Exam 1: Nursing Assessment: Respiratory System, Upper respiratory

A patient with a chronic productive cough and weight loss is receiving a tuberculosis skin test and asks the nurse the reason for the test. Which response should the nurse give? a. The skin test will determine if you have a tuberculosis infection. b. The skin test will indicate whether you have active tuberculosis. c. The skin test is used to decide which antibiotic therapy will work best. d. The skin test is done prior to notification of the public health department.

Correct Answer: A Rationale: A positive skin test will indicate whether the patient has been infected with tuberculosis. It does not indicate active infection, which will be established through chest x-ray and sputum culture. Initial drug treatment with 4 antibiotics uses a standardized protocol. Although the public health department should be notified if the patient has TB, the nurse should focus on the patient, rather than on the public health concerns.

To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with a. arterial blood gas (ABG) analysis. b. hemodynamic monitoring. c. chest x-rays. d. pulse oximetry.

Correct Answer: A Rationale: ABG analysis is useful because it provides information about both oxygenation and ventilation and assists with determining possible etiologies and appropriate treatment. The other tests may also provide useful information about patient status but will not indicate whether the patient has hypoxemia, hypercapnia, or both.

In analyzing the results of a patient's blood gas analysis, the nurse will be most concerned about an a. arterial oxygen tension (PaO2) of 60 mm Hg. b. arterial oxygen saturation (SaO2) of 91%. c. arterial carbon dioxide (PaCO2) of 47 mm Hg. d. arterial bicarbonate level (HCO3) of 27 mEq/L.

Correct Answer: A Rationale: All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.

An 80-year-old patient breathing room air has an ABG analysis. The nurse interprets which results as normal? a. pH 7.38, arterial carbon dioxide (PaO2) 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 92% b. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 sat 90% c. pH 7.48, PaO2 90 mm Hg, PaCO2 31 mm Hg, and O2 sat 98% d. pH 7.52, PaO2 91 mm Hg, PaCO2 42 mm Hg, and O2 sat 94%

Correct Answer: A Rationale: All the values in this answer are correct. The answer beginning "pH 7.32, PaO2 85 mm Hg" shows respiratory acidosis. The answer beginning "pH 7.48, PaO2 90 mm Hg" indicates respiratory alkalosis, and the answer beginning "pH 7.52, PaO2 91 mm Hg" shows metabolic alkalosis.

The emergency department nurse will suspect a tension pneumothorax in a patient who has been in an automobile accident if a. the breath sounds on one side are decreased. b. there are wheezes audible throughout both lungs. c. there is a sucking sound with each patient breath. d. paradoxic movement of the chest is noted.

Correct Answer: A Rationale: Breath sounds are decreased on the affected side with tension pneumothorax because air trapped in the pleural space compresses the lung on that side. Wheezes that are heard in both lungs indicate airway narrowing, but not pneumothorax. A sucking sound with inspiration is heard with an open pneumothorax. Paradoxic chest movement is associated with flail chest.

A patient with COPD is admitted to the hospital with dyspnea and a cough producing yellow sputum. When palpating the patient's thorax, the nurse will expect to find that chest expansion is a. diminished. b. asymmetric. c. normal. d. increased.

Correct Answer: A Rationale: Chronic lung hyperinflation, such as occurs in COPD, decreases expansion of the lungs with inspiration. Lung expansion is usually symmetrical with emphysema.

When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94.

Correct Answer: A Rationale: Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

All of the following orders are received for a patient who has just been admitted with probable bacterial pneumonia and sepsis. Which one will the nurse accomplish first? a. Obtain blood cultures from two sites. b. Give ciprofloxin (Cipro) 400 mg IV. c. Send to radiology for chest radiograph. d. Administer aspirin suppository.

Correct Answer: A Rationale: Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last.

A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have a. Kussmaul's respirations. b. slow, shallow respirations. c. a low oxygen saturation (SpO2). d. a decrease in PVO2.

Correct Answer: A Rationale: Kussmaul's (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Slow, shallow respirations, a low oxygen saturation rate, and a decrease in PVO2 would not be caused by acidosis

Which finding would be the best indication to the nurse that the patient having an acute asthma attack was responding to the prescribed bronchodilator therapy? a. Wheezes are more easily heard. b. The oxygen saturation is 89%. c. Vesicular breath sounds resolve. d. The respiratory effort decreases.

Correct Answer: A Rationale: Louder wheezes indicate that more air is moving through the airways and that the bronchodilator therapy is working. An oxygen saturation level less than 90% indicates continued hypoxemia. Vesicular breath sounds are normal. A decreased respiratory effort may indicate that the patient is becoming too fatigued to breathe effectively and needs mechanical ventilation.

When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to a. use a manometer to assure cuff pressure is at an appropriate level. b. verify the health care provider's order for the amount of cuff pressure required. c. fill the balloon until no leakage around the cuff is auscultated. d. check the pilot balloon after inflation to assure that it is firm.

Correct Answer: A 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 capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for overinflation. A health care provider's order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration.

When teaching the patient who is receiving standard multidrug therapy for TB about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops a. yellow-tinged skin. b. changes in hearing. c. orange-colored urine. d. thickening of the nails.

Correct Answer: A Rationale: Noninfectious hepatitis is a toxic effect of INH, 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 drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

A patient with COPD is admitted to the hospital. How can the nurse best position the patient to improve gas exchange? a. Sitting up at the bedside in a chair and leaning slightly forward b. Resting in bed with the head elevated to 45 to 60 degrees c. In the Trendelenburg's position with several pillows behind the head d. Resting in bed in a high-Fowler's position with the knees flexed

Correct Answer: A Rationale: Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg's position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well.

15. A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which information will the nurse include in the patient teaching plan? a. "Take vitamin B6 daily to prevent peripheral nerve damage." b. "Read a newspaper daily to check for changes in vision." c. "Schedule an audiometric examination to monitor for hearing loss." d. "Avoid wearing soft contact lenses to avoid orange staining."

Correct Answer: A Rationale: Peripheral neurotoxicity associated can be prevented by taking vitamin B6 when being treated with INH. Visual changes, hearing problems, and orange staining are adverse effects of other TB medications.

The nurse observes a nursing assistant doing all the following activities when caring for a patient with right lower-lobe pneumonia. The nurse will need to intervene when the nursing assistant a. turns the patient over to the right side. b. splints the patient's chest during coughing. c. elevates the patient's head to 45 degrees. d. assists the patient to get up to the bathroom.

Correct Answer: A Rationale: Positioning the patient with the left (or "good" lung) down will improve oxygenation. The other actions are appropriate for a patient with pneumonia.

Postural drainage with percussion and vibration is ordered bid for a patient with chronic bronchitis. The nurse will plan to a. carry out the procedure 3 hours after the patient eats. b. maintain the patient in the lateral positions for 20 minutes. c. perform percussion and vibration before placing the patient in the drainage position. d. give the ordered albuterol (Proventil) after the patient has received the therapy.

Correct Answer: A Rationale: Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 to 15 minutes. Percussion and vibration are done after the postural drainage. Bronchodilators are administered before chest physiotherapy.

The nurse is obtaining a health history from a 67-year-old patient with a 40 pack-year smoking history, complaints of hoarseness and tightness in the throat, and difficulty swallowing. Which question is most important for the nurse to ask? a. How much alcohol do you drink in an average week? b. Do you have a history of using chewing tobacco or snuff? c. Do you use antihistamines for upper airway congestion? d. Have you had frequent streptococcal throat infections?

Correct Answer: A Rationale: Prolonged alcohol use is associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Use of chewing tobacco or snuff is associated with oral cancers rather than throat cancers. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but this is not the priority assessment to obtain at this time. Streptococcal throat infections may also cause these clinical manifestations, but patients will also complain of pain and fever.

During the primary assessment of a patient with multiple trauma, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen. The nurse's first action should be to a. initiate isotonic fluid infusion through two large-bore IV lines. b. send blood to the lab for a complete blood count (CBC). c. finish the airway, breathing, circulation, disability survey. d. assess further for a cause of the decreased circulation.

Correct Answer: A Rationale: The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

The nurse makes a diagnosis of impaired gas exchange for a patient with COPD in acute respiratory distress, based on the assessment finding of a. a pulse oximetry reading of 86%. b. dyspnea and respiratory rate of 36. c. use of the accessory respiratory muscles. d. the presence of crackles in both lungs.

Correct Answer: A Rationale: The best data to support the diagnosis of impaired gas exchange are abnormalities in the ABGs or pulse oximetry. The other data would support a diagnosis of risk for impaired gas exchange.

The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use? a. The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days. b. The patient became very short of breath an hour before coming to the hospital. c. The patient has been taking acetaminophen (Tylenol) 650 mg every 6 hours for chest-wall pain. d. The patient says there have been no acute asthma attacks during the last year.

Correct Answer: A Rationale: The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.

A staff nurse has a TB skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the a. use and side effects of INH. b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. recommendation guidelines for bacille Calmette-Guérin (BCG) vaccine.

Correct Answer: A 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 individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection.

A patient with a deep vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP of 100/60, and respirations of 42. The nurse's first action should be to a. elevate the head of the bed. b. administer the ordered pain medication. c. notify the patient's health care provider. d. offer emotional support and reassurance.

Correct Answer: A Rationale: The patient has symptoms consistent with a pulmonary embolism; elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started).

A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care? a. Hypercapnic respiratory failure related to decreased ventilatory effort b. Hypoxemic respiratory failure related to diffusion limitations c. Hypoxemic respiratory failure related to shunting of blood d. Hypercapnic respiratory failure related to increased airway resistance

Correct Answer: A Rationale: The patient with an opioid overdose develops hypercapnic respiratory failure as a result of the decrease in respiratory rate and depth. Diffusion limitations, blood shunting, and increased airway resistance are not the primary pathophysiology causing the respiratory failure

A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next? a. Listen to the patient's lungs. b. Check the patient's O2 saturation. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

Correct Answer: A 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/or decreased breath sounds. The re is no indication that the oxygen saturation has decreased 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.

A 32-year-old patient is seen in the clinic for dyspnea associated with the diagnosis of emphysema. The patient denies any history of smoking. The nurse will anticipate teaching the patient about a. 1-antitrypsin testing. b. use of the nicotine patch. c. continuous pulse oximetry. d. effects of leukotriene modifiers.

Correct Answer: A Rationale: When emphysema occurs in young patients, especially without a smoking history, a congenital deficiency in 1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with emphysema.

A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective? a. "I will need to buy a water bottle to carry with me." b. "Until the radiation is complete, I may have diarrhea." c. "Alcohol-based mouthwashes will help clean oral ulcers." d. "I can use lotions to moisturize the skin on my throat."

Correct Answer: A Rationale: Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not effect 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. Use of lotions on skin being radiated is avoided.

These four patients arrive in the emergency department after a motor-vehicle crash. In which order should they been assessed? a. A 22-year-old with fractures of the face and jaw b. A 30-year-old with a misaligned right leg c. A 45-year-old complaining of 6/10 abdominal pain d. A 72-year-old with palpitations and chest pain

Correct Answer: A, D, C, B Rationale: The highest priority is to assess the 22-year-old patient for airway obstruction, which is the most life-threatening injury. The 72-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pains. The 45-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 30-year-old appears to have a possible fracture of the right leg and should be seen soon, but this patient has the least life-threatening injury.

Which statement by the COPD patient indicates that the nurse's teaching about nutrition has been effective? a. "I will drink lots of fluids with my meals." b. "I will have ice cream as a snack every day." c. "I should exercise for 15 minutes before meals." d. "I should avoid much meat or dairy products."

Correct Answer: B Rationale: High-calorie foods like ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD.

1. The teaching plan for a patient with acute sinusitis will need to include which of the following interventions? (Select all that apply.) a. You will be more comfortable if you keep your head in an upright position. b. Application of cool compresses to your face will improve sinus drainage. c. OTC antihistamines can be used to relieve congestion and inflammation. d. Taking a hot shower will increase sinus drainage and decrease pain. e. Blowing the nose forcefully should be avoided to decrease nosebleed risk. f. Saline nasal spray can be made at home and used to wash out secretions.

Correct Answer: A, D, F Rationale: Maintaining an upright posture decreases sinus pressure and the resulting pain. The steam and heat from a shower will help thin secretions and improve drainage. Patients can use either OTC sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Cool compresses will not improve drainage. Antihistamines are drying to the mucosa and tend to thicken secretions, making them more difficult to expel. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

When taking an admission history of a patient with possible asthma who has new-onset wheezing and shortness of breath, the nurse will be most concerned about which information? a. The patient has a history of pneumonia 2 years ago. b. The patient takes propranolol (Inderal) for hypertension. c. The patient uses acetaminophen (Tylenol) for headaches. d. The patient has chronic inflammatory bowel disease.

Correct Answer: B Rationale: -blockers such as propranolol can cause bronchospasm in some patients. The other information will be documented in the health history but does not indicate a need for a change in therapy.

When caring for a patient who is hospitalized with active TB, the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patient's room. b. puts on a surgical face mask before visiting the patient. c. brings food from a "fast-food" restaurant to the patient. d. hands the patient a tissue from the box at the bedside. .

Correct Answer: B 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. Handwashing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue

The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after having a pneumonectomy. To promote airway clearance, the nurse's first action should be to a. have the patient use the incentive spirometer. b. medicate the patient with the ordered morphine. c. splint the patient's chest during coughing. d. assist the patient to sit up at the bedside.

Correct Answer: B 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.

A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 95%. Which action should the nurse take next? a. Complete a head-to-toe assessment. b. Place the patient on high-flow oxygen. c. Start rewarming the patient. d. Obtain arterial blood gases (ABG).

Correct Answer: B Rationale: Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given until the patient is normothermic. The other actions are also appropriate, but the initial action should be to administer oxygen.

A patient with a tracheostomy is to use a fenestrated tracheostomy tube to provide for speech. Which of the following interventions will be included in the plan of care? a. Placing the decannulation cap in the tube before cuff deflation b. Assessing the patient's ability to swallow without choking c. Keeping the cuff inflated to prevent aspiration of secretions d. Leaving the inner cannula in place to facilitate suctioning

Correct Answer: B 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.

A patient who has mild persistent asthma uses an albuterol (Proventil) inhaler for chest tightness and wheezing has a new prescription for cromolyn (Intal). To increase the patient's management and control of the asthma, the nurse should teach the patient to a. use the cromolyn when the albuterol does not relieve symptoms. b. use the cromolyn to prevent inflammatory airway changes. c. administer the cromolyn first for chest tightness or wheezing. d. administer the albuterol regularly to prevent airway inflammation.

Correct Answer: B Rationale: Cromolyn is prescribed to reduce airway inflammation. It takes several weeks for maximal effect and is not used to treat acute asthma symptoms Albuterol is used as a rescue medication in mild persistent asthma and will not decrease inflammation.

A patient is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation. The spouse arrives as the patient is taken into a treatment room and asks to stay with the patient. The nurse should a. have the spouse wait outside the treatment room with a designated staff member to provide emotional support. b. bring the spouse into the room and ensure him or her that a member of the team will explain the care given and answer questions. c. explain that the presence of family members is distracting to staff and might impair the resuscitation efforts. d. advise the spouse that if the resuscitation effort is unsuccessful, the memories may have an adverse impact on grieving.

Correct Answer: B Rationale: Family members and patients report benefits from family presence during resuscitation efforts, so the nurse should try to accommodate the spouse. Having the spouse wait outside the room is not as supportive to the spouse or patient. It would be inappropriate to imply that the spouse's presence would have adverse consequences for the patient. Family members do not report problems with grieving caused by being present during resuscitation efforts.

A patient with chronic hypoxemia (SaO2 levels of 89%-90%) caused by COPD has just been admitted with increasing shortness of breath. In planning for discharge, which of these actions by the nurse will be most effective in improving compliance with discharge teaching? a. Have the patient repeat the instructions immediately after the teaching. b. Arrange for the patient's spouse to be present during the teaching. c. Accomplish the patient teaching just before the scheduled discharge. d. Start giving the patient discharge teaching on the day of admission.

Correct Answer: B Rationale: Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's spouse present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

Which information given by an asthmatic patient during the admission assessment will be of most concern to the nurse? a. The patient says that the asthma symptoms are worse every spring. b. The patient's only asthma medications are albuterol (Proventil) and salmeterol (Serevent). c. The patient uses cromolyn (Intal) before any aerobic exercise. d. The patient's heart rate increases after using the albuterol (Proventil) inhaler.

Correct Answer: B Rationale: Long-acting 2-agonists should be used only in patients who are also using another medication for long-term control (typically an inhaled corticosteroid). Salmeterol should not be used as the first-line therapy for long-term control. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma.

4. The health care provider has prescribed triamcinolone (Azmacort) metered-dose inhaler (MDI) two puffs every 8 hours and pirbuterol (Maxair) MDI 2 puffs four times a day for a patient with asthma. In teaching the patient about the use of the inhalers, the best instruction by the nurse is a. "Use the Maxair inhaler first, wait a few minutes, then use the Azmacort inhaler." b. "Using a spacer with the MDIs will improve the inhalation of the medications." c. "To avoid side effects, the inhalers should not be used within 1 hour of each other." d. "To maximize the effectiveness of the drugs, inhale quickly when using the inhalers."

Correct Answer: B Rationale: More medication reaches the bronchioles when a spacer is used along with an MDI. There is no evidence that using a bronchodilator before a corticosteroid inhaler is helpful. The medications can be used at the same time. The patient should inhale slowly when using an MDI.

The nurse notes new-onset confusion in an 89-year-old patient in a long-term-care facility; the patient is normally alert and oriented. Which action should the nurse take next? a. Check the patient's pulse rate. b. Obtain an oxygen saturation. c. Notify the health care provider. d. Document the change.

Correct Answer: B Rationale: New-onset confusion caused by hypoxia may be the first sign of pneumonia in older patients. The other actions are also appropriate in this order: check the pulse, notify the health care provider, and document the change in status.

During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. hyperresonance on percussion. b. increased vocal fremitus on palpation. c. fine crackles in all lobes on auscultation. d. asymmetric chest expansion on inspection.

Correct Answer: B Rationale: Pneumonias caused by Streptococcus pneumoniae are typically lobar or segmental. The nurse would expect to find increased vocal fremitus over the affected area of the lungs. The area would be dull to percussion. Fine crackles in all lobes would indicate a diffuse infection, which is more typical of viral pneumonias. Asymmetric chest expansion is not typical with pneumonia.

A patient is admitted to the emergency department after a near-drowning accident in a local lake. The patient received rescue breathing at the site and now has spontaneous respirations. The nurse will observe the patient for several hours to monitor for symptoms of a. hypernatremia. b. pulmonary edema. c. hypothermia. d. head injury.

Correct Answer: B Rationale: Pulmonary edema is a common complication after a near-drowning incident. Hypernatremia would not occur in a freshwater submersion. Hypothermia and head injury may be associated with near-drowning but would be apparent at the time of admission and would not develop after several hours.

8. A patient who has been diagnosed with sleep apnea has CPAP ordered. Which of these nursing actions in the plan of care can the RN delegate to a nursing assistant? a. Monitor the patient's oxygen saturation during the night. b. Remind the patient to apply the CPAP at bedtime. c. Assess for fatigue or depression caused by poor sleep. d. Teach the patient how to apply the CPAP mask.

Correct Answer: B Rationale: Reminding a patient about previously taught self-care activities is within the education level and scope of practice for a nursing assistant. Assessment and teaching are skills that require higher-level nursing education and scope of practice.

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for a a. chest x-ray. b. spiral CT scan. c. bronchoscopy. d. PET scan.

Correct Answer: B Rationale: Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy is used to inspect for changes in the bronchial tree, not to assess for vascular changes. PET scans are most useful in determining the presence of malignancy.

A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a a. shallow breathing pattern. b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg. d. respiratory rate of 32/min.

Correct Answer: B Rationale: The PaO2 indicates severe hypoxemia and that the nurse should take immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain.

13. When auscultating a patient's chest while the patient takes a deep breath, the nurse hears loud, high-pitched, "blowing" sounds at both lung bases. The nurse will document these as a. adventitious sounds. b. abnormal sounds. c. vesicular sounds. d. normal sounds.

Correct Answer: B Rationale: The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at the lung base. Adventitious sounds are crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft sounds heard over all lung areas except the major bronchi.

The health carre provider inserts two chest tubes connected with a Y-connecter in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 ml of blood in the collection chamber. c. severe pain with each deep patient inspiration. d. subcutaneous emphysema at the insertion site.

Correct Answer: B Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The severe 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

All of the following information is obtained by the nurse who is caring for a patient receiving subcutaneous heparin injections to treat a pulmonary embolus. Which assessment data is most important to communicate to the health care provider? a. The patient has many abdominal bruises. b. The patient's BP is 90/46. c. The activated partial thromboplastin time is 2 times the patient baseline. d. The patient's stool is dark green and liquid.

Correct Answer: B Rationale: The low BP may indicate that the patient is experiencing bleeding, a possible adverse effect of heparin therapy. Subcutaneous heparin administration is given into the subcutaneous tissue of the abdomen and abdominal bruising is not unusual. An aPTT 2 times the baseline indicates a therapeutic heparin level. The patient should be monitored for gastrointestinal bleeding, which would be indicated by black or red stools.

When the nurse is caring for an obese patient with left lower-lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the high-Fowler's position. d. in the tripod position.

Correct Answer: B Rationale: The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.

The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Notify the health care provider of the patient's vital signs. b. Obtain oxygen saturation using pulse oximetry. c. Document the vital signs and continue to monitor. d. Administer PRN acetaminophen (Tylenol) 650 mg.

Correct Answer: B Rationale: The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing; the nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Documentation and continued monitoring of the vital signs are needed but do not constitute an adequate response to the patient situation. Tylenol administration is appropriate but not the highest priority for this patient.

When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first? a. Lung sounds b. Oxygen saturation c. Body temperature d. Apical pulse

Correct Answer: B Rationale: The priority assessment data are how well the patient is oxygenating, so O2 saturation should be obtained first because this measure gives the most direct information. The other data will also be collected rapidly but are not as essential as the O2 saturation.

To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to a. turn and reposition immobile patients at least every 2 hours. b. position patients with altered consciousness in lateral positions. c. monitor frequently for respiratory symptoms in patients who are immunosuppressed. d. provide for continuous subglottic aspiration in patients receiving enteral feedings.

Correct Answer: B Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a 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 oxygen saturation will help detect pneumonias in immune compromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.

After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says, a. "I can participate in most of my prior fitness activities except swimming." b. "I must keep the stoma covered with a loose sterile dressing at all times." c. "I need to eat nutritious meals even though I can't smell or taste very well." d. "I should wear a Medic Alert bracelet that identifies me as a neck breather."

Correct Answer: B Rationale: 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.

When teaching a patient with chronic obstructive pulmonary disease (COPD) about reasons to quit smoking, the nurse will explain that long-term exposure to tobacco smoke leads to a a. weakening of the smooth muscle lining the airways. b. decrease in the area available for oxygen absorption. c. lesser number of red blood cells for oxygen delivery. d. decreased production of protective respiratory secretions.

Correct Answer: B Rationale: Tobacco smoke leads to an increase in proteolytic enzymes, which break down alveolar walls and lead to less alveolar surface area for gas exchange. Bronchial smooth muscle is not weakened by chronic smoking. Polycythemia is a common compensatory mechanism for patients with COPD. The quantity of respiratory secretions increases as a result of smoking.

When teaching the patient with COPD about exercise, which information should the nurse include? a. "Stop exercising if you start to feel short of breath." b. "Use the bronchodilator before you start to exercise." c. "Breathe in and out through the mouth while you exercise." d. "Upper body exercise should be avoided to prevent dyspnea."

Correct Answer: B Rationale: Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.

On auscultation of a patient's lungs, the nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes. The nurse records this finding as a. abnormal lung sounds in the bases of both lungs. b. inspiratory wheezes in both lungs. c. crackles in the right and left lower lobes. d. pleural friction rub in the right and left lower lobes.

Correct Answer: B Rationale: Wheezes are high-pitched sounds; in this case, they are heard during the inspiratory phase of the respiratory cycle. Abnormal breath sounds are bronchial or bronchovesicular sounds heard in the peripheral lung fields. Crackles are low-pitched, "bubbling' sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

When caring for a patient with head and neck trauma after a motorcycle accident, the emergency department nurse's first action should be to a. suction the mouth and oropharynx. b. immobilize the cervical spine. c. administer supplemental oxygen. d. obtain venous access.

Correct Answer: B Rationale: When there is a risk of spinal cord injury, the nurse's initial action is immobilization of the cervical spine during positioning of the head and neck for airway management. Suctioning, supplemental oxygen administration, and venous access are also necessary after the cervical spine is protected by immobilization.

A patient is scheduled for a spiral CT scan to rule out a pulmonary embolus. Which information obtained by the nurse is most important to communicate to the health care provider before the examination? a. The apical pulse is irregular. b. The oxygen saturation is 93%. c. The patient is allergic to shellfish. d. The patient is very tachypneic.

Correct Answer: C Rationale: Because the contrast solution is iodine-based, the patient may need to have the CT scan without contrast or be premedicated before contrast injection. The irregular pulse, oxygen saturation, and tachypnea all need further assessment or intervention but are not unusual for a patient with a possible pulmonary embolus.

When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to a. avoid eating or drinking for 4 hours before the forced expiratory volume in 1 second (FEV1)/forced expiratory volume (FEV) test. b. take oral corticosteroids at least 2 hours before the examination. c. withhold bronchodilators for 6 to 12 hours before the examination. d. use rescue medications immediately before the FEV1/FEV testing.

Correct Answer: C Rationale: Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should also be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.

When reading the chart for a patient with COPD, the nurse notes that the patient has cor pulmonale. To assess for cor pulmonale, the nurse will monitor the patient for a. elevated temperature. b. complaints of chest pain. c. jugular vein distension. d. clubbing of the fingers.

Correct Answer: C Rationale: Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular vein distension. The other clinical manifestations may occur in the patient with other complications of COPD but are not indicators of cor pulmonale.

A patient with a history of asthma is admitted to the hospital in acute respiratory distress. During assessment of the patient, the nurse would notify the health care provider immediately about a. a pulse oximetry reading of 90%. b. a peak expiratory flow rate of 240 ml/min. c. decreased breath sounds and wheezing. d. a respiratory rate of 26 breaths/min.

Correct Answer: C Rationale: Decreased breath sounds and wheezing would indicate that the patient was experiencing an asthma attack, and immediate bronchodilator treatment would be indicated. The other data indicate that the patient needs ongoing monitoring and assessment but do not indicate a need for immediate treatment

The nurse has received change-of-shift report about these four patients. Which one will the nurse plan to assess first? a. A 23-year-year-old patient with cystic fibrosis who has pulmonary function testing scheduled in 30 minutes b. A 35-year-old patient who was admitted the previous day with bacterial pneumonia and has a temperature of 100.2° F c. A 46-year-old patient who is complaining of dyspnea after having a thoracentesis an hour previously d. A 77-year-old patient with TB who has four antitubercular medications due in 15 minutes

Correct Answer: C Rationale: Dyspnea after a thoracentesis may indicate a pneumothorax or hemothorax and requires immediate evaluation by the nurse. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

During the primary assessment of a trauma victim, the nurse determines that the patient has a patent airway. The next assessment by the nurse should be to a. check the patient's level of consciousness. b. examine the patient for any external bleeding. c. observe the patient's respiratory effort. d. palpate for the presence of peripheral pulses.

Correct Answer: C Rationale: Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but are not accomplished as rapidly as the assessment of breathing.

All the following medications are ordered for a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) and acute renal failure. Which medication should the nurse discuss with the health care provider before administration? a. IV ranitidine (Zantac) 50 mg IV b. sucralfate (Carafate) 1 g per nasogastric tube c. IV gentamicin (Garamycin) 60 mg d. IV methylprednisolone (Solu-Medrol) 40 mg

Correct Answer: C Rationale: Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.

It will be most important for the nurse to check pulse oximetry for which of these patients? a. A patient with emphysema and a respiratory rate of 16 b. A patient with massive obesity who is refusing to get out of bed c. A patient with pneumonia who has just been admitted to the unit d. A patient who has just received morphine sulfate for postoperative pain

Correct Answer: C Rationale: Hypoxemia and hypoxemic respiratory failure are caused by disorders that interfere with the transfer of oxygen into the blood, such as pneumonia. The other listed disorders are more likely to cause problems with hypercapnia because of ventilatory failure.

The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of these assessments will require the most immediate action by the nurse? a. The patient's temperature is 100.1° F. b. The nose appears red and swollen. c. The oxygen saturation is 89%. d. The patient complains of pain rated as 7 of a 10-point scale.

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

Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90. b. Pain level is 5/10 with a deep breath. c. Oxygen saturation is 89%. d. Respiratory rate is 24 when lying flat.

Correct Answer: C Rationale: Oxygen saturation would be expected to improve after a thoracentesis; a saturation of 89 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 oxygen saturation is the priority.

When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about the risk for poor oxygenation because of a. too-rapid movement of blood flow through the pulmonary blood vessels. b. incomplete filling of the alveoli with air because of reduced respiratory ability. c. decreased transfer of oxygen into the blood because of thickening of the alveoli. d. mismatch between lung ventilation and blood flow through the blood vessels of the lung.

Correct Answer: C Rationale: Pulmonary fibrosis causes the alveolar-capillary interface to become thicker, which increases the amount of time it takes for gas to diffuse across the membrane. Too-rapid pulmonary blood flow is another cause of shunt but does not describe the pathology of pulmonary fibrosis. Decrease in alveolar ventilation will cause hypercapnia. Ventilation and perfusion are matched in pulmonary fibrosis; the problem is with diffusion.

A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen. When will be the best time for the nurse to collect the specimen? a. After the patient rinses the mouth with mouthwash b. As soon as the order is received from the health care provider c. Right after the patient gets up in the morning d. After the skin test is administered

Correct Answer: C Rationale: Sputum specimens are ideally collected in the morning because mucus is likely to accumulate during the night. The patient should rinse the mouth with water; mouthwash may inhibit the growth of the bacilli. There is no need to wait until the tuberculin skin test is administered.

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene? a. The student preoxygenates the patient for 2 minutes before suctioning. b. The student applies suction for 10 seconds while withdrawing the catheter. c. The student puts on clean gloves and uses a sterile catheter to suction. d. The student inserts the catheter about 5 inches into the tracheostomy tube.

Correct Answer: C Rationale: Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 2 minutes of preoxygenation, this would not be unsafe; 10 seconds of suction is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube.

The nurse will anticipate discharge today for which of these patients with community-acquired-pneumonia? a. 24-year-old patient who has had temperatures ranging from 100.6° to 101° F b. 35-year-old patient who has had 600 ml of oral fluids in the last 24 hours c. 50-year-old patient who has an oxygen saturation of 91% on room air d. 72-year-old patient with a pulse of 102 and a blood pressure (BP) of 90/56

Correct Answer: C Rationale: The 50-year-old meets the Infectious Diseases Society of America (IDSA) hospital discharge criteria. The other patients do not meet the criteria for discharge.

A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. The nurse's first action should be to a. assess the patient's oxygen saturation and call the health care provider. b. ventilate the patient with a manual bag mask until the health care provider arrives. c. insert the obturator and attempt to reinsert the tracheostomy tube. d. position the patient in an upright position with the neck extended.

Correct Answer: C Rationale: The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position, but the neck should remain in a neutral position.

Which of these is the best goal for the patient admitted with chronic bronchitis who has a nursing diagnosis of ineffective airway clearance? a. Patient denies having dyspnea. b. Patient's mental status is improved. c. Patient has a productive cough. d. Patient's O2 saturation is 90%.

Correct Answer: C Rationale: The goal for the nursing diagnosis of ineffective airway clearance is to maintain a clear airway by coughing effectively. The other goals may be appropriate for the patient with COPD, but they do not address the problem of ineffective airway clearance.

The nurse recognizes that intubation and mechanical ventilation are indicated for a patient in status asthmaticus when a. ventricular dysrhythmias and dyspnea occur. b. loud wheezes are audible throughout the lungs. c. pulsus paradoxus is greater than 40 mm Hg. d. fatigue and an O2 saturation of 88% develop.

Correct Answer: D Rationale: Although all of the assessment data indicate the need for rapid intervention, the fatigue and hypoxia indicate that the patient is no longer able to maintain an adequate respiratory effort and needs mechanical ventilation. The initial treatment for the other clinical manifestations would initially be administration of rapidly acting bronchodilators and oxygen.

After teaching a patient with allergic rhinitis how to use a nasal inhaler, the nurse observes the patient self-administering a medication with the inhaler. Which patient action indicates that more teaching is needed? a. The patient gently blows the nose before using the inhaler. b. The patient tilts the head back before inhaling the medication. c. The patient breathes out slowly through the nostrils following inhaler use. d. The patient waits a few seconds before exhaling after using the inhaler.

Correct Answer: C Rationale: The nurse needs to teach the patient to breathe out through the mouth after inhaler use to avoid exhaling some of the medication. The other patient actions indicate that the teaching has been effective.

When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The skin on the patient's back is intact and without redness. b. Sputum and blood cultures show no growth after 24 hours. c. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. d. Endotracheal suctioning results in minimal mucous return.

Correct Answer: C Rationale: The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

When admitting a patient who has a pleural effusion, which technique will the nurse use to assess for tactile fremitus? a. Percuss over the entire posterior chest. b. Use the fingertips to assess for vibration. c. Place the palms of the hands on the chest wall. d. Auscultate while the patient says "ninety-nine."

Correct Answer: C Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as "99." Percussion, palpation with the fingertips, and auscultation are also used during the respiratory assessment but will not assess for fremitus.

1. The nurse enters the room of a patient who has 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? a. The NG tube is disconnected from suction and clamped off. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The patient is lying in a lateral position with the head of the bed flat. d. The Hemovac in the neck incision contains 200 ml of bloody drainage.

Correct Answer: C, B, D, A 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 Hemovac should be drained because the 200 ml of drainage will decrease the amount of suction in the Hemovac 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 chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of acute respiratory distress. When monitoring the patient, which assessment by the nurse will be of most concern? a. The patient is sitting in the tripod position. b. The patient has bibasilar lung crackles. c. The patient's pulse oximetry indicates an O2 saturation of 91%. d. The patient's respiratory rate has decreased from 30 to 10/min.

Correct Answer: D Rationale: A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest; therefore, the nurse will need to take immediate action. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

The nurse has received a change-of-shift report about these patients with COPD. Which patient should the nurse assess first? a. A patient with loud expiratory wheezes b. A patient who has a cough productive of thick, green mucus c. A patient with jugular vein distension and peripheral edema d. A patient with a respiratory rate of 38

Correct Answer: D Rationale: A respiratory rate of 38 indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic patient.

After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states a. "I will make an appointment to see the doctor every year." b. "I will not turn the home oxygen up higher than 2 L/minute." c. "I will be careful to use sterile technique with my central line." d. "I will write down my medications and spirometry in a journal."

Correct Answer: D Rationale: After lung transplant, patients are taught to keep logs of medications, spirometry, and laboratory results. Patients require frequent follow-up visits with the transplant team; annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant and patients would not usually have a central IV line.

All of these orders are received for a patient having an acute asthma attack. Which one will the nurse administer first? a. IV methylprednisolone (Solu-Medrol) 60 mg b. triamcinolone (Azmacort) 2 puffs per MDI c. salmeterol (Serevent) 50 mcg per DPI d. albuterol (Ventolin) 2.5 mg per nebulizer

Correct Answer: D Rationale: Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly.

A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. ineffective airway clearance related to thick secretions. c. impaired transfer ability related to weakness. d. impaired gas exchange related to respiratory congestion.

Correct Answer: D Rationale: All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. "PEEP will prevent fibrosis of the lung from occurring." b. "PEEP will push more air into the lungs during inhalation." c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs." d. "PEEP prevents the lung air sacs from collapsing during exhalation."

Correct Answer: D Rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the health care provider of a possible pneumothorax. d. take no further action with the collection device.

Correct Answer: D 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. A new collection device is needed when the collection chamber is filled.

When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes a. positioning on the right side. b. chest tubes to water-seal chest drainage. c. bedrest for the first 24 hours. d. frequent use of an incentive spirometer.

Correct Answer: D 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. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's arterial oxyhemoglobin saturation (SpO2) from 94% to 88%. The nurse will a. assist the patient to cough and deep-breathe. b. help the patient to sit in a more upright position. c. suction the patient's oropharynx. d. increase the oxygen flow rate.

Correct Answer: D Rationale: Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

A nursing diagnosis of body image disturbance related to loss of control of personal care is identified for a patient with a total laryngectomy and radical neck dissection. The nurse evaluates that an expected outcome for the problem has been met when the patient a. wears clothing that minimizes the disfigurement caused by surgery. b. lets the spouse provide hygiene and stoma care. c. asks that only family members be allowed to visit. d. learns to remove and clean the laryngectomy tube independently.

Correct Answer: D Rationale: Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and the body image disturbance is at least partially resolved. Allowing the spouse to provide care, allowing family members to visit, and wearing clothing that masks the body changes are outcomes that do not directly address this nursing diagnosis.

A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. complaints of severe pain. b. heart rate of 110 beats/min. c. a large bruised area on the chest. d. paradoxic chest movement.

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

After teaching the patient with asthma about home care, the nurse will evaluate that the teaching has been successful if the patient states, a. "I will use my corticosteroid inhaler as soon as I start to get short of breath." b. "I will only turn the home oxygen level up after checking with the doctor first." c. "My medications are working if I wake up short of breath only once during the night." d. "No changes in my medications are needed if my peak flow is at 80% of normal."

Correct Answer: D Rationale: Peak flows of 80% or greater indicate that the asthma is well controlled. Corticosteroids are long-acting, prophylactic therapy for asthma and are not used to treat acute dyspnea. Because asthma is an acute and intermittent process, home oxygen is not used. The patient who has effective treatment should sleep throughout the night without waking up with dyspnea.

When a patient with COPD is receiving oxygen, the best action by the nurse is to a. avoid administration of oxygen at a rate of more than 2 L/min. b. minimize oxygen use to avoid oxygen dependency. c. administer oxygen according to the patient's level of dyspnea. d. maintain the pulse oximetry level at 90% or greater. l.

Correct Answer: D Rationale: The best way to determine the appropriate oxygen flow rate is by monitoring the patient's oxygenation either by ABGs or pulse oximetry; an oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an oxygen flow rate of 2 L/min may not be adequate. Because oxygen use improves survival rate in patients with COPD, there is not a concern about oxygen dependency. The patient's perceived dyspnea level may be affected by other factors (such as anxiety) besides blood oxygen leve

A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should a. position the patient so that the right chest is dependent. b. administer high-flow oxygen using a non-rebreathing mask. c. cover the sucking chest wound with an occlusive dressing. d. tape a nonporous dressing on three sides over the chest wound.

Correct Answer: D 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 right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The patient should receive oxygen, but this will have no effect on the development of tension pneumothorax.

A patient returns from surgery with a tracheostomy tube after a total laryngectomy and radical neck dissection. In caring for the patient during the first 24 hours after surgery, the priority nursing action is to a. avoid changing the tracheostomy ties. b. clean the inner cannula every 8 hours. c. monitor for bleeding around the stoma. d. assess the airway and breath sounds.

Correct Answer: D Rationale: The most important goals post-tracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the airway and breath sounds is the priority action. Maintenance of the tracheostomy ties, cleaning the inner cannula, and checking for bleeding are also appropriate nursing actions but are not of as high a priority.

After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. Increased vocal fremitus is palpable over the right chest. c. The patient coughs up small amounts of green mucous. d. The patient's white blood cell (WBC) count is 9000/µl.

Correct Answer: D Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Monitor the patient every 10 to 15 minutes. b. Notify the patient's health care provider immediately. c. Attempt to calm and reassure the patient. d. Assess vital signs and pulse oximetry.

Correct Answer: D Rationale: The nurse needs to collect additional clinical data to share with the health care provider and to start interventions quickly if appropriate (e.g., increased oxygen flow if hypoxic). The change in the patient's neurologic status may indicate deterioration in respiratory function, and the health care provider should be notified immediately but only after some additional information is obtained. Monitoring the patient and attempting to calm the patient are appropriate actions, but they will not prevent further deterioration of the patient's clinical status and may delay care.

A patient in acute respiratory failure as a complication of COPD has a PaCO2 of 65 mm Hg, rhonchi audible in the right lung, and marked fatigue with a weak cough. The nurse will plan to a. allow the patient to rest to help conserve energy. b. arrange for a humidifier to be placed in the patient's room. c. position the patient on the right side with the head of the bed elevated. d. assist the patient with augmented coughing to remove respiratory secretions.

Correct Answer: D Rationale: The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve PaCO2 and will also help to correct fatigue. If the patient is allowed to rest, the PaCO2 will increase. Humidification may help loosen secretions, but the weak cough effort will prevent the secretions from being cleared. The patient should be positioned with the good lung down to improve gas exchange.

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. The patient has a cough that is productive of blood-tinged sputum. b. The patient has scattered crackles throughout the posterior lung bases. c. The patient's temperature is 101.5° F after 2 days of IV antibiotic therapy. d. The patient's SpO2 has dropped to 90%, although the O2 flow rate has been increased.

Correct Answer: D Rationale: The patient's dropping SpO2 despite having an increase in FIO2 indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Resting pulse oximetry (SpO2) of 85% b. Respiratory rate of 28 c. Large amounts of greenish sputum d. Weak, nonproductive cough effort

Correct Answer: D Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.