Final topics - Oxygenation

The student nurse attends a workshop on culture and diversity with regard to sudden infant death syndrome (SIDS) and is now aware that the rate of occurrence is highest among which group of infants? A) American Indians B) Caucasians C) Asians D) Hispanics

A) American Indians Rationale: Rates of SIDS are highest for American Indians and Alaska Natives and lowest for Asians and Hispanics.

The nurse is planning care for the parents of an infant who died as the result of sudden infant death syndrome. Which collaborative interventions does the nurse plan for when providing care to these parents? Select all that apply. A) A psychosocial assessment B) A grief counselor referral C) A psychotherapist referral D) A visit from the chaplain E) A respiratory therapist referral

A) A psychosocial assessment B) A grief counselor referral C) A psychotherapist referral D) A visit from the chaplain Rationale: Collaborative care for the parents may include grief counselors, chaplains and religious leaders, nurses (including school nurses working with older children who lose a sibling), and psychotherapists. In particular, the parents' grief will be acute, and they should receive a psychosocial assessment at each healthcare interaction. A respiratory therapist referral is inappropriate for this situation.

Which population should the nurse assigned to care for pediatric clients recognize as having the highest risk of hospitalization due to RSV? A) Alaskan Native infants B) African American infants C) Native American infants D) Asian American infants

A) Alaskan Native infants Rationale: RSV is a major cause of hospitalization among Alaskan Native infants and is responsible for one-third of hospitalizations of children younger than 3 years in Alaska. The rate of hospitalization is three to five times higher for Alaskan Native infants than for other infants.

What is one genetic cause of COPD? A) Alpha-1 antitrypsin deficiency B) A defect in the CFTR gene C) A mutation in the superoxide dismutase 1 gene D) Mutations in the human leukocyte antigen

A) Alpha-1 antitrypsin deficiency Rationale: In 1% of cases, COPD is caused by a genetic deficiency in alpha-1 antitrypsin, which is necessary for normal lung development and function. A defect in the CFTR gene causes cystic fibrosis. A mutation in the superoxide dismutase 1 gene causes amyotrophic lateral sclerosis (ALS), a neuromuscular disease that can reduce an individual's ability to control breathing muscles. Certain mutations in the human leukocyte antigen (HLA) allele are associated with increased risk of sarcoidosis, which causes inflammatory cells to collect in the lungs.

The nurse is evaluating care provided to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which observation would indicate that care provided to this client has been effective? A) Client conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading. B) Client needs assistance with morning care and meals due to shortness of breath. C) Client states family members are discussing admission to a nursing home for continuing care. D) Client leaves hospital unit to smoke outside four times a day.

A) Client conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading. Rationale: Evidence that care provided to a client with COPD was successful would be the client conducting morning care and ambulating in the room while maintaining an oxygen saturation of 92%. This outcome identifies the client's ability to maintain adequate oxygenation and perform activities of daily living. The client's leaving the unit to smoke suggests that care has not been effective. The client who needs assistance with morning care and meals because of shortness of breath needs additional interventions. The client who states that his family would prefer he go to a nursing home may or may not have been positively affected by the interventions; not enough information is provided to know.

Which prevention strategies would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus (RSV) bronchiolitis? Select all that apply. A) Do not smoke, and avoid all secondhand smoke around the child. B) Practice frequent hand washing. C) Encourage physical activity and play. D) Consider alternatives to sending the child to daycare. E) Ensure an adequate nutritional intake.

A) Do not smoke, and avoid all secondhand smoke around the child. B) Practice frequent hand washing. D) Consider alternatives to sending the child to daycare. Rationale: Exposure to cigarette smoke and attending daycare are both risk factors for RSV/bronchiolitis. The nurse should discuss with the parents smoking cessation and alternative methods of childcare. Practicing frequent hand washing is a primary prevention method for RSV, so this should be practiced by the parents. Nutritional intake and physical activity are good for maintaining general health, but they are not specific for preventing RSV/bronchiolitis.

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothorax. Which interventions are appropriate for this client? Select all that apply. A) Elevate head of the bed B) Administer a high rate of oxygen by nasal cannula C) Prepare for a chest tube insertion D) Administer prescribed antihypertensive medications E) Administer intravenous caffeine per order

A) Elevate head of the bed C) Prepare for a chest tube insertion Rationale: The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed because of the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia, which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.

The nurse is providing care for a client admitted during an acute exacerbation of asthma. Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client? A) Inhaled short-acting beta-agonists B) Oral corticosteroids C) Inhaled long-acting beta-agonists D) Oral anticholinergics

A) Inhaled short-acting beta-agonists Rationale: The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist. Oral corticosteroids, inhaled long-acting beta agonists, and oral anticholinergics are maintenance medications used to treat asthma.

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse select to meet nutritional needs? Select all that apply. A) Encourage a diet high in protein and fats. B) Keep snacks to a minimum. C) Provide frequent small meals with between-meal supplements. D) Encourage carbohydrate-rich foods to provide needed calories for energy. E) Suggest the client eat three meals per day to maintain energy needs.

A) Encourage a diet high in protein and fats. C) Provide frequent small meals with between-meal supplements. Rationale: A diet high in protein and fats without excess carbohydrates is recommended to minimize carbon dioxide production during metabolism. Frequent small meals with between-meal supplements, not three meals with minimal snacking, help maintain intake and reduce fatigue associated with eating.

Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply. A) Encouraging deep breathing exercises B) Assisting with positioning C) Providing suctioning D) Prescribing bronchodilators E) Monitoring activity intolerance

A) Encouraging deep breathing exercises B) Assisting with positioning C) Providing suctioning E) Monitoring activity intolerance Rationale: Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.

The nurse is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply. A) Excessive rapid breathing B) Chest pain C) Rapid breathing at rest D) Shallow breathing E) Cyanosis

A) Excessive rapid breathing C) Rapid breathing at rest D) Shallow breathing Rationale: Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV). What should the nurse stress as the best way to prevent RSV? A) Hand washing B) Monitoring temperature C) Administering antibiotics D) Limiting fluid intake

A) Hand washing Rationale: The best way to prevent RSV is through good hand hygiene and infection-control measures. Monitoring temperature would not prevent infection but would be appropriate for monitoring infection. Administering antibiotics is usually ordered by the physician when a bacterial infection is suspected, not a viral infection. There is no indication of the need to limit fluids, which could potentially produce other complications.

The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply. A) Increased CO2 B) Vasoconstriction C) Decreased O2 D) Decreased intracranial pressure (ICP) E) Increased pulse rate

A) Increased CO2 C) Decreased O2 E) Increased pulse rate Rationale: Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO2). Vasodilatation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation.

The nurse is providing care to a client admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS). When educating the client's family, what should the nurse say is the expected progression of the disease process? A) Initiation of ARDS B) Onset of pulmonary edema C) End-stage ARDS D) Alveolar collapse

A) Initiation of ARDS B) Onset of pulmonary edema D) Alveolar collapse C) End-stage ARDS Rationale: ARDS begins with inflammatory cellular responses and biochemical mediators that damage the alveolar-capillary membrane. Increased interstitial pressure and damage to the alveolar membrane allow fluid to enter the alveoli. The inflammatory process damages surfactant-producing cells, leading to a deficit of surfactant, increased alveolar surface tension, and alveolar collapse. Multiple-organ system dysfunction of the kidneys, liver, gastrointestinal tract, central nervous system, and cardiovascular system are the leading causes of death in ARDS.

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse select to address the client's ineffective breathing pattern? Select all that apply. A) Instruct in pursed-lip breathing B) Teach visualization and meditation C) Deep breathing and coughing every hour D) Instruct in abdominal breathing E) Provide oxygen 2 liters nasal cannula.

A) Instruct in pursed-lip breathing B) Teach visualization and meditation D) Instruct in abdominal breathing Rationale: Techniques used to instruct a client to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation. Providing oxygen 2 liters per nasal cannula will not improve the client's breathing pattern. Deep breathing and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern.

The nurse is placing a newborn baby in the nursery crib with the baby's back down. The mother tells the nurse that she doubts the baby will be able to sleep that way, as all the family members sleep on their stomachs. Which action by the nurse is appropriate? A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS) and it will not interfere with sleep. B) Place the baby on the stomach. C) Suggest the mother place the baby on the stomach when at home. D) Instruct the mother that babies do not really care in which position they are in but placing on the back is easier to provide care.

A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS) and it will not interfere with sleep. Rationale: The nurse should instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome, and it will not interfere with the baby's ability to sleep. The nurse should not place the baby on the stomach or suggest that the mother place the baby on the stomach when at home. Placing the baby on the back does not necessarily make it easier to provide care.

The nurse is caring for a client admitted with septic shock. Which early clinical manifestation might indicate the development of ARDS? A) Intercostal retractions B) Cyanosis C) Tachypnea D) Tachycardia

A) Intercostal retractions Rationale: Dyspnea and tachypnea are early clinical manifestations of ARDS. As the distress progresses, the client would demonstrate an increasing respiratory rate, intercostal retractions, and use of accessory muscles, as well as tachycardia. Cyanosis is a late manifestation.

How does a brainstem abnormality contribute to the risk of SIDS when an infant is placed on his stomach to sleep? A) It decreases the infant's arousal and head turning responses during times of asphyxia. B) It decreases the infant's respiratory drive during NREM sleep. C) It increases periods of apnea, resulting in hypoxia and unconsciousness. D) It increases the risk of aspiration and airway obstruction.

A) It decreases the infant's arousal and head turning responses during times of asphyxia. Rationale: A brainstem abnormality, when combined with a stressor such as sleeping in the prone position in a child in the first 6 months of life, will often result in SIDS due to a decreased arousal and head turning response during times of asphyxia. A brainstem abnormality does not decrease the respiratory drive during NREM sleep, increase periods of apnea, or increase the risk of aspiration and airway obstruction.

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which variables should the nurse highlight as contributing to increased risk of SIDS? Select all that apply. A) Prone sleeping B) Side sleeping C) Loose bedding D) Bed sharing E) Supine sleeping

A) Prone sleeping B) Side sleeping C) Loose bedding D) Bed sharing Rationale: Significant stressors contributing to SIDS are prone or side sleeping, loose bedding, and bed sharing. Infants in the prone or side-lying positions are vulnerable because the brainstem abnormality compromises their protective reflexes, such as arousal and head turning, when experiencing asphyxia. Supine sleeping is a method to decrease the risk for SIDS.

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). When planning care for this client, which interventions are appropriate to enhance the client's breathing pattern? Select all that apply. A) Provide adequate rest periods. B) Assist with activities of daily living (ADLs). C) Educate on relaxation techniques. D) Educate on pursed-lip breathing. E) Administer a cough suppressant.

A) Provide adequate rest periods. B) Assist with activities of daily living (ADLs). C) Educate on relaxation techniques. D) Educate on pursed-lip breathing. Rationale: Providing adequate rest periods and assisting with ADLs prevents fatigue and reduces oxygen demands. Relaxation techniques reduce anxiety and its effect on the respiratory rate. Pursed-lip breathing helps keep airways open by maintaining positive pressure. A cough suppressant is not an appropriate medication for a client with COPD as it is important for the client to expel mucus to maintain adequate oxygenation.

What is the best way nurses can help clients reduce the risk of COPD? A) Providing smoking cessation resources B) Encouraging clients to receive vaccinations C) Referring clients to a nutritionist D) Providing references to local fitness facilities

A) Providing smoking cessation resources Rationale: The primary cause of COPD is smoking, so nurses can reduce the risk of clients developing COPD by providing smoking cessation resources and encouraging clients to follow through with plans to stop smoking. Vaccinations, proper nutrition, and healthy exercise habits may reduce the risk of COPD, but smoking cessation is the best way to prevent COPD.

When assessing the risk of a newborn for sudden infant death syndrome (SIDS), which are risk factors that the nurse should consider? Select all that apply. A) Race B) Gender C) Father's age D) Age E) Eye color

A) Race B) Gender D) Age Rationale: SIDS is most common in American Indians and Alaska Natives, followed by non-Hispanic Blacks, non-Hispanic Whites, Hispanics, and Asian or Pacific Islanders. It is more common in males than in females. SIDS is most common in infants under 6 months of age. Father's age and infant eye color are not related to the risk of SIDS.

The nurse is planning care for a young adolescent client diagnosed with asthma. Which evidence-based age-appropriate interventions will the nurse include in the plan of care? Select all that apply. A) Referring to a peer-led support group B) Teaching the parents how to administer maintenance medication prior to teaching the client C) Assessing peer support when planning care D) Collaborating with teachers for support in the school setting E) Telling the client to avoid medication while at school

A) Referring to a peer-led support group C) Assessing peer support when planning care D) Collaborating with teachers for support in the school setting Rationale: Age-appropriate, evidence-based interventions for a young adolescent client diagnosed with asthma include referral to a peer-led support group, assessing peer support of the client, and collaborating with teachers to ensure the client has the necessary support in the school setting. While it is appropriate to include the parents in the educational process, the client should be taught how to administer medications prior to teaching the parents. Avoiding medication administration while in school could lead to an acute asthma attack.

While performing nasotracheal suctioning, the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse's hand to remove the suction catheter. Which actions by the nurse are appropriate? Select all that apply. A) Remove the suction catheter B) Lower the head of the bed C) Decrease the suction pressure D) Apply restraints to the client's arms and legs E) Hyperoxygenate the client

A) Remove the suction catheter C) Decrease the suction pressure E) Hyperoxygenate the client Rationale: The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client. Restraining the patient does not address the hypoxemia. The client should be in the Fowler or high-Fowler position.

The nurse is providing care to a client with arterial blood gas analysis as follows: PaO2 of 82, PaCO2 of 49, HCO3 of 26, and pH of 7.31. Which assessment by the nurse is correct? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Metabolic acidosis

A) Respiratory acidosis Rationale: Both the pH and the carbon dioxide levels represent acidosis. The PaO2 of 82 is on the low end of normal and the bicarbonate level is normal, indicating that this is respiratory acidosis rather than metabolic acidosis.

The nurse working in the emergency department (ED) is assessing an infant client. Which findings does the nurse anticipate in a child diagnosed with respiratory syncytial virus (RSV)? Select all that apply. A) Rhinorrhea B) Irritability C) Grunting D) Bradypnea E) Tachypnea

A) Rhinorrhea B) Irritability C) Grunting E) Tachypnea Rationale: The early signs of RSV include rhinorrhea (drainage of mucus from the nose), cough, irritability, and a low-grade fever for 1-3 days. Other clinical manifestations include, but are not limited to, tachypnea (not bradypnea), wheezing, and grunting.

The nurse is planning care for a baby born to a mother who smoked during the pregnancy. The mother states that she believes in bed sharing. Which nursing diagnosis would be appropriate for this baby? A) Risk for Sudden Infant Death Syndrome (SIDS) B) Readiness for Enhanced Parenting C) Anxiety D) Deficient Knowledge

A) Risk for Sudden Infant Death Syndrome (SIDS) Rationale: The most important nursing diagnosis for the baby at this time is Risk for SIDS. Both bed sharing and the mother smoking during pregnancy are risk factors for SIDS. Deficient Knowledge, Readiness for Enhanced Parenting, and Anxiety are appropriate nursing diagnoses for the mother, not the baby.

The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? Select all that apply. A) Sepsis B) Viral pneumonia C) Drug overdose D) Near drowning in saltwater E) Fractured humerus

A) Sepsis B) Viral pneumonia C) Drug overdose D) Near drowning in saltwater Rationale: ARDS is a severe form of acute respiratory failure that occurs in response to pulmonary or systemic insults. Such insults include, but are not limited to, sepsis, pulmonary infections, saltwater inhalation, and drug overdose. A fractured humerus is not a risk factor for the development of ARDS.

The nurse working on a pediatric unit is caring for a client newly diagnosed with asthma. Which assessment data indicate impending respiratory failure and the need for immediate intervention? Select all that apply. A) Shallow respirations B) Slightly diminished breath sounds C) Decreased wheezing D) Increased crackles E) Increased respiratory rate

A) Shallow respirations C) Decreased wheezing Rationale: Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow respirations with significantly diminished breath sounds and decreased wheezing may indicate exhaustion and impending respiratory failure. Immediate intervention is necessary. Increased crackles are usually associated with heart failure and are not an indication of respiratory failure. An increased respiratory rate indicates respiratory compromise, but not respiratory failure.

Which of the following triggers can stimulate an acute asthma attack? Select all that apply. A) Stress B) Animal dander C) Loud noises D) Exercise E) Bright lights

A) Stress B) Animal dander D) Exercise Rationale: Stress, exercise, and animal dander are all known triggers of asthma. Loud noises may trigger hearing loss or headaches, but they will not trigger asthma. Bright lights are also not known to trigger asthma.

The nurse is instructing a client who is prescribed ipratropium bromide (Atrovent) for asthma. Which should be included in this client's teaching? Select all that apply. A) Take no more than the prescribed number of doses each day. B) Rinse the mouth after taking this medication. C) Take on an empty stomach. D) Take with meals or a full glass of water. E) Use hard candy or drink extra fluids to help with a dry mouth

A) Take no more than the prescribed number of doses each day. E) Use hard candy or drink extra fluids to help with a dry mouth. Rationale: Appropriate teaching for a client prescribed ipratropium bromide (Atrovent) includes only taking the prescribed number of doses each day to prevent a drug overdose and the use of hard candy or extra fluids to decrease dry mouth. The mouth does not need to be rinsed after taking this medication. This medication does not need to be taken with meals or a full glass of water, or on an empty stomach.

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which intervention is appropriate to decrease an infant's risk for SIDS? A) Using firm bedding B) Ensuring the room temperature is at least 80°F at all times C) Recommending bed sharing D) Placing the infant in a prone position for sleeping

A) Using firm bedding Rationale: Using firm bedding is an appropriate intervention to decrease the risk of SIDS. Other interventions that are appropriate include reducing exposure to secondhand smoke, avoiding overheating, educating on the risk of bed sharing, and placing the infant in a supine position, not a prone position, for sleeping.

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which factors in the client's history support the current diagnosis? Select all that apply. A) Working in an industrial environment B) Working in an office setting with air conditioning C) History of asthma D) Current cigarette smoking E) Playing golf several times a week

A) Working in an industrial environment C) History of asthma D) Current cigarette smoking Rationale: Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking. Working in an office setting with air conditioning and playing golf several times a week are not risk factors for the development of COPD.

The nurse is collecting a health history for a 12-month-old child. The child lives in a home where both parents smoke, and the child has had respiratory syncytial virus twice since birth. The child's older sister was recently diagnosed with asthma. The nurse understands that this child's risk of developing asthma later in life is A) above average. B) average. C) below average. D) well below average.

A) above average. Rationale: Risk factors for asthma include exposure to air pollution, including secondary smoke from cigarettes, and early exposure to respiratory syncytial virus. Genetic factors may also play a role in asthma development. Because of the presence of these risk factors, this child has an above average risk of developing asthma later in life.

The ion that cannot be regulated properly in clients with cystic fibrosis is A) chloride. B) sodium. C) calcium. D) potassium.

A) chloride. Rationale: Cystic fibrosis stems from dysfunction of the CFTR protein, which controls movement of chloride into and out of cells. This may also affect transport of sodium in the form of sodium chloride, but the primary ion affected is chloride. Regulation of calcium and potassium is not affected in cystic fibrosis.

Vaccinations can help promote healthy oxygenation by A) reducing the transmission of preventable diseases. B) increasing the exchange of oxygen for carbon dioxide in the lungs. C) promoting adequate blood circulation to organs and tissues. D) preventing all respiratory infections.

A) reducing the transmission of preventable diseases. Rationale: Vaccinations help decrease the transmission of preventable diseases, many of which are spread by respiratory secretions. Many of these diseases also affect the respiratory system and can alter oxygenation. Vaccinations do not directly increase the exchange of oxygen for carbon dioxide in the lungs, nor do they promote adequate blood circulation. Vaccinations can prevent some respiratory infections, but not all respiratory infections, and they can also prevent some non-respiratory infections.

A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygenation? A) Oxygen via a nasal cannula B) Mechanical ventilation C) Oxygen via a face mask D) Oxygen via a Venturi mask

B) Mechanical ventilation Rationale: With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone. Therefore, mechanical ventilation is often necessary. Oxygen administered via nasal cannula, face mask, or venture mask all require active and adequate breathing by the client, which may not be possible for the client with ARDS.

The nurse is evaluating care provided to a new mother whose infant is at risk for sudden infant death syndrome (SIDS). Which statement by the mother indicates teaching has been effective? A) "I need to purchase loose-fitting sheets and blankets for the bed." B) "I plan to quit smoking." C) "I will place my baby in a side-lying position for sleep." D) "I will bottle-feed my baby since breastfeeding is a risk factor for SIDS."

B) "I plan to quit smoking." Rationale: If the mother of an infant at risk for SIDS expresses her plan to quit smoking, the nursing care has been effective. Loose-fitting sheets and blankets are associated with an increased risk for the syndrome. The prone and side-lying positions increase the risk for the syndrome. The feeding method is not implicated with the syndrome and would not be used to evaluate the plan of care for an infant at risk for SIDS.

The nurse instructs a client with asthma on bronchodilator therapy. Which statement indicates client understanding of how the drug works? A) "The medication widens the airways by causing airway muscle contraction." B) "The medication widens the airways by causing airway muscle relaxation." C) "The medication widens the airways by decreasing histamine production." D) "The medication widens the airways by decreasing mucus production."

B) "The medication widens the airways by causing airway muscle relaxation." Rationale: Bronchodilators stimulate bronchiolar smooth muscle relaxation, not contraction. Smooth muscle relaxation increases the diameter of the airway lumen to enhance airflow. Bronchodilators do not decrease the production of mucus or the production of histamine.

A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching? A) "We'll be sure to use the fireplace often to keep the house warm in the winter." B) "We will replace the carpet in our child's bedroom with tile." C) "We'll keep the plants in our child's room dusted." D) "We're glad the dog can continue to sleep in our child's room."

B) "We will replace the carpet in our child's bedroom with tile." Rationale: Control of dust in the child's bedroom is an important aspect of environmental control for asthma management, and replacing the carpeting in the child's bedroom with tile flooring will reduce dust. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

A 7-year-old client is hospitalized due to complications related to cystic fibrosis. The nurse is responsible for administering medications and performing chest physical therapy. In which order should the nurse perform these actions? A) Place the client in a position for postural drainage B) Administer inhaled albuterol C) Administer inhaled hypertonic saline D) Perform percussion on the client's back and chest E) Administer oxygen by nasal cannula

B) Administer inhaled albuterol C) Administer inhaled hypertonic saline A) Place the client in a position for postural drainage D) Perform percussion on the client's back and chest E) Administer oxygen by nasal cannula Rationale: Inhaled medications should be administered before placing the client in a position for postural drainage and performing percussion. In particular, albuterol, a bronchodilator, should be administered before chest physical therapy and before other inhaled medications. Therefore, albuterol should be administered first, followed by hypertonic saline. Then chest physical therapy should be performed by first placing the client in a position for postural drainage and then performing percussion on the client's back and chest. After the medications and therapy are completed, administration of oxygen by nasal cannula will be more effective.

The nurse is developing a plan of care for a toddler diagnosed with respiratory syncytial virus (RSV). Which intervention is inappropriate for this client? A) Offer small, frequent meals. B) Encourage to ambulate frequently. C) Encourage oral intake. D) Monitor intake and output.

B) Encourage to ambulate frequently. Rationale: It would not be appropriate to encourage frequent ambulation. Nursing interventions should be introduced in an effort to reduce fatigue, such as allowing rest periods. All other interventions are appropriate for this client.

The nurse is providing care to a client with ARDS who has a tracheostomy. The nurse will monitor the client for complications related to the loss of which protective mechanism? A) The ability to cough B) Filtration and humidification of inspired air C) Decrease in oxygen-carrying capacity of the trachea D) The sneeze reflex initiated by irritants in the nasal passages

B) Filtration and humidification of inspired air Rationale: When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming provided by the nasal passages are also bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.

Besides the respiratory system, which system would be critical for the nurse to assess in a client recently diagnosed with cystic fibrosis? A) Nervous system B) Gastrointestinal system C) Musculoskeletal system D) Urinary system

B) Gastrointestinal system Rationale: In addition to respiratory alterations, clients with cystic fibrosis often have alterations to the gastrointestinal system. In particular, obstruction of pancreatic ducts by thick mucus impairs the production of pancreatic enzymes that are necessary for food digestion. This results in malnutrition, chronic diarrhea, and impaired insulin production. Cystic fibrosis does not affect the nervous system, musculoskeletal system, or urinary system directly.

The nurse is providing teaching to the client who is pregnant and has cystic fibrosis. The nurse should explain that the client is at increased risk for which condition? A) Emergency delivery B) Gestational diabetes C) Placenta previa D) Spontaneous abortion

B) Gestational diabetes Rationale: Because of changes in the secretion of insulin in many clients with cystic fibrosis, pregnant women who do not already have diabetes are at increased risk of developing gestational diabetes during pregnancy. Many clients are able to have a natural birth, so planning ahead for an emergency delivery is not necessary. Cystic fibrosis does not increase the client's risk of spontaneous abortion or placenta previa.

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this client? A) Risk for Infection B) Impaired Spontaneous Ventilation C) Risk for Acute Confusion D) Decreased Cardiac Output

B) Impaired Spontaneous Ventilation Rationale: A priority nursing intervention for a client with a respiratory rate of 8 breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the client could experience respiratory arrest. While the other nursing diagnoses may also be appropriate, they are not the priority for this client.

The nurse is caring for a 72-year-old client who has presented to the emergency department for the third time in 8 months with acute asthma exacerbations. The client states that he has trouble holding his inhaler, and sometimes he forgets to take his medication. He is also worried because he thinks his new drugs are adversely interacting with medications for his other conditions. What nursing diagnosis is appropriate for this client? A) Deficient Knowledge B) Ineffective Health Management C) Risk for Aspiration D) Ineffective Coping

B) Ineffective Health Management Rationale: Based on his repeated trips to the emergency department, his reported trouble holding his inhaler, and his inconsistency with taking his medications, an appropriate nursing diagnosis for this client is Ineffective Health Management. The client appears to have adequate knowledge about how to cope with his diseases; he is just unable to follow through with managing his medications at all times. Therefore, Deficient Knowledge and Ineffective Coping are not appropriate diagnoses based on this information. Not enough information is provided to determine if the client is at risk for aspiration.

The nurse is providing parenting teaching regarding reducing the risk of sudden infant death syndrome (SIDS). Which teaching point is a priority for the nurse to include? A) Instruct on side-lying and face-down positions when in the crib. B) Instruct on face-up position when in the crib. C) Ensure adequate nutritional intake for the mother and newborn. D) Encourage good hand washing.

B) Instruct on face-up position when in the crib. Rationale: The nurse should instruct the mother to place the baby in the face-up position when in the crib. Side-lying and face-down positions are associated with a higher risk of the syndrome and should not be instructed. Although important, good hand washing and adequate nutrition are not interventions that would assist in preventing SIDS.

The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should the nurse include in the child's plan of care to address the nursing diagnosis Impaired Gas Exchange? Select all that apply. A) Weigh daily. B) Monitor vital signs and pulse oximetry. C) Administer oxygen as prescribed. D) Weigh diapers. E) Provide frequent rest periods.

B) Monitor vital signs and pulse oximetry. C) Administer oxygen as prescribed. Rationale: Interventions appropriate for the client with the nursing diagnosis of Impaired Gas Exchange due to RSV bronchiolitis include monitoring vital signs, pulse oximetry, and breathing pattern, and administering oxygen. Daily weight would be appropriate for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the nursing diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the nursing diagnosis of Activity Intolerance.

A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen 24% 2 L/min. Which is the best method to administer oxygen to this client? A) Face mask B) Nasal cannula C) Nonrebreather mask D) Venturi mask

B) Nasal cannula Rationale: The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.

Which data supports the nurse's assessment that a newborn with acute respiratory distress syndrome (ARDS) is improving? A) Increased PaCO2 B) Oxygen saturation of 92% C) Pulmonary vascular resistance increases D) Thick secretions from the respiratory tract

B) Oxygen saturation of 92% Rationale: An expected outcome for a client being treated for ARDS is maintaining an oxygen saturation of greater than 90%. The newborn diagnosed with ARDS with an oxygen saturation of 92% is improving. Increased PaCO2, increased pulmonary vascular resistance, and thick secretions from the respiratory tract are indicative of continued distress.

The nurse is caring for an 18-month-old client who is newly diagnosed with cystic fibrosis. The client is currently hospitalized due to a Pseudomonas aeruginosa infection in the lungs. The client's vital signs are: P 138, R 43, T 101.3°F, BP 86/40, SpO2 88%. The client is coughing up thick, green mucus. What independent nursing intervention can the nurse implement to improve the client's oxygenation? A) Administration of CFTR modulators B) Percussion and postural drainage C) Nutritional counseling D) Teaching the client to cough into a tissue

B) Percussion and postural drainage Rationale: Percussion and postural drainage are chest physical therapy techniques that the nurse can implement to help clear the client's lungs of mucus, which will improve oxygenation. Administration of CFTR modulators and nutritional counseling are both collaborative interventions. Teaching the client to cough into a tissue is an infection control measure. It will not improve oxygenation compared to any other type of coughing. In addition, the client is likely too young to understand and follow through with this teaching consistently.

A client with acute respiratory distress syndrome (ARDS) is being weaned from ventilatory support. Which nursing actions are appropriate for this client? Select all that apply. A) Increase percentage of oxygen being provided through the ventilator. B) Place in the Fowler position. C) Provide morning care during the weaning procedures. D) Begin weaning procedures in the morning. E) Medicate with morphine for pain as needed.

B) Place in the Fowler position. D) Begin weaning procedures in the morning. Rationale: Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. The percentage of oxygen is typically reduced during the weaning process.

The mother of a 5-month-old baby, who attends daycare, is concerned because the child has developed a runny nose, cough, and low-grade fever over the last few days. These symptoms are consistent with which condition? A) Meningitis B) Respiratory syncytial virus (RSV) bronchiolitis C) Bronchitis D) The common cold

B) Respiratory syncytial virus (RSV) bronchiolitis Rationale: The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade fever for 1-3 days. A fever is not associated with the common cold. A runny nose and cough are not symptoms associated with meningitis. Bronchitis has a distinctive cough and may or may not be associated with a fever.

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention? A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler. B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment. C) The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds. D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment. Rationale: The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use of a stethoscope is appropriate.

The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). The client is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a decrease of cardiac output secondary to positive pressure ventilation? A) Blood pressure increases from 88/58 mmHg to 90/60 mmHg B) Urine output decreases from 30 mL/hr to 25 mL/hr C) Heart rate drops from 108 bpm to 104 bpm D) Oxygen saturation increases from 82% to 90%

B) Urine output decreases from 30 mL/hr to 25 mL/hr Rationale: Reduced cardiac output results in reduced perfusion of the kidneys, with a resulting decrease in urine output. Expected urine output is at least 30 mL/hr. This client's urine output is decreased; therefore, this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, both indicate improvement from the previous assessment, suggesting that they are not contributing to decreased cardiac output. The oxygen saturation level is within normal limits for this client and improving from the previous assessment.

The client with ARDS who is likely to have the poorest outcome is A) a Hispanic male with pneumonia. B) an African American male with sepsis. C) a Caucasian female with sepsis. D) an African American female with chest trauma.

B) an African American male with sepsis. Rationale: The risk for mortality from ARDS is greater for men than for women, and it is greater for African Americans than people from other races. In addition, clients who develop ARDS from sepsis have poorer outcomes than clients who develop ARDS from pulmonary infections or trauma. Therefore, the African American male with ARDS from sepsis will likely have the poorest outcome.

One primary method for preventing ARDS in hospitalized clients is A) performing postural drainage for clients with respiratory congestion. B) elevating the head of the bed for clients who are ingesting food. C) providing smoking cessation literature to clients who smoke. D) administering oxygen as ordered by the healthcare provider.

B) elevating the head of the bed for clients who are ingesting food. Rationale: Aspiration of gastric contents is a major risk factor for developing ARDS. Therefore, simple interventions such as elevating the head of the bed for clients who are ingesting food can help prevent ARDS. Performing postural drainage and administering oxygen will not prevent ARDS. Although smoking may increase the risk for ARDS, it is not a direct cause of ARDS, so smoking cessation literature will not prevent ARDS in hospitalized clients.

The pathophysiologic stimulus that initiates asthma is A) bronchoconstriction. B) inflammation in the airways. C) airway edema. D) mucus secretion.

B) inflammation in the airways. Rationale: In asthma, the airways are in a persistent state of inflammation. This inflammation can lead to bronchoconstriction, airway edema, and increased mucus secretion. Therefore, inflammation is the primary stimulus that initiates asthma.

The nurse caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) is educating the client on effective coughing techniques. Which statement made by the client indicates a need for further teaching? A) "I should inhale by sniffing." B) "I should exhale sharply with a 'huff."' C) "I should limit my fluid intake to 1-1.5 quarts daily." D) "I should cough twice and then rest."

C) "I should limit my fluid intake to 1-1.5 quarts daily." Rationale: Adequate fluid intake is at least 2-2.5 quarts of fluid daily, so the statement about drinking 1-1.5 quarts daily indicates the need for further teaching. The other statements are accurate so do not indicate a need for further teaching.

The pediatric nurse is providing education to a new mother regarding ways to decrease the risk of sudden infant death syndrome (SIDS). Which statement by the nurse is appropriate? A) "You should keep the baby with you at all times to assess for apnea." B) "Make sure the baby has a soft blanket and pillow when sleeping." C) "It is recommended that you place your baby on his back for sleep." D) "SIDS has been linked to immunizations. I recommend that you avoid immunizing your baby."

C) "It is recommended that you place your baby on his back for sleep." Rationale: A side-lying or prone position increases the infant's risk of SIDS, so the mother should be taught to always place the baby on his back for sleep. Soft pillows and blankets also increase the risk for SIDS, so they should not be used. Keeping the infant with the mother at all times is unreasonable and will not prevent SIDS. Immunizations have no known link to SIDS.

A 15-year-old client with cystic fibrosis asks why she has not started her menstrual period yet. Which response by the nurse is correct? A) "Usually girls with cystic fibrosis start menstruating earlier than their peers." B) "It is normal for girls with cystic fibrosis to start their period at age 16. Just be patient." C) "Some girls with cystic fibrosis do not experience menstruation due to nutritional problems." D) "Because secretions are thicker in people with cystic fibrosis, your period will be very heavy once it starts."

C) "Some girls with cystic fibrosis do not experience menstruation due to nutritional problems." Rationale: Disease-related nutritional deficiencies may interfere with normal reproductive development, causing some girls with cystic fibrosis to not experience menstruation. They do not usually start menstruating earlier than their peers, nor does their period usually start specifically at age 16. CF affects the thickness of mucus secretions, but it does not affect the thickness of the blood. Therefore, the statement about heavy periods is inaccurate.

A client asks why asthma medication is needed even though the client's last attack was several months ago. Which response by the nurse is appropriate? A) "The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack." B) "The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him." C) "The medication is still needed to decrease inflammation in your airways and help prevent an attack." D) "The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it."

C) "The medication is still needed to decrease inflammation in your airways and help prevent an attack." Rationale: Effective treatment of asthma includes long-term treatment to prevent attacks and decrease inflammation, as well as short-term treatment when an attack occurs. Long-term treatment of asthma continues indefinitely, not for just 1 year. Telling a client that lungs will be severely damaged is nontherapeutic; the inability to prevent an acute attack in this client is not true. The nurse is able to answer the client's question; it does not need to be referred to the physician.

The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV)/bronchiolitis wants to know which factors contribute to the risk of contracting RSV. Which response by the nurse is appropriate? A) "There is a higher risk in children who are being breastfed." B) "There is no way to avoid the illness." C) "There is a higher risk in children who are exposed to secondary cigarette smoke." D) "It is seen more frequently in children who do not attend daycare."

C) "There is a higher risk in children who are exposed to secondary cigarette smoke." Rationale: The risk of infection with RSV is higher for infants and toddlers who are not breastfed, live in homes with secondary cigarette exposure, attend daycare, live in crowded conditions, or are socioeconomically disadvantaged. RSV can be avoided by limiting these risk factors.

The nurse is reviewing discharge instructions with a client who is newly diagnosed with asthma. Which client statement indicates a need for further teaching? A) "I need to rinse my mouth after every use of my inhaler." B) "I need to take my Singulair at least 1 hour before I eat." C) "When inhaling two different medications, I should use the bronchodilator last." D) "Because I am on theophylline, I will need to have therapeutic blood levels drawn."

C) "When inhaling two different medications, I should use the bronchodilator last." Rationale: When using two different medications taken by inhalation, the bronchodilator should always be used first. This helps open the airways to enhance the effectiveness of the second medication. The other statements are accurate and require no further education.

An infant with respiratory syncytial virus (RSV) bronchiolitis is prescribed intubation to maintain an adequate airway. Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? A) An advanced practice nurse B) The primary healthcare provider C) A respiratory therapist D) A play therapist

C) A respiratory therapist Rationale: Infants who need endotracheal intubation will be closely cared for by the respiratory therapist. The advanced practice nurse, primary healthcare provider, and play therapist are not responsible for maintaining the client's endotracheal tube and ventilation.

The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial virus (RSV). Which nursing diagnosis would be most appropriate for the infant? A) Acute Pain B) Ineffective Tissue Perfusion C) Activity Intolerance D) Decreased Cardiac Output

C) Activity Intolerance Rationale: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Increased levels of fatigue may indicate the disease is more severe. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion is not affected by this respiratory disease process.

The nurse is providing care to a client with sepsis due to a severely infected leg wound. The client states that he is having trouble breathing. Upon assessment, the nurse notes dyspnea, a respiratory rate of 32, the use of accessory muscles to breathe, and rales and rhonchi upon auscultation of the lungs. The nurse recognizes these findings as characteristic of what condition? A) Allergic response from antibiotic therapy B) Deep vein thrombosis C) Acute respiratory distress syndrome D) Anemia

C) Acute respiratory distress syndrome Rationale: Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The client has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. Pulmonary assessment data indicate that the client is developing acute respiratory distress. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS.

The nurse is instructing new parents on ways to decrease the risk of sudden infant death syndrome (SIDS) with their newborn son. What should be included in these instructions? Select all that apply. A) There is nothing that can be done, so requirements for toys and bedding are of no consequence. B) Instruct that it is more common in babies from ages 6 months to 18 months. C) Avoid placing the baby in the prone or side-lying position for sleep. D) Remind the parents that the syndrome is more common in females than males, and that they have a male child. E) Do not smoke near the child and reduce all exposure to secondhand smoke.

C) Avoid placing the baby in the prone or side-lying position for sleep. E) Do not smoke near the child and reduce all exposure to secondhand smoke. Rationale: The nurse should instruct the parents to not smoke and to reduce all exposure to secondhand smoke to reduce the child's risk of SIDS. Sleeping in the prone or side-lying position is a risk factor for the syndrome. Other risk factors for SIDS include being male, being under 6 months of age, having loose bedding and toys that could occlude the airway, and being exposed to smoke or having a mother who smoked during pregnancy.

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this client? A) Tachycardia B) Cough C) Barrel chest D) Wheezing

C) Barrel chest Rationale: Barrel chest occurs because the lungs are chronically overinflated with air, so the rib cage stays partially expanded. While coughing, wheezing, and tachycardia may also be experienced by a client diagnosed with COPD, these are not specific to COPD caused by emphysema.

When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate to the nurse? A) Narrow bronchi B) Narrow trachea passages C) Blocked large airway passages D) Inflamed pleural surfaces

C) Blocked large airway passages Rationale: The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.

The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD). Which conditions will you include when you teach the client's family about the types of COPD? A) Asthma and bronchitis B) Asthma and emphysema C) Bronchitis and emphysema D) Emphysema and atelectasis

C) Bronchitis and emphysema Rationale: Although one or the other may dominate, COPD typically includes components of both chronic bronchitis and emphysema, two distinctly different processes. Asthma and atelectasis are not types of COPD, although asthma is a risk factor for COPD.

The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which assessment finding indicates that treatment has been effective? A) Client ingesting small amounts of clear fluids when encouraged B) Client resting in bed with limited interest in play or activities C) Client respiratory rate within normal limits for age D) Client coughing copious amounts of green sputum and requires occasional suctioning

C) Client respiratory rate within normal limits for age Rationale: Evidence that care is effective would include normal rate, rhythm, and quality of the breathing patterns for the client's age. The client who is resting in bed with limited interest in play or activities is not demonstrating an improvement in respiratory status. The client who is ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is coughing copious amounts of green sputum and requiring occasional suctioning, the interventions have not been effective, as the child still needs assistance with clearing the airway.

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations are the direct result of altered perfusion? Select all that apply. A) Bounding pulse B) Pink nail beds C) Cyanosis D) Confusion E) Wheezing

C) Cyanosis D) Confusion Rationale: A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Wheezing is an abnormal breath sound that is the result of excess mucus in the airways.

The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings should the nurse identify as signs that the client has progressed to respiratory failure? Select all that apply. A) Retractions and fatigue B) Tachycardia and tachypnea C) Inaudible breath sounds D) Diffuse wheezing and the use of accessory muscles when inhaling E) Reduced wheezing and an ineffective cough

C) Inaudible breath sounds E) Reduced wheezing and an ineffective cough Rationale: Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that the client is progressing to respiratory failure, and immediate interventions are necessary. During an asthma attack, tachycardia and tachypnea are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing, the use of accessory muscles when inhaling, retractions, and fatigue indicate a progression of the severity of the symptoms and may require nursing intervention, but they do not indicate respiratory failure.

A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate? A) Ineffective Airway Clearance B) Impaired Tissue Perfusion C) Ineffective Breathing Pattern D) Activity Intolerance

C) Ineffective Breathing Pattern Rationale: The client is experiencing an increased respiratory rate and is wheezing, which is an ineffective breathing pattern. Not enough information is provided to determine whether the client has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.

A client receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety related to having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select all that apply. A) Explain about care areas specifically designed for long-term ventilatory support. B) Dim the lights and reduce distracting noise, such as the television. C) Instruct that intubation and ventilation are temporary measures. D) Encourage family visits and participation in care. E) Remain with the client as much as possible.

C) Instruct that intubation and ventilation are temporary measures. D) Encourage family visits and participation in care. E) Remain with the client as much as possible. Rationale: A critical illness creates anxiety for any client. For the client with ARDS, anxiety is compounded by intubation and mechanical ventilation. To reduce this client's anxiety, the nurse should encourage the family to visit and participate in care. The nurse should also remain with the client as much as possible and instruct that intubation and ventilation are temporary measures to allow the lungs to rest and heal. Explaining that there are care areas designed for long-term ventilatory support could increase the client's anxiety. The nurse should provide distractions such as television or radio and not dim the lights or turn off the television, which could also increase the client's anxiety.

A client diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35 bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which order does the nurse question for this client? A) Antibiotic therapy B) Nonsteroidal anti-inflammatory agents (NSAIDs) C) Oxygen by nasal cannula at 3-4 liters/minute D) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents

C) Oxygen by nasal cannula at 3-4 liters/minute Rationale: Based on the hypoxic drive theory and the need for hypoxia to stimulate breathing, oxygen saturation for clients with COPD should be between 88% and 92%. Therefore, this client may not require oxygen administration at this time, and oxygen at 3-4 L/min may lead to respiratory depression or respiratory failure. The prescriptions for antibiotics, NSAIDs, and bronchodilators are expected for this client's condition.

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate? A) Encourage strenuous activity. B) Consult a dietitian for low-calorie meals. C) Space periods of activity with periods of rest. D) Encourage dependence with activities of daily living.

C) Space periods of activity with periods of rest. Rationale: The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. It will often be appropriate to space periods of activity with periods of rest. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage strenuous activity. The nurse would want the client to be as independent as possible and would not encourage dependence with activities of daily living.

The nurse observes a toddler, admitted with possible respiratory syncytial virus (RSV) bronchiolitis, grunting with expiration. Which action by the nurse is appropriate? A) Assist the child to clear the nasal passages. B) Limit fluids. C) Suction the airway to relieve the obstruction. D) Lay the child on his back.

C) Suction the airway to relieve the obstruction. Rationale: Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on his back will not improve the child's ability to breathe. Fluids should be increased to thin secretions. Assisting the child to clear the nasal passages would be applicable if the child were experiencing rhinorrhea.

Which is the most appropriate outcome for the nurse to select for a 78-year-old resident of a long-term care facility with regard to preventing RSV? A) The client's airways will remain clear of secretions. B) The client's fluid intake will meet daily requirements of 2000 mL per day. C) The client will demonstrate knowledge of proper hand washing techniques. D) The client will meet daily nutritional needs as provided by a nutritionist.

C) The client will demonstrate knowledge of proper hand washing techniques. Rationale: RSV is spread by direct contact with contaminated surfaces or an infected individual, so use of proper hand washing techniques can help prevent infection in susceptible individuals. Both adequate fluid intake and meeting daily nutritional needs will be beneficial for the client, but they are not specifically related to preventing infection. An outcome related to airways remaining clear of secretions is more appropriate for an individual who already has RSV.

The structure of the respiratory system that serves as the site of gas exchange is the A) macrophage. B) bronchi. C) alveoli. D) bronchiole.

C) alveoli. Rationale: The alveoli comprise the terminal structures of the lower respiratory system. Alveoli serve as the sites of gas exchange, specifically, carbon dioxide and oxygen. Bronchi and bronchioles are larger structures in the respiratory system that serve as tracts for airflow. Macrophages are immune cells that keep the alveoli region free of microbes.

The primary cells involved in infection by respiratory syncytial virus (RSV) are the A) smooth muscle cells in the bronchi and bronchioles. B) granular pneumonocytes in the alveoli. C) squamous epithelial cells of the bronchioles and alveoli. D) macrophages and monocytes of the bronchioles and alveoli.

C) squamous epithelial cells of the bronchioles and alveoli. Rationale: Respiratory syncytial virus infects the squamous epithelial cells of the bronchioles and alveoli. It does not infect smooth muscle cells, granular pneumonocytes (the surfactant-secreting cells), or the macrophages and monocytes.

Sudden infant death syndrome is diagnosed A) when an autopsy reveals a brainstem defect. B) when an infant dies after being shaken violently. C) when an autopsy fails to find a cause of death. D) when an infant is found dead in their crib.

C) when an autopsy fails to find a cause of death. Rationale: SIDS is only diagnosed after a review of the child's clinical history, an examination of the scene of death, and an autopsy that fails to find a cause of death. Infants who die after being shaken violently have shaken baby syndrome, not SIDS. An infant found dead in their crib may have died from other causes rather than SIDS. Although a brainstem defect related to respiratory and autonomic responses must be present, this is not usually found through autopsy.

The nurse assigned to the newborn nursery is conducting shift assessments. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate? A) Notify the healthcare provider of this assessment finding. B) Obtain an arterial blood gas for further respiratory assessment. C) Begin monitoring the respiratory rate every 5 minutes. D) Continue to monitor the newborn per facility policy.

D) Continue to monitor the newborn per facility policy. Rationale: A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute. Therefore, this client only needs monitoring. No other actions are necessary.

For couples in which both individuals carry one defective CF gene, any offspring from the couple has a ________ percent chance of inheriting two abnormal genes and developing cystic fibrosis. A) 100 B) 75 C) 50 D) 25

D) 25 Rationale: When both parents are carriers of the CF gene, each conception allows for a 25% possibility that two abnormal genes will be passed to the child, along with a 50% possibility that the child will be a carrier of one CF gene. Each conception also allows for a 25% possibility that the child will not carry the CF gene.

Friends of a client hospitalized with asthma would like to bring the client a gift. Which gift should the nurse recommend for this client? A) A basket of flowers B) A stuffed animal C) Fruit and candy D) A book

D) A book Rationale: A client with asthma must not be exposed to items that can exacerbate their disease process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and items that may contain dust, such as a stuffed animal, should be avoided. Objects void of irritants, such as a book, would be an appropriate gift.

The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD). Which medication does the nurse anticipate to decrease this client's risk for developing a respiratory infection? A) A broad-spectrum antibiotic B) A bronchodilator C) A corticosteroid D) An influenza vaccine

D) An influenza vaccine Rationale: An influenza vaccine may be ordered to reduce the risk of respiratory infections. A broad-spectrum antibiotic may be prescribed if infection is suspected but would not be ordered to reduce the risk of developing an infection. Bronchodilators and corticosteroid therapy are not used to prevent infections.

The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function. Which laboratory finding would be most significant for this client? A) Hemoglobin level 14 g/dL B) Oxygen saturation 96% C) Serum sodium 140 mg/dL D) Blood pH 7.32

D) Blood pH 7.32 Rationale: Normal blood pH is 7.35-7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.

The nurse is providing supportive care for the parents of an infant who died from sudden infant death syndrome (SIDS). Which action by the nurse is appropriate? A) Advising the parents that an autopsy is not necessary B) Refraining from recommending support groups until after the investigation C) Interviewing the parents to determine the cause of the SIDS incident D) Contacting the family's spiritual leader for support

D) Contacting the family's spiritual leader for support Rationale: The family will need emotional support during this time, including support from the family's spiritual leader and support groups for parents who have lost children. This support should not be delayed for the investigation. An autopsy will be necessary, and interviews to determine the cause of death will be the responsibility of the medical examiner and law enforcement agents, not the nurse.

Which assessment finding by the nurse supports the diagnosis that a client is in the early stages of chronic obstructive pulmonary disease (COPD)? A) Dysrhythmias B) Cyanotic nail beds C) Clubbing of the fingers D) Cough in the morning producing clear sputum

D) Cough in the morning producing clear sputum Rationale: The earliest-presenting symptom of COPD is coughing in the morning with clear sputum unless the client develops an infection, in which case the sputum would become yellow or green in color. With the progression of COPD, the body compensates by producing extra red blood cells. These extra blood cells clog the small blood vessels of the fingers, leading to the development of cyanotic nail beds and clubbing of the fingertips. Enlargement and thickening of the right ventricle of the heart often results in dysrhythmias.

Which clinical manifestation does the nurse correctly attribute to hypoxia in a client with acute respiratory distress syndrome (ARDS)? A) Fluid imbalance B) Hypertension C) Bradycardia D) Dyspnea

D) Dyspnea Rationale: Dyspnea is a clinical manifestation of clients experiencing hypoxia secondary to ARDS. Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with ARDS. The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.

The nurse is caring for a woman who is 32 weeks pregnant and requires mechanical ventilation for ARDS. In addition to standard nursing interventions for adult clients with ARDS, what special interventions need to be implemented for this client? A) Inducing labor B) Administering nitric oxide and corticosteroids C) Providing nutritional support D) Fetal monitoring

D) Fetal monitoring Rationale: Care for pregnant clients with ARDS who are at least at 20-24 weeks' gestation should include close fetal monitoring for potential emergency delivery. If the ARDS leads to compromised placental oxygen transfer, the neonate should be delivered immediately for the best outcome. However, not all pregnant women with ARDS will need immediate emergency delivery of the neonate. Providing nutritional support and administering nitric oxide and corticosteroids are interventions for all adult clients with ARDS, not only pregnant women

The nurse is assessing an adult client with respiratory syncytial virus (RSV). Which symptom will the nurse expect to assess that is not seen in infants with RSV? A) Rhinorrhea B) Cough C) Apnea D) Headache

D) Headache Rationale: Rhinorrhea (runny nose) and cough are symptoms that are common to both infants and adults with RSV. Apnea is more commonly seen in infants, not in adults. However, a headache must be reported by the client, which infants are unable to do. Therefore, headaches are more commonly assessed in adults with RSV and not infants.

The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minute, elevated blood pressure, and fatigue. Which nursing diagnosis is the priority for this client? A) Ineffective Coping B) Ineffective Airway Clearance C) Anxiety D) Ineffective Breathing Pattern

D) Ineffective Breathing Pattern Rationale: The client's respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the client at this time. There is no information to support Ineffective Airway Clearance, as there is no mention that the client is coughing. There is no information to support Anxiety or Ineffective Coping.

The nurse is providing care to a 7-month-old child hospitalized with RSV/bronchiolitis. The nurse can expect to provide client teaching to the parents about which medication? A) Corticosteroids B) Nebulized epinephrine C) Antibiotics D) Nebulized hypertonic saline

D) Nebulized hypertonic saline Rationale: Nebulized hypertonic saline is used to promote mucociliary clearance in hospitalized clients with RSV/bronchiolitis. Nebulized epinephrine and corticosteroids are no longer recommended for clients with RSV/bronchiolitis. Because RSV is a virus, antibiotics should not be used.

The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The client speaks very little English and is a smoker. Which action would be the most beneficial for this client? A) Have the adult child of the client translate during the assessment process B) Encourage aerobic activity C) Encourage the client to write down questions prior to seeing the healthcare provider D) Obtain educational materials about smoking cessation written in Spanish.

D) Obtain educational materials about smoking cessation written in Spanish. Rationale: A Spanish-speaking client who smokes and is diagnosed with COPD requires information regarding smoking cessation. For clients who do not speak English, it is appropriate for the nurse to obtain written education material for the client in the client's native language, Spanish. Relatives should not be used as medical interpreters because of the need for knowledge of medical terminology. Encouraging aerobic activity is not an appropriate intervention for a client diagnosed with COPD. Writing down questions might be appropriate for an English-speaking client but will not be appropriate for a Spanish-speaking client being treated in an English-speaking healthcare environment.

The nurse is providing care to a client with asthma. When developing the client's plan of care, which intervention would be most appropriate to promote effective gas exchange? A) Provide adequate rest periods B) Reduce excessive stimuli C) Assist with activities of daily living D) Place in Fowler position

D) Place in Fowler position Rationale: Placing the client in Fowler position facilitates breathing and lung expansion, promoting effective gas exchange. Providing adequate rest periods prevents fatigue and reduces oxygen demands. Reducing excessive stimuli promotes rest. Assisting with activities of daily living conserves energy and reduces oxygen demands.

The nurse is planning care for a new mother who smoked during the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS). Which interventions are appropriate for the nurse to include in the plan of care for the new mother and baby? Select all that apply. A) Information on bottle-feeding the infant B) Reasons why the child should sleep with others C) Ages at which the child should receive immunizations D) Using bedding that is firm E) Smoking cessation information

D) Using bedding that is firm E) Smoking cessation information Rationale: The plan of care to decrease the child's risk of SIDS should include habits to lower the risk of SIDS, one of which is smoking cessation. The nurse should also instruct the mother to use bedding that is firm. The method of feeding is not associated with the syndrome; however, the risk is decreased with breastfeeding, not bottle feeding. While age-appropriate immunizations are important for the overall health of the baby, this intervention does not specifically reduce the risk for SIDS. Sleeping with others will increase the child's risk of the syndrome and should not be in the plan of care.