus instead of driving." B. "I will stay indoors whenever possible." C. "My spouse will sleep in another room." D. "I will keep the windows closed at home."

C. "My spouse will sleep in another room." Rationale: Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? A. "Are you afraid that the surgery will be very painful?" B. "Did you have bad experiences with previous surgeries?" C. "Tell me what you know about the treatments available." D. "Surgery is the treatment of choice for stage I lung cancer."

C. "Tell me what you know about the treatments available." Rationale: More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.

A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patient's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response? A. "The physician may feel that mechanical ventilation will have to be used long-term." B. "Long-term use of an endotracheal tube diminishes the normal breathing reflex." C. "When an endotracheal tube is left in too long it can damage the lining of the windpipe." D. "It is much harder to breathe through an endotracheal tube than a tracheostomy."

C. "When an endotracheal tube is left in too long it can damage the lining of the windpipe." Rationale: Endotracheal intubation may be used for no longer than 2 to 3 weeks, by which time a tracheostomy must be considered to decrease irritation of and, trauma to, the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. The need for long-term ventilation would not be the primary rationale for this change in treatment. Endotracheal tubes do not diminish the breathing reflex.

Which statement by a client indicates an accurate understanding of home self-care of a tracheostomy? A. "The stoma should be left uncovered during the day to dry." B. "I need to put normal saline in my airway twice daily." C. "While showering, I need to keep water out of my airway." D. "I don't need to use tracheostomy ties on a daily basis."

C. "While showering, I need to keep water out of my airway." Rationale: The client should put a shield over the tracheostomy to keep water from entering the airway. The airway should remain covered during the day with cotton or foam. Saline should be put in the airway 10 to 15 times daily. Tracheostomy ties should be used daily.

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the most accurate response by the nurse? A. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." B. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." C. "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration." D. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally."

C. "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration." Rationale: Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern A. A large air leak in the water-seal chamber B. Report of pain with each deep inspiration C. 400 mL of blood in the collection chamber D. Subcutaneous emphysema at the insertion site

C. 400 mL of blood in the collection chamber Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

After change-of-shift report, which patient should the nurse assess first? A. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain B. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet C. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion D. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101° F (38.3° C)

C. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion Rationale: The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the interprofessional management will include______________. Select all that apply. A. Antiviral agents to treat influenza. B. Treatment with antibiotics starting ASAP. C. A throat culture or rapid strep antigen test. D. Supportive care, including cool, bland liquids. E. Comprehensive history to determine possible cause.

C. A throat culture or rapid strep antigen test. D. Supportive care, including cool, bland liquids. E. Comprehensive history to determine possible cause.

A client requires oxygen received via a face mask but wants to remain as mobile as possible once discharged home. Which intervention by the home health nurse best provides the client with maximal mobility? A. Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs. B. Encourage the client to remove the mask occasionally to assess tolerance. C. Add extra connecting pieces of tubing to the client's existing oxygen setup. D. Change the face mask to a nasal cannula occasionally, such as at mealtimes.

C. Add extra connecting pieces of tubing to the client's existing oxygen setup. Rationale: To increase mobility, up to 50 feet of connecting tubing can be used with connecting pieces. A client with a chronic respiratory condition needing home oxygen may not be able to decrease oxygen needs through pulmonary rehabilitation, but that would not increase mobility with an oxygen device. The nurse should not independently encourage the client to remove the mask for periods of time or change to a cannula.

Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? A. Patient complains of discomfort during the procedure. B. Patient has a severe bout of nonproductive coughing and complains of sore throat. C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%. D. Patient's pulse rate increases by 10 bpm.

C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%. Rationale: This decline in peripheral blood oxygen saturation must be reported. It represents a decline in the patient's condition following a procedure that should have improved his or her SpO2 reading. Discomfort need not be reported. Symptoms of coughing and sore throat do not require immediate reporting. This change in heart rate is anticipated with the procedure. Taken by itself, it does not require reporting.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? A. Purpose of antibiotic therapy B. Ways to limit oral fluid intake C. Appropriate use of cough suppressants D. Safety concerns with home O2 therapy

C. Appropriate use of cough suppressants Rationale: Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home O2 is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of chronic alcohol use. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? A. Repeat warnings about the high risk for infecting others several times. B. Give the patient written instructions about how to take the medications. C. Arrange for a daily meal and drug administration at a community center. D. Arrange for the patient's friend to administer the medication on schedule.

C. Arrange for a daily meal and drug administration at a community center. Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen. Arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient's situation.

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? A. Teach about drug-resistant TB. B. Schedule directly observed therapy. C. Ask the patient whether medications have been taken as directed. D. Discuss the need for an injectable antibiotic with the health care provider.

C. Ask the patient whether medications have been taken as directed. Rationale: The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? A. Leave the tracheostomy inner cannula inserted at all times. B. Place the decannulation cap in the tube before cuff deflation. C. Assess the ability to swallow before using the fenestrated tube. D. Inflate the tracheostomy cuff during use of the fenestrated tube.

C. Assess the ability to swallow before using the fenestrated tube. Rationale: Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.

The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurse's first step in the suctioning process? A. Explain the suctioning procedure to the patient and reposition the patient. B. Turn on suction source at a pressure not exceeding 120 mm Hg. C. Assess the patient's lung sounds and SAO2 via pulse oximeter. D. Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.

C. Assess the patient's lung sounds and SAO2 via pulse oximeter. Rationale: Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patient's level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step.

After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? A. Arrange for arterial blood gases to be drawn immediately. B. Cover stoma with sterile gauze and ventilate through stoma. C. Attempt to reinsert the tracheostomy tube with the obturator in place. D. Assess the patient's oxygen saturation and notify the health care provider.

C. Attempt to reinsert the tracheostomy tube with the obturator in place. Rationale: The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Assessing the patient's oxygenation is an important action, but it is not as appropriate until there is an established airway.

A patient is seen in the clinic for a nosebleed, which is controlled by placement of anterior nasal packing. During discharge teaching, the nurse teaches the patient to A. Use aspirin for pain relief. B. Remove the packaging later that day. C. Avoid vigorous nose blowing and strenuous activity. D. Insert more packing into the nose if rebleeding occurs.

C. Avoid vigorous nose blowing and strenuous activity.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? A. Dry cough B. Hematuria C. Bronchospasm D. Blood-streaked sputum

C. Bronchospasm Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure. Test-Taking Strategy: Note the strategic word, immediately. Eliminate option B first because it is unrelated to the procedure. Next, eliminate option A because a dry cough may be expected. Noting that a biopsy has been performed will assist in elimination option D, because blood-streaked sputum would be expected. Note that the correct option relates to the airway.

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication? A. Should always be taken with food or antacids B. Should be double-dosed if 1 dose is forgotten C. Causes orange discoloration of sweat, tears, urine, and feces D. May be discontinued independently if symptoms are gone in 3 months

C. Causes orange discoloration of sweat, tears, urine, and feces Rationale: Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently. Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a health care provider. It is best to administer the medication on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication.

How would the nurse assess a patient's central venous access device (CVAD) for damage or breakage? A. Assess the patient's neck veins for distention. B. Palpate the patient's arm. C. Check the catheter for pinholes and tears. D. Palpate the area around the insertion site.

C. Check the catheter for pinholes and tears. Rationale: To assess the CVAD for damage or breakage, the nurse would check the catheter every shift for pinholes, leaks, and tears. Assessing the neck veins for distention would not be an appropriate way to check the catheter for damage or breakage. Palpating the patient's arm would not be an appropriate way to check the catheter for damage or breakage. Palpating the area around the insertion site would not be an appropriate way to check the catheter for damage or breakage.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? A. Hot, flushed feeling B. Sudden chills and fever C. Chest pain that occurs suddenly D. Dyspnea when deep breaths are taken

C. Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient? A. Safe technique for self-suctioning of secretions B. Technique for performing postural drainage C. Correct and safe use of oxygen therapy equipment D. How to provide safe and effective tracheostomy care

C. Correct and safe use of oxygen therapy equipment Rationale: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use. The scenario does not indicate the patient needs help with suctioning, postural drainage, or tracheostomy care.

The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the nurse's immediate action? A. Cuff pressure readings consistently between 14 and 20 mm Hg. B. Need to change Velcro tube holders three times in 1 day. C. Crackling sensation around the neck when skin is palpated. D. Small amount of bleeding around the incision for the first few days.

C. Crackling sensation around the neck when skin is palpated. Rationale: Subcutaneous emphysema occurs when an opening or tear occurs in the trachea and air escapes into fresh tissue planes of the neck. Air can also progress through the chest and other tissues into the face. Inspect and palpate for air under the skin around the new tracheostomy. If the skin is puffy and you can feel a crackling sensation, notify the physician immediately. Cuff pressures should be maintained between 14 and 20 mm Hg or between 20 and 28 cm H2O. Tracheostomy ties need to be changed at least once a day or whenever soiled. It is not uncommon for a client with a new tracheostomy to have heavy secretions that would necessitate changing them. It is not unusual to have a small amount of bleeding around the incision for the first few days after surgical placement.

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution? A. Osteoarthritis B. Hypothyroidism C. Diabetes mellitus D. Polycystic disease

C. Diabetes mellitus Rationale: Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.

While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 bpm to 80 bpm. What is the best course of action? A. Encourage the patient to take several deep breaths. B. Interrupt suction to the catheter for at least 10 seconds. C. Discontinue suctioning by removing the suction catheter. D. Assess the patient's pulse oximetry reading to see if oxygenation is adequate.

C. Discontinue suctioning by removing the suction catheter. Rationale: A drop in pulse of 20 bpm or more necessitates discontinuation of suctioning and removal of the catheter. Deep breathing will not adequately address the patient's response. Pausing the suctioning briefly will not adequately address the patient's response. Taking an oximetry reading will not address the patient's response.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? A. Ask the patient about any visual changes in red-green color discrimination. B. Question the patient about experiencing shortness of breath, hives, or itching. C. Explain that orange discolored urine and tears are normal while taking this medication. D. Advise the patient to stop the drug and report the symptoms to the health care provider.

C. Explain that orange discolored urine and tears are normal while taking this medication. Rationale: Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occur when taking ethambutol, which is a different tuberculosis medication.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? A. Bed rest for the first 24 hours B. Positioning only on the right side C. Frequent use of an incentive spirometer D. Chest tube placement to continuous suction

C. Frequent use of an incentive spirometer Rationale: Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? A. Restrict oral fluids during the day. B. Encourage pursed-lip breathing technique. C. Help the patient to splint the chest when coughing. D. Encourage the patient to wear the nasal O2 cannula.

C. Help the patient to splint the chest when coughing. Rationale: Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.

Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? A. Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago B. Removing the outer cannula and placing the obturator C. Holding the tracheostomy tube while the nurse changes the neck ties D. Monitoring oxygen saturation levels and placing oxygen if needed.

C. Holding the tracheostomy tube while the nurse changes the neck ties Rationale: NAP may hold the tube while the nurse changes the ties during tracheostomy care. If agency policy allows it, the NAP may perform tracheostomy care only for a patient with an established tracheostomy. Removing the outer cannula would mean that the entire tracheostomy would come out. Placing an obturator is not within the NAP's scope of practice. NAP may take a pulse oximetry reading but may not monitor changes or administer oxygen.

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? A. Monitor the incision for bleeding. B. Maintain adequate IV fluid intake. C. Keep the patient in semi-Fowler's position. D. Teach the patient to suction the tracheostomy.

C. Keep the patient in semi-Fowler's position. Rationale: The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of th tracheostomy tube. The patient may be USNT O taught to suction after the tracheostomy is stable, if needed, but not during the immediate postoperative period.

A client with tuberculosis is being started on anti-tuberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed? A. Electrolyte levels B. Coagulation times C. Liver enzyme levels D. Serum creatinine level

C. Liver enzyme levels Rationale: Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 years or abuses alcohol. The laboratory tests in options A, B, and D are not necessary.

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? A. Platelet count B. Neutrophil count C. Liver function tests D. Complete blood count

C. Liver function tests Rationale: Zafirlukast is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlikast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication. It is not necessary to perform the other laboratory tests before administration of the medication.

A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? A. Determine whether the patient can now perform forced expiratory technique (FET). B. Percuss the patient's lungs and thorax. C. Measure the patient's oxygen saturation. D. Have the patient perform incentive spirometry.

C. Measure the patient's oxygen saturation. Rationale: The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take FIRST? A. Assist the patient to sit upright in a chair. B. Splint the patient's chest during coughing. C. Medicate the patient with prescribed morphine. D. Observe the patient use the incentive spirometer.

C. Medicate the patient with prescribed morphine. Rationale: A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.

Which precautions would the nurse take when suctioning a tracheostomy? A. Limit suction time to 30 seconds. B. Rinse the catheter with clean water between suction passes. C. Monitor oxygen saturation and lung sounds after suctioning. D. Apply suction when inserting the catheter into the tracheostomy.

C. Monitor oxygen saturation and lung sounds after suctioning. Rationale: Lung sounds and oxygen saturation are assessed before and after tracheostomy suction to establish the need for suctioning and to evaluate the effectiveness of suctioning. The suction time should be limited to 10 to 15 seconds to prevent hypoxemia. The catheter should be rinsed in sterile water to prevent infection. Suction should not be applied when the catheter is inserted into the tracheostomy because this can deplete oxygen and cause tracheal trauma. p. 491

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? A. Deflate the cuff overnight to prevent tracheal tissue trauma. B. Inflate the cuff to the highest possible pressure in order to prevent aspiration. C. Monitor the pressure in the cuff at least every 8 hours D. Keep the tracheostomy tube plugged at all times.

C. Monitor the pressure in the cuff at least every 8 hours Rationale: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? A. Cyanosis B. Hypotension C. Paradoxical chest movement D. Dyspnea, especially on exhalation

C. Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest. Test-Taking Strategy: Note the strategic word, most. Cyanosis and hypotension occur with many different disorders, so eliminate options A and B first. From the remaining options, choose paradoxical chest movement over dyspnea on exhalation by remembering that a flail chest has broken rib segments that move independently of the rest of the rib cage.

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? A. Report of chest wall pain B. Heart rate of 110 beats/min C. Paradoxical chest movement D. Large bruised area on the chest

C. Paradoxical chest movement Rationale: Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

Which finding indicates to the nurse that the administered nifedipine (Procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH)? A. Heart rate is between 60 and 100 beats/min. B. Patient's chest x-ray indicates clear lung fields. C. Patient reports a decrease in exertional dyspnea. D. Blood pressure (BP) is less than 140/90 mm Hg.

C. Patient reports a decrease in exertional dyspnea. Rationale: Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.

Which actions will the nurse take when a patient with a complete laryngectomy has a dislodged tracheostomy tube and is experiencing dysnea? Select all that apply. A. Provide dry air to the patient's stoma. B. Cover the tracheostomy stoma with a dressing. C. Position the patient in a semi-Fowler's position. D. Attempt to insert a replacement tracheostomy tube. E. Ventilate the patient through the tracheostomy stoma.

C. Position the patient in a semi-Fowler's position. D. Attempt to insert a replacement tracheostomy tube. E. Ventilate the patient through the tracheostomy stoma. Rationale: The nurse should place the patient in a semi-Fowler's position to alleviate dyspnea. A replacement tracheostomy tube should be inserted if possible, using an obturator and lubricating the obturator and tube with sterile saline. Ventilation through the tracheostomy stoma should be provided because the patient has undergone a laryngectomy. Humidified air should be provided instead of dry air to moisten the secretions. Covering the stoma with a dressing will prevent airflow and cause respiratory arrest in a patient with a complete laryngectomy because there is a complete separation between the upper airway and the trachea. pp. 490-491

Which action should the nurse take to prepare a patient with a pleural effusion for a thoracentesis? A. Remind the patient not to eat or drink 6 hours. B. Start a peripheral IV line to administer sedation. C. Position the patient sitting up on the side of the bed. D. Obtain a collection device to hold 3 liters of pleural fluid.

C. Position the patient sitting up on the side of the bed. Rationale: When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.

The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? A. Encourage increased incentive spirometer use. B. Encourage the patient to increase oral fluid intake. C. Put on sterile gloves and use a sterile catheter to suction. D. Preoxygenate the patient for 3 minutes before suctioning.

C. Put on sterile gloves and use a sterile catheter to suction. Rationale: This patient needs suctioning to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary; 30 seconds is recommended. Incentive spirometer use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

Which action by the student nurse when providing tracheostomy care to a patient indicates a need for further teaching? A. Performs hand hygiene when indicated B. Positions the patient in the semi-Fowler's position C. Removes dried secretions from the stoma using gauze that is soaked with alcohol D. Suctions the patient as needed because the patient is unable to cough up secretions.

C. Removes dried secretions from the stoma using gauze that is soaked with alcohol Rationale: Dried secretions from the stoma are removed using gauze that is soaked in sterile water or normal saline, not in alcohol. Hand hygiene reduces the risk of infection to the patient. Tracheostomy care is performed while the patient is in the semi-Fowler's position. The nurse can suction as needed when the patient is unable to cough up the thick and hard secretions.

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? A. Treat workers with pulmonary fibrosis. B. Teach about symptoms of lung disease. C. Require the use of protective equipment. D. Monitor workers for coughing and wheezing.

C. Require the use of protective equipment. Rationale: Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.

The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if needed? A. Nasogastric tube B. Paracentesis tray C. Resuscitation equipment D. Central line insertion tray

C. Resuscitation equipment Rationale: The nurse administering naloxone for suspected opioid overdose should have resuscitation equipment readily available to support naloxone therapy if it is needed. Other adjuncts that may be needed include oxygen, a mechanical ventilator, and vasopressors.

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? A. Chest x-ray B. Bronchoscopy C. Sputum culture D. Tuberculin skin test

C. Sputum culture Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and a histological evidence of granulomatous disease on biopsy.

While discontinuing a PICC, the nurse meets resistance and the catheter appears stuck. What should be the nurse's next action? A. Ask another, more experienced nurse to try to remove the catheter. B. Switch hands and try to remove the catheter again. C. Stop the procedure and notify the practitioner. D. Have the patient take several deep breaths and cough.

C. Stop the procedure and notify the practitioner. Rationale: If resistance is met while discontinuing a PICC, the procedure should be stopped and the practitioner should be notified. The nurse should never pull the catheter because it may break or cause venous wall damage. Switching hands, trying again, and asking another nurse to try may only aggravate the situation. Having the patient take several deep breaths and cough may increase the risk of a venous air embolism, particularly while the catheter exit site is open (undressed).

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? A. Continue to suction. B. Notify the health care provider immediately. C. Stop the procedure and reoxygenate the client. D. Ensure that the suction is limited to 15 seconds.

C. Stop the procedure and reoxygenate the client Rationale: During suctioning, the nurse should monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated. Test-Taking Strategy: Focus on the subject, a decreased heart rate, and recall that suctioning can cause cardiac irregularities. Also, use of the ABCs-airway-breathing-circulation-should direct you to the correct option.

A client has a prescription to take guaifenesin. The nurse determines that the client understands the proper administration of this medication if the client states that he or she will perform which action? A. Take an extra dose if fever develops B. Take the medication with meals only C. Take the tablet with a full glass of water D. Decrease the amount of daily fluid intake

C. Take the tablet with a full glass of water Rationale: Guaifenesin is an expectorant and should be taken with a full glass of water to decrease the viscosity of secretions. Extra doses should not be taken. The client should contact the health care provider if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache. Fluids are needed to decrease the viscosity of secretions. The medication does not have to be taken with meals.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? A. Providing supportive care to patients diagnosed with pertussis B. Teaching family members about the need for careful hand washing C. Teaching patients about the need for adult pertussis immunizations D. Encouraging patients to complete the prescribed course of antibiotics

C. Teaching patients about the need for adult pertussis immunizations Rationale: The increased rate of pertussis in adults is thought to be caused by decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the MOST immediate action by the nurse? A. The O2 saturation is 90%. B. The blood pressure is 98/56 mm Hg. C. The epoprostenol (Flolan) infusion is disconnected. D. The international normalized ratio (INR) is prolonged.

C. The epoprostenol (Flolan) infusion is disconnected. Rationale: The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.

The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which assessment finding does the nurse intervene to correct? A. The bad is 2/3 inflated during inhalation. B. The client's pulse oximetry reading is 93%. C. The oxygen flow rate is 2 L/min. D. The arterial oxygen level is 90%.

C. The oxygen flow rate is 2 L/min. Rationale: Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag. A bag that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is adequate, as is an arterial oxygenation of 90%.

A patient who had a total laryngectomy has previously expressed hopelessness about the loss of control over personal care. Which information obtained by the nurse indicates that this identified problem is resolving? A. The patient allows the nurse to suction the tracheostomy. B. The patient's spouse provides the daily tracheostomy care. C. The patient asks to learn how to clean the tracheostomy stoma. D. The patient uses a communication board to request "No Visitors."

C. The patient asks to learn how to clean the tracheostomy stoma. Rationale: Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment? A. The patient desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min. B. The patient requires a high-flow system for use with a tracheostomy collar. C. The patient desires a portable oxygen delivery system that can deliver 2 L/min. D. The patient's respiratory status requires a system that provides an FiO2 of 65%.

C. The patient desires a portable oxygen delivery system that can deliver 2 L/min. Rationale: The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in the home setting. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%. They require regular maintenance and are not used for high-flow applications. The patient desiring a portable oxygen delivery system of 2L/min will benefit from the use of an oxygen concentrator.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? A. Bronchial breath sounds are heard at the right base. B. The patient coughs up small amounts of green mucus. C. The patient's white blood cell (WBC) count is 6000/μL. D. Increased tactile fremitus is palpable over the right chest.

C. The patient's white blood cell (WBC) count is 6000/μL. Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude? A. The system is functioning normally. B. The patient has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed.

C. The system has an air leak. Rationale: Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? A. Administer oxygen B. Check the client's vital signs C. Ventilate the client manually D. Start cardiopulmonary resuscitation

C. Ventilate the client manually Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client.

A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? A. Non-rebreather air mask B. Tracheostomy collar C. Venturi mask D. Face tent

C. Venturi mask Rationale: The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the precision of a Venturi mask.

The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patient's airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? A. Continue suctioning the patient until no more secretions are obtained. B. Perform chest physiotherapy rather than nasotracheal suctioning. C. Wait several minutes and then repeat suctioning. D. Perform postural drainage and then repeat suctioning.

C. Wait several minutes and then repeat suctioning. Rationale: If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.

The nurse is providing care to a patient with pulmonary tuberculosis. What should the nurse do to ensure personal protection while caring for this patient? A. Wear a gown and eye goggles. B. Wear a gown and surgical mask. C. Wear a gown and HEPA mask. D. Wear a gown and sterile gloves.

C. Wear a gown and HEPA mask. Rationale: The Occupational Safety and Health Administration (OSHA) requires use of a HEPA-filtered respirator for protection against occupational exposure to tuberculosis. A gown and eye goggles are not sufficient personal protective devices for this condition. Surgical masks are ineffective to filter droplet nuclei, which necessitates the use of protective devices capable of filtering bacteria and particles smaller than 1 micron. A gown and sterile gloves are not sufficient personal protection devices for this condition.

A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient? A. "Hold the spirometer at your lips and breathe in and out like you normally would." B. "When you're ready, blow hard into the spirometer for as long as you can." C. "Take a deep breath and then blow short, forceful breaths into the spirometer." D. "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."

D. "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." Rationale: The patient should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The patient should then exhale slowly through the mouthpiece.

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is important for the nurse to ask before the skin test? A. "Do you take any over-the-counter (OTC) medications?" B. "Do you have any family members with a history of TB?" C. "How long has it been since you moved to the United States?" D. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

D. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?" Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? A. "I need to continue medication therapy for 1 month." B. "I can't shop at the mall for the next 6 months." C. "I can return to work if a sputum culture comes back negative." D. "I should not be contagious after 2 to 3 weeks of medication therapy."

D. "I should not be contagious after 2 to 3 weeks of medication therapy." Rationale: The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative.

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates that the teaching has been effective? A. "I will make an appointment to see the doctor every year." B. "I will stop taking the prednisone if I experience a dry cough." C. "I will not worry if I feel a little short of breath with exercise." D. "I will call the health care provider right away if I develop a fever."

D. "I will call the health care provider right away if I develop a fever." Rationale: Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.

The nurse provides discharge instructions after a rhinoplasty. Which statement by the patient indicates that the teaching was successful? A. "My nose will look normal after 24 to 48 hours." B. "I can take 800 mg ibuprofen every 6 hours for pain." C. "I will remove and reapply the nasal packing every day." D. "I will elevate my head for 48 hours to minimize swelling."

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

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? A. "I am going to buy a rib binder to wear during the day." B. "I can take shallow breaths to prevent my chest from hurting." C. "I should plan on taking the pain pills only at bedtime so I can sleep." D. "I will use the incentive spirometer every hour or two during the day."

D. "I will use the incentive spirometer every hour or two during the day." Rationale: Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.

The nurse has just administered the first dose of omalizumab to a client. Which statement by the client would alert the nurse that the client may be experiencing a life-threatening effect? A. "I have a severe headache." B. "My feet are quite swollen." C. "I am nauseated and may vomit." D. "My lips and tongue are swollen."

D. "My lips and tongue are swollen." Rationale: Omalizumab is an antiinflammatory used for long term control of asthma. Anaphylactic reactions can occur with the administration of omalizumab. The nurse administering the medication should monitor for adverse reactions of the medication. Swelling of the lips and tongue are an indication of an anaphylaxis. The client statements in options A, B, and C are not indicative of an adverse reaction.

The nurse observes a nursing student suctioning a client. Which intervention by the student nurse requires the supervising nurse to intervene? A. Checking oxygen saturation post suctioning B. Hyperoxygenating the client after removal of the catheter C. Applying intermittent suction during catheter removal D. Applying suction when the catheter is inserted

D. Applying suction when the catheter is inserted Rationale: Applying suction as the catheter is introduced allows the tubing to adhere to the airway and destroys cells. The other options are appropriate actions on the part of a nurse or student who is suctioning a client.

A patient's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? A. Administer the treatment with the patient in a high Fowler's or semi-Fowler's position. B. Perform the procedure immediately following the patient's meals. C. Apply percussion firmly to bare skin to facilitate drainage. D. Assist the patient into a position that will allow gravity to move secretions.

D. Assist the patient into a position that will allow gravity to move secretions. Rationale: Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal.

A Cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication? A. Insomnia B. Constipation C. Hypotension D. Bronchospasm

D. Bronchospasm Rationale: Cromolyn sodium is an inhaled non-steroidal anti-allergy agent and a mast cell stabilizer. Undesirable effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia.

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? A. Emergency pericardiocentesis B. Stabilization of the chest wall C. Bronchodilator administration D. Chest tube connected to suction

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

Which action by a student nurse who is suctioning a patient's tracheostomy tube indicates a need for further instruction? A. Washes hands and wears goggles B. Inserts catheter without suctioning C. Provides preoxygenation for at least 30 seconds D. Continues to suction when patient heart rate drops

D. Continues to suction when patient heart rate drops Rationale: A drop in heart rate in response to suctioning may indicate hypoxemia or a vagal response and is an indication that suctioning should be halted. The other actions by the student are correct. p. 491

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that he or she will IMMEDIATELY report which finding? A. Impaired sense of hearing B. Gastrointestinal side effects C. Orange-red discoloration of body secretions D. Difficulty in discriminating the color red from green

D. Difficulty in discriminating the color red from green Rationale: Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from anti-tubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin.

The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patient's respirations. How should the nurse best respond to this assessment finding? A. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. B. Inform the physician promptly that there is in imminent leak in the drainage system. C. Encourage the patient to do deep breathing and coughing exercises. D. Document that the chest drainage system is operating as it is intended.

D. Document that the chest drainage system is operating as it is intended. Rationale: Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take FIRST? A. Administer anticoagulant drug therapy. B. Notify the patient's health care provider. C. Prepare patient for a spiral computed tomography (CT). D. Elevate the head of the bed to a semi-Fowler's position.

D. Elevate the head of the bed to a semi-Fowler's position. Rationale: The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be performed after the head is elevated and O2 is started. The health care provider may order a spiral CT to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient? A. Assure the patient that everything will be all right and that remaining calm is the best strategy. B. Ask a family member to interpret what the patient is trying to communicate. C. Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely. D. Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.

D. Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board. Rationale: If the patient uses an alternative method of communication, he will feel in better control and likely be less frustrated. Assuring the patient that everything will be all right offers false reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods helps the patient to communicate. In a patient with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the patient's wishes. Making them responsible for interpreting the patient's gestures may frustrate the family. The patient may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

A patient arrives in the ear, nose, and throat clinic with foul-smelling nasal drainage from the right nare, reporting a piece of tissue being "stuck up my nose." Which action should the nurse take first? A. Notify the clinic health care provider. B. Obtain aerobic culture specimens of the drainage. C. Ask the patient about how the cotton got into the nose. D. Have the patient occlude the left nare and blow the nose.

D. Have the patient occlude the left nare and blow the nose. Rationale: Because the highest priority action is to remove the foreign object from the nare, the nurse's first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose.

The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped? A. Heart rate increases from 86 to 102 beats/min. B. Respiratory rate increases from 16 to 20 breaths/min. C. Blood pressure increases from 110/70 to 120/80 mm Hg. D. Heart rate decreases from 78 to 40 beats/min.

D. Heart rate decreases from 78 to 40 beats/min. Rationale: A decrease in heart rate indicates that the client is not tolerating the procedure, and the vasovagal reflex may be stimulated. An increase in heart rate may be stimulated by suctioning and is expected, as is a slight increase in blood pressure. A slight increase in respiratory rate after the procedure might be caused by the feeling of oxygen being suctioned from the client's airway, along with secretions.

The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patient's discharge teaching? A. How to count her respirations accurately B. How to collect serial sputum samples C. How to independently wean herself from treatment D. How to perform diaphragmatic breathing

D. How to perform diaphragmatic breathing Rationale: Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer. Patient teaching would not include counting respirations and the patient should not wean herself from treatment without the involvement of her primary care provider. Serial sputum samples are not normally necessary.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? A. Bilateral wheezing B. Inspiratory crackles C. Intercostal retractions D. Increased respiratory rate

D. Increased respiratory rate Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. Test-Taking Strategy: Note the strategic word, earliest. Eliminate option C first because intercostal retraction is a later sign of respiratory distress. Of the remaining options, recall that adventitious breath sounds (options A and B) would occur later than an increased respiratory rate.

A patient with allergic rhinitis reports severe nasal congestion; sneezing; and watery, itching eyes and nose at various times of the year. When teaching the patient about how to control these symptoms, the nurse teaches the patient to A. Avoid all intranasal sprays and oral antihistamines. B. Limit the usage of nasal decongestant spray to 10 days. C. Use oral decongestants at bedtime to prevent symptoms during the night. D. Keep a dairy of when the allergic reaction occurs and what precipitates it.

D. Keep a dairy of when the allergic reaction occurs and what precipitates it.

The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A. Keep the patient in a low Fowler's position. B. Perform tracheostomy care at least once per day. C. Maintain continuous bedrest. D. Monitor cuff pressure every 8 hours.

D. Monitor cuff pressure every 8 hours. Rationale: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowler's position is not indicated.

Upon removal of a PICC, the nurse notices that the catheter length is less than the original insertion length. What should the nurse do first? A. Remove the dressing from the catheter exit site. B. Place the patient on the right side. C. Initiate oxygen therapy at 2 L/min via a nasal cannula. D. Notify the practitioner immediately.

D. Notify the practitioner immediately. Rationale: If a discrepancy between insertion length and removal length is identified, this indicates the tip of the catheter may have broken off during removal and a fragment retained in the patient; the nurse should immediately notify the practitioner. Oxygen therapy may or may not be needed, depending on the patient's symptoms, and the catheter exit site should be dressed to prevent bleeding; however, these are not the priority nursing actions.

While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. Which action by the nurse is most appropriate? A. Increase the inflation pressure in the tracheostomy cuff. B. Add blue dye to a beverage to assess for aspiration. C. Make the client NPO and notify the health care provider. D. Perform a more thorough assessment of the client.

D. Perform a more thorough assessment of the client. Rationale: presence of cough, pulse oximetry reading, and possibly mental status. The nurse could temporarily make the client NPO while conducting this assessment, but calling the provider must wait until he or she has more complete data. The nurse should not decide to increase the inflation pressure in the tracheostomy cuff on his or her own. Adding dye to food, drink, or tube feeding formulas was commonly done in the past but should be avoided because the dye is toxic to lung tissues if aspirated.

The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge? A. Walk 1 mile 3 to 4 times a week. B. Use weights daily to increase arm strength. C. Walk on a treadmill 30 minutes daily. D. Perform shoulder exercises five times daily.

D. Perform shoulder exercises five times daily. Rationale: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.

After the removal of a PICC, the patient becomes hypotensive, lightheaded, confused, tachycardic, anxious, and short of breath. What should the nurse do next? A. Instruct the patient to take a deep breath and hold it. B. Obtain an arterial blood gas measurement. C. Administer a sedative to the patient. D. Place the patient in the left lateral Trendelenburg position.

D. Place the patient in the left lateral Trendelenburg position. Rationale: The nurse should suspect the patient has a venous air embolism and should immediately place her in the left lateral Trendelenburg position; this helps prevent air from traveling through the right side of the heart into the pulmonary arteries, leading to right ventricular outflow obstruction (air lock). Obtaining an arterial blood gas measurement is also important, but it should not be the most immediate action. Sedating the patient is contraindicated because she is hypoxemic; sedation given at this time may suppress her respirations and worsen the hypoxemia. Instructing the patient to take a deep breath and hold it does not help once the air has already entered the venous system; this action should have been initiated before removing the catheter.

After changing a patient's tracheostomy ties, how will the nurse best ensure that the ties are correctly applie? A. Have the respiratory therapist check the ties. B. Ask the patient whether the ties feel comfortable. C. Visually inspect the tracheostomy ties for appropriate fit. D. Place two fingers underneath the ties to check the fit.

D. Place two fingers underneath the ties to check the fit. Rationale: When securing tracheostomy ties, two fingers are placed underneath the ties to ensure that the ties are not too tight around the patient's neck. Although the respiratory therapist may check the ties, the nurse doing tracheostomy care will not rely on another staff member to evaluate for a secure fit of the tracheostomy ties. Patient comfort should be assessed, but maintaining the ties to ensure that the tracheostomy tube is secure is a higher priority. The nurse may visually check the tracheostomy ties, but the tightness of the ties is best evaluated by inserting two fingers under the ties after tying them. pp. 490, 491

Which action is part of the preparation for nasotracheal suctioning? A. Place the patient in a supine position. B. Preoxygenate the patient with 100% oxygen. C. Suction 100 mL of warm tap water to flush the suction catheter. D. Place water-soluble lubricant onto the open sterile catheter package.

D. Place water-soluble lubricant onto the open sterile catheter package. Rationale: Lubricant facilitates the insertion of the catheter. The patient should be in the semi-Fowler's position or sitting upright. Preoxygenation is not needed before nasotracheal suctioning. Sterile water or sterile 0.9% sodium chloride is used to flush the catheter.

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? A. Promote oxygen intake B. Strengthen the diaphragm C. Strengthen the intercostal muscles D. Promote carbon dioxide elimination

D. Promote carbon dioxide elimination Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Option A, B, and C are not the purposes of this type of breathing. Test-Taking Strategy: Note the strategic word, primary, and the subject, client understanding of pursed-lip breathing and visualize the use of this procedure to assist you in answering correctly. Knowledge of the respiratory conditions in which this type of breathing is helpful also will assist in directing you to the correct option.

A client is becoming frustrated because of an inability to communicate with a tracheostomy. Which intervention by the nurse most effectively enhances communication? A. Explain to the client that speech will be clear and distinct with a fenestrated tube. B. Reassure the client that in time he or she will get used to the speech difficulties. C. Place a sign above the client's bed indicating that the client cannot speak. D. Provide the client with a communication board and call light within easy reach.

D. Provide the client with a communication board and call light within easy reach. Rationale: A communication board and the call light will reassure the client that needs will be communicated and met. It is doubtful that the client with a tracheostomy will ever speak clearly and distinctly, no matter what type of tube he or she uses. Reassuring the client that he or she will get used to the speech difficulties does nothing to alleviate the discomfort and fear associated with impaired communication. Placing a sign above the client's bed indicating that he cannot speak will not enhance his ability to communicate, although it may help staff remember that the client has impaired communication.

A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the nurse is most appropriate? A. Drain condensation back into the humidifier, maintaining a closed system. B. Keep the water sterile by draining it from the water trap back into the humidifier. C. Turn down the humidity when condensation begins to collect in the tubing. D. Remove condensation in the tubing by disconnecting and emptying it appropriately.

D. Remove condensation in the tubing by disconnecting and emptying it appropriately. Rationale: Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and nebulizers have a water trap that hangs from the tubing so the condensation can be drained without disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or the nebulizer. Do not turn down the humidity because the physician has ordered it and the client needs it. Minimize how long the tubing is disconnected because the client does not receive oxygen during this period.

What will the nurse do after removing the soiled dressing from a patient's CVAD device? A. Cleanse the site with soap and water. B. Use 2% chlorhexidine swabs to cleanse the site. C. Apply a skin protectant. D. Remove the catheter stabilization device, if present.

D. Remove the catheter stabilization device, if present. Rationale: The nurse would remove the catheter stabilization device, if present, after removing the soiled dressing. Soap and water is not used to cleanse the site of a central venous access device. The site is cleansed after the catheter stabilization device has been removed. Skin protectant is applied after cleansing the site.

A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A. Maintaining positive chest-wall pressure B. Monitoring pleural fluid osmolarity C. Providing positive intrathoracic pressure D. Removing excess air and fluid

D. Removing excess air and fluid Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure.

The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation? A. Fever B. Fatigue C. Weight loss D. Shortness of breath

D. Shortness of breath Rationale: Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.

The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? A. Resumption of the patient's ADLs B. The family's willingness to care for the patient C. Nutritional status and fluid balance D. Signs and symptoms of respiratory complications

D. Signs and symptoms of respiratory complications Rationale: The nurse assesses the patient's adherence to the postoperative treatment plan and identifies acute or late postoperative complications. All options presented need assessment, but respiratory complications are the highest priority because they affect the patient's airway and breathing.

A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued? A. Chest x-ray shows no upper lobe infiltrates. B. TB medications have been taken for 6 months. C. Mantoux testing shows an induration of 10 mm. D. Sputum smears for acid-fast bacilli are negative.

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

The nurse is teaching a family member how to suction the client's tracheostomy at home. Which information does the nurse include in the teaching plan? A. Always suction using sterile technique. B. Suction the mouth first and then the airway. C. Be prepared to recannulate the tube frequently. D. Suctioning with clean technique is acceptable.

D. Suctioning with clean technique is acceptable. Rationale: The family member can suction using clean technique because fewer organisms are present in the home than in the hospital. Never suction the mouth first because airway pathogenic organisms could be introduced into the airway. The family member should not be required to recannulate the tube except in an emergency.

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? A. Keep the head of the patient's bed positioned flat. B. Cover the wound tightly with an occlusive dressing. C. Position the patient so that the left chest is dependent. D. Tape a nonporous dressing on three sides over the wound.

D. Tape a nonporous dressing on three sides over the wound. Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? A. Assist the patient with chest physiotherapy and postural drainage. B. Teach the patient to avoid the use of over-the-counter expectorants. C. Notify the health care provider immediately about any bloody or foul-smelling sputum. D. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

D. Teach about the need for prolonged antibiotic therapy after discharge from the hospital. Rationale: Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul-smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? A. Assess patient for allergies to penicillin antibiotics. B. Teach the patient to sleep in a warm, dry environment. C. Avoid giving the patient warm food or warm liquids to drink. D. Teach patient to "swish and swallow" prescribed oral nystatin.

D. Teach patient to "swish and swallow" prescribed oral nystatin. Rationale: Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the "swish and swallow" technique is to expose all the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin allergy because C. albicans infection is treated with antifungals.

The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A. Cognition is decreased. B. Daily arterial blood gases (ABGs) are necessary. C. Slight tracheal bleeding is anticipated. D. The cough reflex is depressed.

D. The cough reflex is depressed. Rationale: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patient's cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.

The nurse supervises unlicensed assistive personnel (UAP) providing care for a patient who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene? A. UAP assists the patient to ambulate to the bathroom. B. UAP helps splint the patient's chest during coughing. C. UAP transfers the patient to a bedside chair for meals. D. UAP lowers the head of the patient's bed to 15 degrees.

D. UAP lowers the head of the patient's bed to 15 degrees. Rationale: Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.