Med Surg week 4

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication would the nurse being most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium

ANS: A Alteplase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows that this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse assess for? (Select all that apply.) a. Oral mucosa is gray or dark brown b. Pain when drinking grapefruit juice c. Persistent weight gain over the past 2 months d. Oral lesions that are over 2 weeks old e. Changes in the patient's voice quality

ANS: A, B, D, E Symptoms of head and neck cancer include color changes in the mouth or tongue to gray or dark brown; pain in the mouth, neck, and throat; burning sensation when drinking citrus juices; weight loss; oral lesions or soars that do not heal in 2 weeks; and hoarseness or changes in voice quality.

A hospital nurse is participating in a drill during which many "clients" with inhalation anthrax are being admitted. What drugs would the nurse anticipate administering? (Select all that apply.) a. Vancomycin b. Ciprofloxacin c. Doxycycline d. Ethambutol e. Sulfamethoxazole-trimethoprim (SMX-TMP)

ANS: A, B, C Vancomycin, ciprofloxacin, and doxycycline are all possible treatments for inhalation anthrax. Ethambutol is used for tuberculosis. SMX-TMP is commonly used for urinary tract infections and other common infections.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take first? a. Contact the primary health care provider and prepare forintubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowler position. d. Ask the client to perform deep-breathing exercises.

ANS: A Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, would be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowler position and asking the client to perform breathing exercises may temporarily improve the patient's comfort, these actions will not decrease the underlying problem or improve airway patency.

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

ANS: A Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inclient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with established goals.

A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next? a. Assess the client for obstructive sleep apnea. b. Arrange a home sleep apnea test. c. Encourage the client to begin exercising. d. Schedule a polysomnography

ANS: A Hypertension not responding to medications can be a sign of obstructive sleep apnea (OSA). The nurse would assess the client using an evidence-based tool, such as the STOP-Bang Sleep Apnea Questionnaire, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, and the Multiple Sleep Latency Test. If the results of the assessment indicate OSA may be a problem, the nurse would consult the primary health care provider for further testing. An at-home sleep-study is often done prior to a polysomnography. Excessive weight can contribute to OSA so exercising is always encouraged, but this is not specific to assessing for OSA.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other signs of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

ANS: A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse would conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

. A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process would the nurse correlate with this client's history and clinical signs and symptoms? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucous glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

ANS: A Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left-heart failure and is not directly caused by a 40-year smoking history.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." 234 b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?"

ANS: A Tachypnea and mouth breathing (from increased work of breathing), both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information that addresses this specific concern.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.

ANS: A The client with nasal drainage after facial trauma could have a skull fracture resulting in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper and tests positive for glucose. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the patient's risk for infection.

A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action would the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

ANS: A The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse would document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity is not necessary to care for this client.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. 246 d. Sedate the client immediately.

ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary but not as a first step. Ensuring the client is adequately oxygenated is the priority.

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

ANS: A The nurse needs to obtain further information about the spouse's specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining Isolation Precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse that it's safe to visit is demeaning of the spouse's feelings.

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

ANS: A The treatment regimen for TB often ranges from 26 weeks, but can be up to 2 years, making adherence problematic for many people. The nurse would stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.

A client in the emergency department has several broken ribs and reports severe pain. What care measure will best promote comfort? a. Prepare to assist with intercostal nerve block. b. Humidify the supplemental oxygen. c. Splint the chest with a large ACE wrap. d. Provide warmed blankets and warmed IV fluids.

ANS: A Uncomplicated rib fractures generally are simple to manage; however, opioids may be needed for pain. For severe pain, an intercostal nerve block is beneficial. The client needs to be able to breathe deeply and cough so as not to get atelectasis and/or pneumonia. Humidifying the oxygen will not help with the pain. Rib fractures are not wrapped or splinted in any way because this inhibits chest movement. Warmed blankets and warm IV fluids are nice comfort measures, but do not help with severe pain.

A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture. Which statements would the nurse include in this patient's teaching? (Select all that apply.) a. "You will need to cut the wires if you start vomiting." b. "Eat six soft or liquid meals each day while recovering." c. "Use a Waterpik for dental hygiene until you can brush again. d. "Sleep in a semi-Fowler position after the surgery." e. "Gargle with mouthwash that contains hydrogen peroxide once a day."

ANS: A, B, C, D The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client would also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowler position to assist in avoiding aspiration. Mouthwash with hydrogen peroxide is not a recommendation.

A client has been diagnosed with an empyema. What interventions would the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion 240 b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours

ANS: A, B, C, D The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse would perform frequent respiratory system assessments. Antipyretic medications are also used. Suction is only used when needed and is not done deeply to prevent tissue injury.

A nurse assesses a client who is 6 hours postsurgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.

ANS: A, B, C, D The nurse would observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse would assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse would also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which would be changed by the surgeon the first time.

A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.) a. Hypertension b. Stroke c. Weight gain d. Diabetes e. Cognitive deficits f. Pulmonary disease

ANS: A, B, C, D, E, F The long-term effects of untreated sleep apnea include increased risk for hypertension, stroke, cognitive deficits, weight gain, diabetes, and pulmonary and cardiovascular disease.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule f. Turning and positioning the client at least every 2 hours

ANS: A, B, C, D, F The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is done as needed.

A client with a new pulmonary embolism (PE) is anxious. What nursingactions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the assistive personnel (AP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

A client, who has become increasingly dyspneic over a year, has been diagnosed with pulmonary fibrosis. What information would the nurse plan to include in teaching this client? (Select all that apply.) a. The need to avoid large crowds and people who are ill b. Safety measures to take if home oxygen is needed c. Information about appropriate use of the drug nintedanib d. Genetic therapy to stop the progression of the disease e. Measures to avoid fatigue during the day f. The possibility of receiving a lung transplant if infection-free for ayear

ANS: A, B, C, E Pulmonary fibrosis is a progressive disorder with no cure. Therapy focuses on slowing progression and managing dyspnea. Clients need to avoid contracting infections so should be taught to stay away from large crowds and sick people. Home oxygen is needed and the nurse would teach safety measures related to oxygen. The drug nintedanib has shown to improve cellular regulation and slow progression of the disease. Gene therapy is not available. Energy conservation measures are also an important topic. Lung transplantation is an unlikely option due to selection criteria

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this client's teaching? (Select all thatapply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Use pursed-lip breathing during meals." f. "Choose soft, high-calorie, high-protein foods."

ANS: A, B, C, E, F Clients with COPD often are malnourished for several reasons. The nurse would teach the client not to drink fluids before and with meals to avoid early satiety. The client needs to rest before eating, and eat smaller frequent meals: 4 to 6 a day. Pursed-lip breathing will help control dyspnea. Food that is easy to eat will be less tiring and the client should choose high-calorie, high-protein foods.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing f. Chronic anemia

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity. Anemia can make it difficult to wean a client, but this is not a normal age-related change.

A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure that the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Ask the client to drink 2 L of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating chest physiotherapy device. e. Encourage diaphragmatic breathing. f. Administer the ordered mucolytic agent.

ANS: A, B, D, F 229 Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating chest physiotherapy device can also help clients remove thick secretions but is usually used in clients with cystic fibrosis. Mucolytic agents help thin secretions, making them easier to bring up. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client's ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

A nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms would the nurse be aware of? (Select all that apply.) a. Gynecomastia in male patients b. Frequent shaking and sweating relieved by eating c. Positive Chvostek and Trousseau signs d. "Moon" face and "buffalo" hump e. Expectorating purulent sputum f. General edema

ANS: A, B, D, F Lung cancer often is associated with paraneoplastic syndromes. Symptoms of these include gynecomastia from ectopic follicle-stimulating hormone release, hypoglycemia from ectopic insulin production (shaking and sweating relieved by eating), and Cushing syndrome (moon facies and buffalo hump) from ectopic adrenocorticotropic hormone. General edema can be caused by antidiuretic hormone.

A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this client's evaluation? (Select all that apply.) a. Examination of mucous membranes and nail beds b. Measurement of rate, depth, and rhythm of respirations c. Auscultation of bowel sounds for abnormal sounds d. Check peripheral veins for distention while at rest e. Determine the client's need and use of oxygen f. Ability to perform activities of daily living

ANS: A, B, E, F A home health nurse would assess the client's respiratory status and adequacy of ventilation including an examination of mucous membranes and nail beds for evidence of hypoxia, measurement of rate, depth and rhythm of respirations, auscultation of lung fields for abnormal breath sounds, checking neck veins for distention with the client in a sitting position, and determining the client's needs and use of supplemental oxygen. The home health nurse would also determine the client's ability to perform his or her own ADLs. Auscultation of bowel sounds and assessment of peripheral veins are not part of a focused assessment for a client with COPD.

A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the client regarding this drug? (Select all that apply.) a. Contact the primary health care provider if preexisting gout becomesworse. b. Report any changes in vision immediately to the health care provider. c. Avoid drinking alcoholic beverages due to the chance of liver damage. d. Do not take antacids or eat within 2 hours after taking thismedication. e. You will take this medication along with some others for 8 weeks. f. Take this medicine with a full glass of water.

ANS: A, B, E, F The nurse would teach the client that preexisting gout may get worse and the client should report this as medications for gout may need to be adjusted. The nurse would also inform the client about the multi-drug routine used for TB. Optic neuritis can occur with this drug so the client needs to report visual changes right away. The medication should be taken with a full glass of water. Drinking while taking ethambutol causes severe nausea and vomiting. Avoiding antacids and food (within 2 hours) is a precaution with isoniazid.

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. A 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client 239 e. Client who is taking medication for hypertension

ANS: A, C, D, E Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for airway loss related to aspirated oral and nasopharyngeal secretions? (Select all thatapply.) a. A 24 year old with a traumatic brain injury b. A 36 year old who fractured his left femur c. A 58 year old getting radiation therapy d. A 66 year old who is a quadriplegic e. An 80-year-old who is aphasic

ANS: A, C, D, E Thickly crusted, dry secretions that potentially can cause asphyxiation and airway obstruction (inspissated secretions or mucoid impaction) are seen most often in clients who have an altered mental status and level of consciousness (brain injury), are dehydrated, are unable to communicate (aphasic), are unable to cough effectively (quadriplegic), or are at risk for aspiration. The clients with the femur fracture and receiving radiation therapy are not as high of a risk. The location of the radiation is not known.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary artery hypertension. What actions would the nurse take to ensure the client's safety while on this medication? (Select all that apply.) a. Keep an intravenous line dedicated strictly to the infusion. b. Teach the client that this medication increases pulmonary pressures. c. Ensure that there is always a backup drug cassette available. d. Start a large-bore peripheral intravenous line. e. Use strict aseptic technique when using the drug deliverysystem.

ANS: A, C, E Intravenous prostacyclin agents would be administered to a client with pulmonary artery hypertension through a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted even briefly; therefore, a backup drug cassette would also be available. The nurse would use strict aseptic technique when using the drug delivery system. The nurse would teach the client that this medication decreases pulmonary pressures and increases lung blood flow.

A 100-kg client has developed ARDS and needs mechanical ventilation. Which of the following are potentiallycorrect ventilator management choices? (Select all that apply.) a. Tidal volume: 600 mL b. Volume-controlled ventilation c. PEEP based on oxygen saturation d. Suctioning every hour e. High-frequency oscillatory ventilation f. Limited turning for ventilator pressures

ANS: A, C, E The client with ARDS who needs mechanical ventilation benefits from "open lung" and lung protective strategies, such as using low tidal volumes (6 mL/kg body weight). Pressure-controlled ventilation is preferred due to the high pressures often required in these clients. PEEP usually starts at 5 cm H2O and adjusted to keep oxygen saturations in an acceptable range. Suctioning may need to be frequent due to secretions, but is not scheduled hourly. High-frequency oscillatory ventilation is an alternative to traditional modes of ventilation. Early mobility is encouraged as is turning and positioning the client

The nurse is learning about endemic pulmonary diseases. Which diseases are matched with correct information? (Select all that apply.) a. Hanta virus: found in urine, droppings, and saliva of infected rodents. b. Aspergillosis: requires a prolonged course of antibiotics. c. Histoplasmosis: sources include soil containing bird and bat droppings. d. Blastomycosis: requires strict adherence to multi-antibiotic regimen. e. Cryptococcosis: has been eradicated due to strategic deforestation. f. Coccidioidomycosis: found in the southwest and far west of the United States.

ANS: A, C, F Hanta virus is often seen in the southwest United States and is found in the urine, droppings, and saliva of infected rodents. Histoplasmosis is found in soil containing bird and bat droppings and on surfaces covered with bird droppings. Apergillosis is a common mold found both indoors and outdoors and is treated with a long course of antifungal drugs. Blastomycosis is a fungal disease requiring a prolonged course of antifungal medications. Cryptococcosis is a fungus found on trees and in the soil beneath trees, but has not been eradicated with strategic deforestation. Coccidioidomycosis is found in the southwest and far west of the United States, plus Mexico, and Central and South America.

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

ANS: A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called "battle sign" and indicates basilar skull fracture. Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.

Which teaching point is most important for the client with a peritonsillarabscess? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Let us know if you want liquid medications. d. Wash hands frequently.

ANS: B Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.

A nurse cares for a client with arthritis who reports frequent asthma attacks. What action would the nurse take first? a. Review the client's pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the primary health care provider and request arterial blood gases.

ANS: B Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a likely culprit given the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good time to review response to bronchodilators, but assessing triggers is more important. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action? a. Bronchodilator—stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. c. Corticosteroid—relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. d. Cromone—disrupts the production of pathways of inflammatory mediators.

ANS: B Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that activates beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators.

A clinic nurse is reviewing care measures with a client who has asthma, Step 3. What statement by the client indicates the need to review the information? a. "I still will use my rapid-acting inhaler for an asthmaattack." b. "I will always use the spacer with my dry powder inhaler." c. "If I am stable for 3 months, I might be able to reduce mydrugs." d. "My inhaled corticosteroid must be taken regularly to work well."

ANS: B Dry powder inhalers are not used with a spacer. The other statements are accurate.

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin.

ANS: B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure from the emergency department. What action does the nurse take first? a. Assessing that the ventilator settings are correct b. Ensuring that there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

ANS: B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse would know and check the settings. Personal protective equipment is important, but ensuring client safety is the most important action. The client may or may not need suctioning on arrival

A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately? a. Albumin: 5.1 g/dL (7.4 mcmol/L) b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/million/μL (5.2 1012/L) d. White blood cell (WBC) count: 12,500/mm3 (12.5 109/L)

ANS: B INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the chest tube is dislodged. Which action by the nurse is best? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the primary health care provider. d. Reinsert the tube using sterile technique.

ANS: B Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse would not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The nurse does not need to assess the site at this moment. The primary health care provider would be called to reinsert the chest tube or prescribe other treatment options.

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

ANS: B It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive signs and symptoms are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has symptoms of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond? a. "I will consult the speech therapist to ensure you are swallowing properly." b. "This is normal after surgery. What types of food do you like to eat?" c. "I will ask the dietitian to change the consistency of the food in your diet." d. "Replacement of protein, calories, and water is very important aftersurgery."

ANS: B Many clients experience changes in taste after surgery. The nurse would identify foods that the client wants to eat to ensure that the client maintains necessary nutrition. Although the nurse would collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the patient's concerns.

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.

ANS: B Often clients are discharged from the hospital on warfarin after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The other option is to lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Inquire as to recent travel outside the United States. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.

ANS: B Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Preventing the spread of disease is vital. The nurse would ask the "clients" about recent overseas travel to assess the risk of a pandemic flu. Clients with possible pandemic flu need to be in Contact and Airborne Precautions the infectious organism is identified and routes of transmission known. There is no specific danger to pregnant caregivers. Droplet Precautions are not appropriate.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient's teaching? a. "Add peppermint oil to the humidifier to relax the airway." b. "Make sure you clean the humidifier to prevent infection." c. "Keep the humidifier filled with water at all times." d. "Use the humidifier when you sleep, even during daytime naps."

ANS: B Priority teaching related to the use of a room humidifier focuses on infection control. Clients would be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil would not be added to a humidifier. The humidifier would be refilled with water as needed and would be used while awake and asleep.

A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse to determine the best course of action. What will the new nurse do? a. Contact the primary health care provider. b. Give the ordered diuretic as scheduled. c. Request an increase in the IV rate. d. Calculate the client's 24-hour fluid balance.

ANS: B Research has shown that clients with ARDS may benefit from conservative fluid therapy along with diuretics to maintain fluid balance. The nurse will give the ordered diuretic as scheduled. There is no reason to contact the provider or request an increased IV rate. The nurse can calculate the 24-hour fluid balance, but this will not influence the administration of the medication.

A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Swallow twice while bearing down. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

ANS: B The client post supraglottic laryngectomy has a high risk for aspiration. The nurse or speech language pathologist teaches the client the supraglottic method of swallowing. This includes placing a small amount of food in the mouth, performing the Valsalva maneuver, then swallowing twice. The client sits upright. The client holds the breath while swallowing twice. Keeping the head still and straight will not decrease the risk of aspiration.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client would the nurse assess first? a. A 46 year old with a 30-pack-year history of smoking b. A 52 year old in a tripod position using accessory muscles to breathe c. A 68 year old who has dependent edema and clubbed fingers d. A 74 year old with a chronic cough and thick, tenacious secretions

ANS: B The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how effectively the client is breathing and provide interventions to minimize respiratory distress. The other clients are not in acute distress.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

ANS: B This client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

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

ANS: B This client has signs and symptoms of early inhalation anthrax. For treatment, after IV antibiotics are finished, oral antibiotics are continued for at least 60 days. Sputum cultures are not needed. Anthrax is not transmissible from person to person, so Standard Precautions are adequate. Directly observed therapy is often used for tuberculosis.

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL (142 g/L) b. Platelet count: 82,000/L (82 109/L) c. Red blood cell count: 4.8/mm3 (4.8 1012/L) d. White blood cell count: 8700/mm3 (8.7 109/L)

ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands theteaching? a. The client lies on his or her side with knees bent. b. The client places his or her hands on the abdomen. c. The client lies in a prone position with straight. d. The client places his or her hands above the head.

ANS: B To perform diaphragmatic breathing correctly, the client would place his or her hands on the abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

A client in the emergency department is taking rifampin for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL (6.7 mmol/L) b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L (130 mmol/L) e. White blood cell (WBC) count: 72,000/mm3 (72 109/L)

ANS: B, C Rifampin can cause liver damage, evidenced by the client's high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this client's problem.

The nurse is preparing to teach a community group about warning signs of lung cancer. What information does the nurse include? (Select all that apply.) a. Over 10-pack-year history of smoking b. Persistent coughing c. Rusty or blood-tinged sputum d. Dyspnea e. Hoarseness f. Fatigue

ANS: B, C, D, E Some common signs of lung cancer include persistent cough, rusty or blood-tinged sputum, dyspnea, and hoarseness. Fatigue is common to many conditions. Smoking history is a risk factor for lung cancer.

A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which statements indicate that the client correctly understood the teaching? (Select all that apply.) a. "I will vigorously blow my nose multiple times each day." b. "Nasal saline sprays will help to prevent rebleeding." c. "I will wait at least 1 month before resuming weight lifting." d. "Ibuprofen will decrease nasal swelling and pain." e. "I will apply a small amount of petroleum jelly to mynares."

ANS: B, C, E A nurse would teach a client to avoid vigorous nose blowing, the use of aspirin or other NSAIDs, and strenuous activities such as heavy lifting for at least 1 month. The nurse would also teach the client to apply petroleum jelly sparingly to the nares for lubrication and comfort, and to use nasal saline sprays and humidification to prevent rebleeding.

A nurse is teaching a client how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? (Select all that apply.) a. "Open your mouth and breathe deeply." b. "Use your abdominal muscles to squeeze air out of your lungs." c. "Breath out slowly without puffing your cheeks." d. "Focus on inhaling and holding your breath as long as you can." e. "Exhale at least twice the amount of time it took to breathe in." f. "Lie on your back with your knees bent."

ANS: B, C, E A nurse would teach a client to close his or her mouth and breathe in through his or her nose, purse his or her lips and breathe out slowly without puffing his or her cheeks, and use his or her abdominal muscles to squeeze out every bit of air. The nurse would also remind the client to use pursed-lip breathing during any physical activity, to focus on exhaling, and to never hold his or her breath. Lying on the back with bent knees is the preferred position for diaphragmatic breathing.

The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP. What information does the nurse include? (Select all that apply.) a. Insurance will cover the cost if you wear it at least 4 hours a day. b. Once the delivery mask is adjusted, do not loosen the straps. c. The CPAP provides pressure that holds your upper airways open. d. You need to clean the mask at least once a week to prevent infection. e. The humidification increases the risk of fungal infections. f. Be patient when first using the system, it can be frustrating at first.

ANS: B, C, E, F A CPAP for OSA provides pressure that keeps the upper airway open. A properly fitting mask or nasal pillows is necessary to provide the pressure. Humidification in the system leads to an increased risk for fungal infections. Patients may have anxiety about using the equipment and worry about it being disruptive; most clients have a period of adjustment when first starting to use a CPAP. Medicare will usually cover the cost if the client wears the CPAP at least 6 hours a day. The mask or pillows should be cleaned daily.

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the client's activity tolerance? (Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?" f. "How does your activity compare to this time last year?"

ANS: B, C, E, F Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously. The nurse would ask the client to compare his or her current level of activity with that of a month or even a year ago.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-age client with an exacerbation of asthma d. Older client who is 1 day post-hip replacement surgery e. Young obese client with a fractured femur f. Middle-age adult with a history of deep vein thrombosis

ANS: B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site

ANS: B, D, E, F Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum and pain at the insertion site are not signs/symptoms that would require immediate intervention.

A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."

ANS: C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Acute respiratory distress syndrome can occur, but this is not as likely soon after the client starts on oxygen plus there is no indication of how much oxygen the client is on. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, "What does this mean?" How would the nurse respond? a. "Your children will be at high risk for chronic obstructive pulmonarydisease." b. "I will contact a genetic counselor to discuss your condition." c. "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." d. "This is a recessive gene and would have no impact on your health."

ANS: C Alpha1-antitrypsin deficiency is an important risk factor for COPD. The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent COPD unless the client smokes or there is sufficient exposure to other inhalants. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partner's AAT levels. Contacting a genetic counselor may be helpful but does not address the client's current question.

A nurse cares for a client who is infected with Burkholderia cepacia. What action would the nurse take first when admitting this client to a pulmonary care unit? a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client separated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.

ANS: C B. cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for infected clients to be separated from noninfected clients. Strict isolation measures will not be necessary. Although the client would wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with B. cepacia infection.

A nurse is teaching a client who has cystic fibrosis (CF). Which statement would the nurse include in this client's teaching? a. "Take an antibiotic each day." b. "You should get genetic screening." c. "Eat a well-balanced, nutritious diet." d. "Plan to exercise for 30 minutes every day."

ANS: C Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening might be an option; however, the nurse would not just tell the client to do something like that.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first? a. "Do you have a strong support system?" b. "What do you understand about your disease?" c. "Do you experience shortness of breath with basic activities?" d. "What medications are you prescribed to take each day?"

ANS: C Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse would ask the client if shortness of breath is interfering with basic activities. Although the nurse would need to know about the client's support systems, current knowledge, and medications, these questions do not address the client's appearance

A nurse cares for a client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How would the nurse respond? a. "Since many of your family members are carriers, your children will also be carriers of the gene." b. "Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder." c. "Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." d. "Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder."

ANS: C Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse would encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best? a. Ensure that the client has adequate sedation. b. Find another qualified provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.

ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse would interrupt the intubation attempt and give the client oxygen. The nurse would also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another qualified provider to intubate the client is not appropriate at this time.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

ANS: C Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder would be asked about family history and referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best? a. Teach the client about possible drowsiness. b. Instruct the client to drink plenty of water. c. Consult with the PHCP about the medication. d. Encourage the client to take the medication with food.

ANS: C First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. The nurse would consult with the PHCP and request a different medication. Diphenhydramine does cause drowsiness, but the nurse would request a different medication. Drinking plenty of fluids is appropriate for the condition and is not related to the medication. Antihistamines can be taken without regard to food.

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

ANS: C Isoniazid needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin.

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates that the client comprehends the teaching? a. "I will carry this medication with me at all times in case I need it." b. "I will take this medication when I start to experience an asthma attack." c. "I will take this medication every morning to help prevent an acute attack." d. "I will be weaned off this medication when I no longer need it."

ANS: C Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that going out with friends is no longer enjoyable. How would the nurse respond? a. "There are a variety of support groups for people who haveCOPD." b. "I will ask your primary health care provider to prescribe an antianxiety agent." c. "I'd like to hear about thoughts and feelings causing you to limit socialactivities." d. "Friends can be a good support system for clients with chronic disorders."

ANS: C Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. While friends can be good sources of support, the client specifically is discussing going out of the home.

A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

ANS: C Oral colonization by gram-negative bacteria is a risk factor for health care-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the AP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients are important to detect the onset of possible pneumonia but do not prevent it.

After teaching a client who is prescribed salmeterol, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in myasthma." c. "I will use the drug when I have an asthma attack." d. "I will be careful not to let the drug escape out of my nose and mouth."

ANS: C Salmeterol is a long-acting beta2 agonist designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it would not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client's part allows the drug to escape through the nose and mouth.

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection would the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole-wheat bread d. Pasta salad, custard, orange juice

ANS: C Side effects of radiation therapy may include inflammation of the esophagus. Clients would be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen, the client's lungs are clear. What explanation does the more senior nurse provide? a. "The client is too dehydrated for moist-sounding lungs." b. "The client hasn't started having any bronchospasm yet." c. "Lung edema is in the interstitial tissues, not the airways." d. "Clients with ARDS usually have clear lung sounds."

ANS: C The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues, where it can't be auscultated, instead of in the airways. It is not related to the client being dehydrated or having bronchospasm. The statement about all clients with ARDS having clear lung sounds does not provide any information.

4. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant. b. A 42-year-old man with gastroesophageal reflux disease. c. A 55-year-old woman who is 50 lb (23 kg) overweight. d. A 73-year-old man with type 2 diabetes mellitus.

ANS: C The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea. Clients with sleep apnea may develop gastroesophageal reflux.

A client with acute respiratory failure is on a ventilator and is sedated. What care may the nurse delegate to the assistive personnel AP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the AP. The other actions fall within the scope of practice of the nurse.

8. A nurse cares for a client who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

ANS: C The client will not be able to speak after surgery. The nurse would assist the client to choose a communication method that he or she would like to use after surgery. Assessing the patient's airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this patient's gait would not be impacted by a total laryngectomy and therefore is not a priority.

The nurse is caring for a client who has cystic fibrosis (CF). The client asks for information about gene therapy. What response by the nurse is best? a. "Unfortunately, gene therapy is only provided to children upondiagnosis." b. "Do you know that you will have to have genetic testing?" c. "There is a good treatment for the most common genetic defect in CF." d. "Gene therapy will only help improve your pulmonary symptoms."

ANS: C The drug ivacaftor/lumacaftor is effective as therapy for patients whose CF is caused by the F508del (also known as the Phe508del) mutation, the most common mutation involved in CF, even in patients who are homozygous for the mutation with both alleles being affected. The nurse would provide that information as the best response. Asking if the client understands he or she will have to undergo genetic testing is a correct statement, but is a yes/no question which is not therapeutic and might sound paternalistic. It also does not provide any information on the therapy itself. The drug is not limited to children and helps move chloride closer to the membrane surfaces so it would have an effect on any organ compromised by CF.

A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? a. Client reports pain is controlled satisfactorily with analgesic regime. b. Client does not have foul odor to the breath or beefy red mucus membranes. c. Client is able to swallow own secretions without drooling. d. Client's vital signs are within normal parameters.

ANS: C The priority after a modUPPP is maintaining a patent airway. The client who has a patent airway can swallow his or her own secretions without drooling. Controlled pain is important, but not the priority. Foul breath odor and beefy red mucus membranes indicate possible infection, which probably would not occur this soon after surgery, but preventing infection does not take priority over airway. Vital signs "within normal parameters" are vague.

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

ANS: C The priority for any chest trauma client is airway, breathing, and circulation. The nurse first ensures that the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

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

ANS: C This client has rhinosinusitis. Comfort measures for this condition include humidification, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.

An intubated client's oxygen saturation has dropped to 88%. What action by the nursetakes priority? a. Determine if the tube is kinked. 245 b. Ensure that all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube.

ANS: C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and perform suction if needed, assess for pneumothorax, and finally check the equipment.

A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer IV fluid boluses every 2 hours. c. Explain that xerostomia may be a permanent side effect. d. Assess the client's neck for redness and swelling.

ANS: C Xerostomia, or dry mouth, is a potential side effect of radiation, particularly if the salivary glands were in the radiation zone. Unfortunately, this may be long term or even permanent. Gargling with lidocaine would not help. Increasing fluids is somewhat helpful, but the client would be encouraged to drink. The client's neck may have redness and swelling, but this finding is not related to the reported dry mouth.

The emergency department nurse is participating in a bioterrorism drill in which several "clients" are suspected to have inhalation anthrax. Which "clients" would the nurse see as the priorities? (Select all that apply.) a. Widened mediastinum on chest x-ray b. Dry cough c. Stridor d. Oxygen saturation of 91% e. Diaphoresis f. Oral temperature of 99.9° F (37.7° C)

ANS: C, D, E Clients with fulminant anthrax may exhibit stridor, hypoxia, and diaphoresis. Although an oxygen saturation of 91% is not critical, it is abnormally low. These clients would be seen as the priority. A widened mediastinum and dry cough are usually seen in the prodromal phase when the temperature elevation is not as severe.

When working with women who are taking hormonal birth control, what health promotion measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

ANS: C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best? (Select all that apply.) a. Administer prescribed salmeterol inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen and place client on an oximeter. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol inhaler. f. Assess the client's lung sounds after administering the inhaler.

ANS: C, E, F Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is becoming unstable, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would reassess the lung sounds after the rescue inhaler. The nurse would not do a peak flow reading at this time, nor would a code be called. The nurse could assess for tracheal deviation after administering oxygen and albuterol.

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the client's anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

ANS: D A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse would provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client's discomfort and need to take deep breaths to prevent complications.

A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency

ANS: D A patent airway is the priority. The nurse first would make sure that the airway is patent and then would determine whether the client is in pain and whether bone displacement or blood loss has occurred

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

ANS: D Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate.

A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first? a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Assess the client's airway.

ANS: D If the packing slips out of place, it may obstruct the client's airway. The other options are good interventions, but ensuring that the airway is patent in the priority objective.

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

ANS: D Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax seen in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately. The other questions are appropriate for anyone with an infection.

A nurse cares for a client who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction as prescribed by the primary health care provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

ANS: D Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not clamped. Wall suction would be set at the level indicated by the device's manufacturer, not the primary health care provider.

A new nurse asks for an explanation of "refractory hypoxemia." What answer by the staff development nurse is best? a. "It is chronic hypoxemia that accompanies restrictive airway disease." b. "It is hypoxemia from lung damage due to mechanical ventilation." c. "It is hypoxemia that continues even after the client is weaned from oxygen." d. "It is hypoxemia that persists even with 100% oxygen administration."

ANS: D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

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

ANS: D Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have symptoms of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client would be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

A client is on mechanical ventilation and the client's spouse wonders why ranitidine is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation."

ANS: D Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them and possible subsequent aspiration. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Ranitidine is a histamine-blocking agent.

1. A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who reports orthopnea in bed d. A 27-year-old client with a heart rate of 120 beats/min

ANS: D Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. Orthopnea at night in bed is breathlessness when lying down but is not an acute finding at this moment.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what would the nurse ensure? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent barotrauma to the lungs. Alarms are never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action does the nurse take first? a. Administer oxygen and reassess. b. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

ANS: D This client has signs and symptoms of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.