Medsurg Respiratory & HIV/Ebola/Corona

The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to the scan, which of these assessment questions is essential for the nurse to ask? a. "Do you take supplements containing vitamin K?" b. "Did you take metformin today?" c. "Are you allergic to peanuts?" d. "Have you had shortness of breath recently?"

"Did you take metformin today?" The assessment question that is essential for the nurse to ask is, "Did you take metformin today?" IV contrast material can be nephrotoxic. Metformin is stopped at least 24 hours before contrast dye is used and is not restarted until adequate kidney function is confirmed.If pulmonary embolism is confirmed, warfarin may be prescribed. If so, vitamin K-containing foods and vitamins will need to be limited. Peanut allergy does not pose a risk with contrast. Shortness of breath is a typical finding when a PE is present, and is not the priority assessment prior to CT.

A client with CF who is 2 months post-operative from a bilateral lung transplant wants to begin riding his bicycle again, as his pulmonary specialist has said he can do, but his wife is concerned that this will "wear out" his new lungs faster. How will the nurse advise this couple? a. Remind the wife that activity does not damage or "wear out" the lungs and that exercise will reduce the risk for other health complications. b. Tell the wife that because the client has a reduced life expectancy, she should allow him to do whatever he wants. c. Remind the client that this is the "honeymoon phase" of recovery and that he will not feel well for very long. d. Advise the client to protect his lungs at all cost.

ANS: A Although the disease process may cause problems eventually in the new lungs, activity does not damage the lungs. All exercise in a client who has undergone a lung transplant for CF must begin slowly and progress at an appropriate rate for each client, there is no restriction on the type and eventual intensity of the exercise unless another health problem is present.

Which interventions are important for the nurse to teach a client with severe chronic obstructive pulmonary disease (COPD) to help ensure adequate nutrition? (Select all that apply.) a. Avoid eating gas-producing foods b. Cough to clear mucus right before eating c. Drink plenty of fluid with every meal d. Eat smaller meals more frequently e. Rest immediately following a meal f. Eat more raw fruits and vegetables g. Use your bronchodilator about 30 minutes before each meal

ANS: A, B, D, G Gas-producing foods contribute to early satiety (feeling full) and interfere with adequate food intake. Coughing and clearing mucus right before a meal makes the client more comfortable (not to mention those eating with him or her) and helps prevent the need to cough during a meal, interrupting the process. Eating 4 to 6 smaller meals daily instead of 3 larger ones helps improve nutrition by not tiring the client out as much. Psychologically, a smaller-appearing meal looks less daunting to someone who may not be feeling very hungry. Using the bronchodilator before a meal eases respiratory effort by reducing dyspnea. This allows the client to concentrate on eating instead of on breathing. Drinking liquids during a meal is discouraged because it contributes to early satiety and reduces the amount of food the client actually eats. Eating raw fruits and vegetables requires considerable chewing and is likely to tire the client without increasing the overall caloric intake.

What must the nurse include for discharge education for a client who is newly prescribed to use oxygen therapy at home? (Select all that apply.) a. The consequences of smoking while using oxygen b. The need to limit potted plants in the home c. The types of oxygen delivery devices available for home use d. The use of oxygen when performing ADLs e. The need to travel only in specially designated cars f. Performing proper skin care under the device and its straps

ANS: A, C, D, F Oxygen enhances combustion. Any open flame (smoking, candles, etc.) can cause a fire in an oxygen-rich environment. The client must not smoke while on oxygen and he or she along with caregivers needs to be aware of frayed cords that may spark and cause fire. Oxygen should be worn so the client is able to participate in ADLs and other events. He or she should also be educated about proper skin care and the use of non-petroleum jelly (avoiding solutions that contain high amounts of alcohol or oil and are flammable) to prevent skin irritation. It is not necessary to limit potted plants or to travel in specially designated cars.

Which assessment findings are most important for the nurse to determine when assessing a client with dyspnea? (Select all that apply.) a. Onset of or when the client first noticed dyspnea b. Results of most recent pulmonary function test c. Conditions that relieve the dyspnea sensation d. Whether or not dyspnea interferes with ADLs e. Inspection of the external nose and its symmetry f. Whether stridor is present with dyspnea

ANS: A, C, D, F Rationale: Dyspnea, especially if it is new onset, is a sensitive indicator of the possible presence of life-threatening respiratory problems. Dyspnea is subjective and determining onset, relieving factors, interference with ADLs, and presence of stridor should be elicited from the client to help assess severity and determine the level of intervention needed. Pulmonary functioning and inspection of the external nose are objective data.

Which conditions are most likely to cause a "left shift" of the oxyhemoglobin dissociation curve? (Select all that apply.) a. Reduced blood and tissue levels of diphosphoglycerate (DPG) b. Reduced blood and tissue pH c. Increased metabolic demands d. Alkalosis e. Increased body temperature f. Reduced blood and tissue levels of oxygen

ANS: A, D Rationale: The oxyhemoglobin dissociation curve is shifted to the left when conditions are present that reduce overall oxygen needs. This left shift makes it harder for oxygen to dissociate from the hemoglobin molecule. Such conditions are those associated with slower or lower metabolism and oxygen need. These include less DPG, and alkalosis (fewer hydrogen ions). Reduced pH, increased metabolic demand, increased body temperature, and hypoxia are all associated with increased oxygen need and a right shift in the oxyhemoglobin dissociation curve.

A nursing is caring for a client who suddenly developed acute respiratory distress after returning home from an extended business trip in a foreign country. What actions by the nurse are most appropriate before the cause of the problem is identified? (Select all that apply.) a. Ask the client where the travel specifically occurred and whether he or she was exposed to anyone who was ill. b. Use Contact Precautions with this client and use gloves and gown for care. c. Prepare to administer isoniazide (INH) as soon as the first dose is available. d. Monitor the results of the client's blood urea nitrogen (BUN, creatinine, and liver function studies. e. Collaborate with the interprofessional team to obtain arterial blood gases and prepare to intubate the client. f. Assist with obtaining sputum cultures for acid-fast bacilli to send to the laboratory for analysis.

ANS: A, D, E A is correct. This client has recently traveled and perhaps been exposed to MERS. It is critical to determine the geographic area(s) the client has been in. B is not completely correct. Although Contact Precautions should be used, Airborne Precautions must also be instituted. C is not correct. Isoniazide is used only for tuberculosis. The sudden and rapid onset of this client's respiratory distress is not consistent with tuberculosis. D is correct because MERS can rapidly be complicated with sepsis and multi-organ dysfunction syndrome. E is correct because any client with acute respiratory distress can have progression to complete respiratory failure. Arterial blood gas results help determine the adequacy of gas exchange and the need for oxygen therapy and/or mechanical ventilation. F is incorrect. This test is only for tuberculosis. The sudden and rapid onset of this client's respiratory distress is not consistent with tuberculosis.

What information is most important for a nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy? a. "Report darkening or reddening of the urine while taking Rifampin." b. "Do not drink alcohol in any quantity while taking Isoniazid." c. "Restrict fluid intake to 2 quarts of liquid a day on pyrazinamide." d. "Temporary visual changes while taking ethambutol are not serious."

ANS: B All the drugs for tuberculosis are liver toxic and can cause liver damage. Drinking alcohol compounds this damage and should be ingested only in small quantities, if at all. The reddened urine is an expected side effect of Rifampin therapy and, while the patient should be taught about this side effect, it does not need to be reported. Fluids should be increased, not decreased for a patient taking pyrazinamide to prevent gout or hyperuricemia. The visual changes associated with ethambutol are serious and not temporary. If the drug is not stopped when changes occur, it can cause optic neuritis and lead to blindness.

When reviewing the laboratory values for a client admitted with pneumonia, which result would cause the nurse to collaborate quickly with the health care provider? a. White blood cell (WBC) count of 14,526 mm3 b. PaO2 68 mm Hg c. PaCO2 46 mm Hg d. Blood glucose 146 mg/dL

ANS: B Although all values are abnormal (PaCO2 is only slightly elevated), they are expected findings in clients with pneumonia or any other severe infection. The very low PaO2 level indicates severe hypoxemia and great risk for death without immediate intervention.

Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? a. Activating the viral enzyme "integrase" within the infected host's cells b. Binding of the virus to the CD4+ receptor and either of the two co-receptors c. Clipping the newly generated viral proteins into smaller functional pieces d. Fusing of the newly created viral particle with the infected cell's membrane

ANS: B Entry inhibitors work by binding to and blocking the CCR5 receptors on CD4+ T-cells, the main target of HIV. In order to successfully enter and infect a host cell, the virus must have its gp120 protein attached to the CD4 receptor and have its gp41 bound to the CD4+ T cell's CCR5 receptor. Viral binding to both receptors is required for infection. By blocking the HIV's attachment to the CCR5 receptor, infection is inhibited.

The nurse assessing the respiratory status of a client discovers that tactile fremitus has increased from the assessment performed yesterday. For which possible respiratory problem should the nurse assess further? a. Pneumothorax b. Pneumonia c. Pleural effusion d. Emphysema

ANS: B Tactile (vocal) fremitus is a vibration of the chest wall produced when the patient speaks. This vibration can be felt on the chest wall. Fremitus is decreased if the transmission of sound waves from the larynx to the chest wall is slowed, such as when the pleural space is filled with air (pneumothorax) or fluid (such as with a pleural effusion) or when the bronchus is obstructed. Fremitus is increased with pneumonia and lung abscesses because the increased density of the chest enhances transmission of the vibrations.

A client with pulmonary artery hypertension on a continuous IV epoprostenol infusion is in the emergency department with symptoms of possible sepsis. The health care provider prescribes a broad-spectrum antibiotic to be administered IV immediately. What is the nurse's best action? a. Request a prescription for an oral antibiotic. b. Start a peripheral IV line and administer the antibiotic. c. Administer the IV antibiotic through the continuous infusion's side port. d. Stop the epoprostenol infusion for 15 minutes to administer the IV antibiotic

ANS: B The epoprostenol infusion cannot be stopped for even 15 minutes without endangering the client's life. The drug also cannot be mixed with any other drug. With possible sepsis, the antibiotic must be administered intravenously.

A nurse is providing community education on seasonal influenza. What information will the nurse include in this presentation? (Select all that apply.) a. Adults older than 65 years should get the Prevnar-13 vaccination yearly. b. All adults older than 49 years should receive a Fluzone immunization annually. c. Sneeze into a disposable tissue or into your sleeve instead of your hand. d. Avoid large crowds during spring and summer to limit the change for getting the flu. e. Wash your hands frequently and after blowing your nose, coughing, or sneezing. f. Call your provider for an antiviral prescription within 3 days of getting symptoms.

ANS: B, C, E A is incorrect because Prevnar-13 is a pneumonia vaccine (not for influenza) and is only given once. B is correct because this is the injectable form of the influenza vaccine that is recommended for adults 49 and older to receive as an immunization yearly. C is correct because this technique is the one recommended by the CDC to limit infection spread. D is incorrect because influenza season in North America is in the fall and winter. E is correct because this action can limit infection spread. F is incorrect because these drugs are effective only if taken within 24 to 48 hours after symptoms begin.

With which activities does the nurse teach unlicensed assistive personnel (UAP) and nursing students caring for a client who is HIV positive to wear gloves to prevent disease transmission? (Select all that apply.) a. Applying lotion during a back rub b. Brushing the client's teeth c. Emptying a Foley catheter reservoir d. Feeding the client e. Filing the client's fingernails f. Providing perineal care

ANS: B, C, F Standard Precautions for preventing the spread of any type of infection including HIV requires wearing gloves when coming into contact with moist mucous membranes, including oral and perineal membranes. Although saliva has a low concentration of HIV unless blood is present, oral mucous membranes harbor many types of infectious organisms. Standard precautions also require that gloves be worn when contact with urine is possible, including during such tasks as emptying a Foley catheter reservoir. Perspiration is not considered a body fluid with risk for transmission and neither is in contact with the client's intact skin. Feeding the client should not result in direct contact with transmissible fluids and neither should clipping finger nails.

Which white blood cell types are involved in the development of antibody-mediated immunity? (Select all that apply.) a. Basophils b. B-lymphocytes c. Cytotoxic/cytolytic T-cells d. Helper/inducer T-cells e. Macrophages f. Natural killer cells g. Neutrophils

ANS: B, D, E Basophils, cytotoxic/cytolytic T-cells, natural killer cells, and neutrophils have no role in antibody production, which is the basis of antibody-mediated immunity. Antibody production requires the interaction of macrophages, helper/inducer T-cells, and B-lymphocytes. The macrophages initially recognize and process the antigen. The helper/inducer T-cell presents to and assists the unsensitized B-lymphocyte to recognize the antigen as an invader. The B-lymphocyte then becomes sensitized to the antigen and begins producing antibodies against it.

A client newly diagnosed with moderate asthma asks whether he can just take salmeterol instead of salmeterol and albuterol, because he has read that they are both beta agonists. What is the nurse's best advice? a. Yes, both of these drugs have the same action, and you only need one. b. Yes, because they both need to be used daily whether you are having symptoms or not, just take a little more of the salmeterol and don't take any of the albuterol. c. No, albuterol is used to relieve the symptoms during an actual asthma attack and salmeterol is used to prevent an attack. Both are needed. d. No, albuterol is taken through the use of an aerosol inhaler and salmeterol is an oral drug (tablet) that is activated in the stomach. Both are needed.

ANS: C Albuterol is a short-acting beta agonist (SABA) that has an immediate onset of action with a short duration. It is used as needed to relieve (rescue) and stop an actual asthma attack. Salmeterol is an inhaled only long-acting beta agonist (LABA) that has a slow onset of action with a longer duration. It is taken daily whether symptoms are present to prevent or control asthma, not to stop an attack that has already started. It has no real benefit as a rescue inhaler. Both forms of beta adrenergic agonists are needed in the management of moderate asthma.

The nurse notes that a client with a history of chronic obstructive pulmonary disease (COPD), who is receiving oxygen therapy at 2 L/min and had an oxygen saturation of 88% 1 hour ago, now has dyspnea and an oxygen saturation of 80%. Does the nurse increase the FiO2? a. No, increasing the FiO2 will severely depress the respiratory rate by blunting the hypoxic drive. b. No, an oxygen saturation of 80% is acceptable for a client with COPD. c. Yes, hypoxia must be treated despite the risk for oxygen-induced hypercapnia. d. Yes, the expected outcome for any client with hypoxia is to achieve a saturation of at least 97%.

ANS: C Hypoxia is a greater threat to life than oxygen-induced hypercapnia. It must be treated despite the risk for oxygen-induced hypercapnia. However, the lowest possible FiO2 should be used to maintain and oxygen saturation between 88% and 92%. An oxygen saturation of 80% indicates hypoxia and is not acceptable for anyone. Although increasing the PaO2 may cause hypercapnia, it has not been proven to severely depress the respiratory rate. The desired outcome is to correct hypoxemia but is not usually possible for a client who has COPD. For this client, an acceptable saturation range is 88% to 92%.

Which description of respiratory physiologic features is correct? a. The elastic tissues of the tracheobronchial tree are the major structures responsible for gas exchange. b. The epiglottis closes during speech to divert air movement into and through the vocal cords to produce sound. c. Any problem with the right lung interferes with gas exchange and perfusion to a greater degree than a problem in the left lung. d. The left lung is responsible for approximately 60% of gas exchange and the right lung is responsible for 60% of pulmonary perfusion

ANS: C Rationale: The right lung is larger and has more diffusing surface and more blood vessels than does the left lung. All lung functions (gas exchange and perfusion) are greater in the right lung, which means that problems in the right lung more severely affect (reduce) gas exchange than do similar problems in the left lung. Surfactant reduces surface tension rather than increases it. Gas exchange does not occur within the tracheobronchial tree because the tissues are too thick for adequate diffusion of gas in either direction

A client has a white blood cell change in which the number of suppressor T-cells is well below normal and asks the nurse what type of health problem(s) could be expected as a result of this deficiency. What is the nurse's best response a. "You will need to receive booster vaccinations more often because your ability to make antibodies is reduced." b. "Try to avoid crowds and people who are ill because you are now more susceptible to bacterial and viral infections." c. "You will be more prone to allergic reactions when exposed to allergens or drugs." d. "Your risk for cancer development is increased."

ANS: C Suppressor T-cells have the opposite action of helper/inducer T-cells. For optimal CMI, then, a balance between helper/inducer T-cell activity and suppressor T-cell activity must be maintained. This balance occurs when the helper/inducer T-cells outnumber the suppressor T-cells by a ratio of 2:1. When this ratio increases, indicating that helper/inducer T-cells vastly outnumber the suppressor cells, in this case because of way too few suppressor T-cells, overreactions can occur. These include allergies to almost anything, including drugs. Some of these overreactions are tissue damaging and dangerous, as well as unpleasant.

For which possible complication of tracheostomy tube dislodgement does the nurse remain alert in a client during the first 72 hours after placement? a. Oxygen toxicity b. Increased secretions c. Movement of the tube into a "false passage" d. Increased risk for aspiration during swallowing

ANS: C The stoma has not had time to mature and the dislodgement may allow the tube to slide into a "false passage" or subcutaneous space. The client will not be able to be ventilated. This is a true emergency requiring a Rapid Response Team and notification of the surgeon. Although oxygen toxicity can occur in this client, it is not a complication of tube dislodgement, neither are increased secretions or increased risk for aspiration

A client diagnosed with AIDS who is receiving combination antiretroviral therapy (cART) now has a CD4+ T-cell count of 525 cells/mm3. How will the nurse interpret this result? a. The client can reduce the dosages of the prescribed drugs. b. The virus is resistant to the current combination of drugs. c. The client no longer has AIDS. d. The drug therapy is effective.

ANS: D A client diagnosed with AIDS meets the criteria for Stage 3 category of HIV infection. Even when this client's CD4+ T-cell count increases as a result of therapy, the diagnosis of AIDS remains. The fact that the T-cell count has risen indicates that the combination of drugs used for therapy is effective; however, the dosages are not decreased.

The chest tube of a client who is 12 hours postoperative from a lobectomy separates from the drainage system. What is the nurse's best first action? a. Immediately call the surgeon or rapid response team. b. Notify respiratory therapy to set up a new drainage system. c. Cover the insertion site with a sterile occlusive dressing and tape down on three sides. d. Place the end of the disconnected tube into a container of sterile water positioned below the chest.

ANS: D This soon after surgery an open chest drainage tube can have air suck through it back into the client's chest and collapse the lung. This is an emergency. Although the surgeon or rapid response team should be called, the nurse first prevents the situation from becoming worse by sealing the tube with water. Because the chest tube is still in place in the client, using an occlusive dressing will not help prevent a lung collapse. Setting up a new drainage system can wait until after the tube is secured.

Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? a. Client with possible ulcer who just returned from an endoscopy b. Client with emphysema who needs teaching about pulmonary function testing c. Client with pancreatitis who needs a preoperative chest x-ray d. Client who had 1200 mL of pleural fluid removed by thoracentesis

Client who had 1200 mL of pleural fluid removed by thoracentesis A nurse working in the PACU would be most familiar with assessing vital signs and respiratory status for a postoperative client after an invasive procedure such as thoracentesis. When a large volume of fluid has been removed, there is a greater risk for instability. This client is within this nurse's skill set.Endoscopy is typically performed with sedation, not general anesthesia, which will not require the critical rescue skills of the PACU nurse. Pulmonary function testing is not a procedure the PACU nurse would typically encounter nor will it require the skill level of the PACU nurse. Although a client with pancreatitis is seriously ill and would require a chest x-ray before undergoing operative procedures, a nurse with a PACU monitoring skill set would not be required.

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? Select all that apply. a. "I can only take baths, but no showers." b. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." c. "I should put cotton or foam over the tracheostomy hole." d. "I will have to learn to suction myself." e. "I will be unable to wear a necklace."

a, b, c, e Need for teaching is indicated when the client says that only baths and no showers can be taken. The client is permitted to shower with the use of a shower shield over the tracheostomy, which prevents water from entering the airway. Also, the client does not instill anything into the artificial airway unless prescribed. The client would not put cotton or foam over the tracheostomy hole; this action may cause airway obstruction. The stoma may be covered loosely with a small cotton cloth to protect it during the day. This filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. Attractive coverings are available as cotton scarves, decorative collars, and jewelry including necklaces.The client is correct when commenting about learning to suction self, and will be taught clean suction technique to use at home.

The nurse is providing education for a client who is taking isoniazid, rifampin, and ethambutol for tuberculosis. Which of these points does the nurse include in the plan of care? Select all that apply. a. Take a supplement containing B vitamins. b. Avoid alcohol containing beverages. c. Have kidney function tests monthly. d. Report changes in vision to the health care provider. e. Notify the health care provider for red-orange urine.

a, b, d Teach the client to take a daily multiple vitamin that contains the B-complex vitamins while on this drug as deficiency may occur. These medications can cause liver damage, which is potentiated by alcohol. Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Contact lenses will also be stained and oral contraceptives will be less effective.Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless and expected. Both isoniazid and pyrazinamide may cause liver failure. Side effects of major concern include jaundice, bleeding, and abdominal pain

The nurse is providing education on preventing pulmonary disorders at a community health fair. Which of these groups does the nurse target? Select all that apply. a. Bakers b. Coal miners c. Electricians d. Furniture refinishers e. Plumbers f. Potters

a, b, d, e The groups the nurse targets as people at risk for pulmonary disorders include bakers, coal miners, furniture refinishers, and potters. Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. Coal miners are at risk for developing pneumoconiosis as the result of inhalation of coal dust. Owing to the chemicals used to refinish furniture (paint strippers, solvents, etc.), masks and adequate ventilation are essential for furniture refinishers. One of the main solvents involved will metabolize in the body to carbon monoxide and will impair the ability of the tissue to extract oxygen. Silicosis or inhalation of silica dust is a hazard for professional and recreational potters.Except in unique situations, electricians and plumbers do not need to wear masks or utilize special ventilation for their jobs.

Which interventions does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)-related dementia? Select all that apply. a. Change the decorations in the home according to the season. b. Put the bed close to the window. c. Write out detailed instructions, and have the client read them over before performing a task. d. Ask the client what time he or she prefers to shower or bathe. e. Mark off the days of the calendar, leaving open the current date.

a, b, d, e Changing decorations according to the season and using a calendar to mark off the days will help to keep the client oriented. Keeping the bed close to the window may help keep the client oriented. The client should be included in planning the daily schedule.Directions to the client need to be short and uncomplicated, and not detailed.

Which factors are possible transmission routes for human immune deficiency virus (HIV)? Select all that apply. a. Breast-feeding b. Anal intercourse c. Mosquito bites d. Toileting facilities e. Oral sex

a, b, e HIV can be transmitted via breast milk from an infected mother to the child. Anal intercourse not only allows seminal fluid to make contact with the mucous membranes of the rectum, but it also tears the mucous membranes, making infection more likely. Oral sexual contact exposes the mucous membranes to infected semen or vaginal secretions.HIV is not spread by mosquito bites or by other insects. It is not transmitted by casual contact. Sharing toilet facilities does not cause transmission of HIV.

The nurse is providing preoperative teaching for the client with lung cancer for whom a lobectomy is planned. Which of these does the nurse include in the preoperative education session? Select all that apply. a. "You will wake up with a drain in your chest which removes blood and allows the remaining lung to expand." b. "You will be able to get out of bed after the chest tube is removed." c. "Plan to request pain medication before your pain becomes severe." d. "You may have a tube in your throat connected to a mechanical ventilator to assist you with breathing." e. "You will need to lie on the operative side until the area of tissue removal heals."

a, c, d Preoperative teaching for a client scheduled to have a lobectomy for cancer includes telling the client that a chest drain will be in place, to request pain medication before the pain gets severe, and the possibility of having an endotracheal tube in the throat to assist with breathing.The nurse providing preoperative teaching for the lobectomy client would not tell the client that he or she will be able to get out of bed after the chest tube is removed. Bed rest may be necessary beyond the time the chest tube is removed in order to allow for proper healing; conversely the presence of the tube is not a contraindication for sitting in a chair. The nurse would not tell the client to lie on the operative side; this is typical after a pneumonectomy. Lying on either the operative or nonoperative side is a decision made by the surgeon.

The nurse presents a seminar on human immune deficiency virus (HIV) testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention regarding HIV testing? Select all that apply. a. "I am 78 years old, and I was treated and cured of syphilis many years ago." b. "In 1986, I received a transfusion of platelets." c. "Seven years ago, I was released from a penitentiary." d. "I used to smoke marijuana 30 years ago, but I have not done any drugs since that time." e. "At 68, I am going to get married for the fourth time."

a, c, e People who have had a sexually transmitted disease should be tested. People who are in or have been in correctional institutions such as jails or prisons and people who are planning to get married should be tested for HIV.HIV testing is recommended for clients who received a blood transfusion between 1978 and 1985. People who have used injectable drugs (not marijuana) should be tested.

In discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? a. "Have you had sex with men or women or both?" b. "I hope you use condoms to protect your partners." c. "You must tell me all of your partners' names, so I can let them know about possibly having AIDS." d. "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know."

a. "Have you had sex with men or women or both?" The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate."I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. Asking for information in the name of the public health department is not straightforward, and the tone of this entire statement is judgmental. Judgmental statements to clients by healthcare providers (HCPs) can impede the collaborative relationship and communication between client and HCP.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about prevention of complications? a. "I am here to receive the yearly pneumonia shot again." b. "I am here to get my yearly flu shot again." c. "I should avoid large gatherings during cold and flu season." d. "I should cough into my upper sleeve instead of my hand."

a. "I am here to receive the yearly pneumonia shot again." The statement by the client, "I am here to receive the yearly pneumonia shot again" indicates a need for further teaching. The CDC recommends that adults older than 65 years be vaccinated with two vaccines, first with Prevnar 13 followed by Pneumovax about 6 to 12 months later. Adults who have already received the Pneumovax would have Prevnar 13 about a year or more later, but not annually.Older clients are encouraged to receive a flu shot annually because the vaccine is formulated annually, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. Recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

Which statement by a client with chronic obstructive pulmonary disease (COPD) and a 10 pound (4.5 kg) weight loss indicates the need for additional follow-up instruction? a. "I should consume plenty of fluids with my meal." b. "I will try eating smaller more frequent meals." c. "I will try to eat more protein." d. "I will perform mouth care prior to eating."

a. "I should consume plenty of fluids with my meal." The need for additional follow-up instruction is noted when the client states that he or she will drink more fluids before and during meals. This action will cause a sensation of fullness and limit adequate nourishment.Eating smaller, more frequent meals, trying to eat more protein, and performing mouth care before eating are all appropriate and positive client comments.

The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client's discharge plan? a. "Please report any increased redness, swelling, warmth, or pain to your health care provider." b. "Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed." c. "A referral has been made to the American Cancer Society's Reach to Recovery program, and a volunteer will call you next week." d. "Avoid the prone and hunchback positions, and ask your health care provider for any other needed activity restrictions."

a. "Please report any increased redness, swelling, warmth, or pain to your health care provider." Instruction on increased signs and symptoms of inflammation could reveal signs of potential infection and is most important.Although information about having blood pressure taken or having blood drawn should be included, it is not the most important instruction for postoperative day 1 discharge. Referrals are important in helping with coping but are not the most important consideration when the client is being sent home on postoperative day 1. Positioning is important but is not the priority here.

A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? a. "With this treatment, I probably cannot spread this virus to others." b. "This treatment does not kill the virus." c. "This medication prevents the virus from replicating in my body." d. "Research has shown the effectiveness of this therapy if I do not forget to take any doses."

a. "With this treatment, I probably cannot spread this virus to others." HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids.HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance

The nurse is caring for a client who has had a lobectomy and placement of a chest tube 8 hours ago. When performing an initial assessment, which of these requires immediate follow up? a. 200 mL red drainage from chest tube over 2 hours b. Client sleepy but able to be aroused c. 3 cm area of red drainage on the incisional dressing d. Report of pain at the chest tube insertion site

a. 200 mL red drainage from chest tube over 2 hours The nurse must immediately report 200 mL of red drainage over a 2 hour span of time. Chest drainage should slow down after surgery. More than 70 mL of drainage/hour must be reported to the surgeon.A client who had a surgical procedure, anesthesia, and analgesia may spend most of the day sleeping, but should be able to be aroused. A small amount of drainage after surgery is expected, such as a 3 cm area. The nurse should circle the area and report increasing amounts to the surgeon. Pain at the surgical and chest tube insertion site is expected and will be managed by the nurse in collaboration with the provider after airway, breathing, and circulation are ensured.

The nurse is caring for a group of clients on a medical surgical unit. Which client will the nurse assess first? a. A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by Venturi mask b. A client who has had a tracheostomy for 1 week, who has SpO2 of 95%-97% and foul-smelling drainage on the tracheostomy ties c. A client who is being discharged with a new prescription for home oxygen therapy by nasal cannula d. A client who was admitted yesterday with pneumonia and is receiving antibiotics and oxygen through a nasal cannula

a. A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by Venturi mask The first client to assess is the newly admitted client with a long smoking history receiving 50% oxygen by Venturi mask. There is insufficient data to determine if this client is stable. The client is at an elevated risk for respiratory depression due to the hypoxic drive of respirations countered by high levels of oxygen and must be assessed frequently.The client with the tracheostomy is showing no signs or symptoms of respiratory compromise, and the client who meets discharge criteria do not require frequent assessment. Although the client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the client wearing the Venturi mask must be assessed first.

A client with chronic obstructive pulmonary disease (COPD) has a prescription to adjust oxygen to maintain SpO2 between 90% and 92%. Which action can be delegated to an unlicensed assistive personnel (UAP) under the supervision of an RN? a. Adjust the position of the oxygen tubing. b. Assess for signs and symptoms of hypoventilation. c. Change the O2 flow rate to keep SpO2 as prescribed. d. Select the O2 delivery device used for the clien

a. Adjust the position of the oxygen tubing.The scope of a UAPs role includes positioning of oxygen tubing for client comfort.Assessing for signs and symptoms of hypoventilation, choosing which O2 delivery device to use, and changing the O2 flow rate are actions that are skills that should be performed by skilled personnel and are beyond the scope of practice for a UAP.

A client with acute exacerbation of asthma has been admitted to the medical surgical unit for treatment. The client is reporting increased shortness of breath with inspiratory and expiratory wheezes. When planning care for this client, which medication will the nurse administer first? a. Albuterol-2 inhalations b. Fluticasone-2 inhalations c. Ipratropium-2 inhalations d. Salmeterol-2 inhalations

a. Albuterol-2 inhalations The nurse first needs to administer Albuterol, which is a rescue medication, to treat the client with increased shortness of breath with inspiratory and expiratory wheezes. Albuterol is a rapidly acting beta2 agonist that promotes bronchodilation.Fluticasone is a corticosteroid and needs to be given after a bronchodilator is given to open the airways. It is used to prevent asthma attacks by decreasing airway inflammation, and is not used as a rescue medication. Ipratropium is an anticholinergic drug that allows the sympathetic system to dominate and cause bronchodilation. It is not immediately effective like a short acting a beta2agonist, so it is not a first-line drug. Salmeterol is a long-acting beta2 agonist that must be used regularly over time and is not used as a rescue medication.

The community health nurse is planning treatment for multi-drug resistant tuberculosis for a client who is addicted to heroin. Which action will be most effective in ensuring that the client completes treatment? a. Arrange for a health care worker to observe the client take the medication. b. Give the client written instructions about how to take prescribed medications. c. Have the client repeat medication names and side effects. d. Instruct the client about the possible consequences of nonadherence.

a. Arrange for a health care worker to observe the client take the medication. The most effective action for the nurse to take to ensure that the client completes the treatment is to arrange for the client to be directly observed during therapy. The client is unlikely to adhere to long-term treatment unless closely supervised while taking medications.Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. The fact that the client can state the names and side effects of medications does not mean that the client understands what the medications are and why he or she needs to take them. A client who is homeless and addicted to opiates would most likely be more concerned with obtaining drugs and shelter than with properly taking his or her medication.

When caring for the client returning from thoracotomy and placement of a chest tube, the client reports severe pain. What does the nurse do first? a. Assess location and quality of pain. b. Call for the Rapid Response Team (RRT). c. Check the patency of the chest tubes. d. Call the health care provider.

a. Assess location and quality of pain. The nurse would assess the location, quality, radiation, severity of the pain, and the last time the client received pain medication before other actions are taken. Taking medication before pain becomes severe needs to be emphasized.The professional nurse is qualified to assess pain and provide pain medication when indicated. There is no information that suggests the client is unstable requiring the RRT to be called. The nurse will assess the chest drainage system at intervals, but pain is not typical when a chest tubes is blocked. The nurse would not call the health care provider before assessing the client's pain.

An adult resident with a C 6 spinal cord injury who resides in a long-term-care facility develops new onset of confusion, agitation and shouting, "Get out of here! You're trying to kill me!" Which action will the nurse take first? a. Check the resident's oxygen saturation. b. Do a complete neurologic assessment. c. Administer the prescribed PRN lorazepam. d. Perform a mini mental status exam.

a. Check the resident's oxygen saturation. The nurse's first action is to assess the client's oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A common reason for sudden confusion in adult clients and those with spinal cord injury that may weaken respiratory muscles is hypoxemia caused by undiagnosed pneumonia or pulmonary embolism.A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation, but this will take several minutes to complete. Administering lorazepam may mask symptoms of hypoxemia, delaying treatment. Benzodiazepine medications may cause a paradoxical reaction, or opposite effect, in some older clients, enhancing agitation. A mini mental status exam determines cognitive function and may give direction to the diagnosis of Alzheimer's or traumatic brain injury.

The charge nurse is making assignments for clients cared for on the intensive care stepdown unit. Which client will the charge nurse assign to the RN who has floated from the pediatric unit? a. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask b. Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour c. Client with emphysema who requires instruction about correct use of oxygen at home d. Client with lung cancer who has just been transferred from the intensive care unit after a left lower lobectomy yesterday

a. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask The charge nurse would assign the asthma client to the float pediatric nurse. Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis.Although chronic pleural effusions can occur in the pediatric population, this diagnosis is more common in the adult population. If this client has not already received teaching for this procedure, he or she may have questions that the pediatric nurse would not be as comfortable answering as a nurse who is regularly assigned to the stepdown unit. Emphysema is a diagnosis associated with an adult population. Although an RN could instruct a client about home oxygen therapy, this client might have questions that would be better answered by an RN with adult experience. The adult client who has just had a lobectomy needs careful assessment from an RN with adult stepdown unit experience.

The RN has received report about four clients. Which client needs the most immediate assessment? a. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry b. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes c. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago d. Client with pleural effusion who has decreased breath sounds at the right base

a. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry The client in need of the most immediate assessment is the one with acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen saturation level less than 91% indicates hypoxemia and instability requiring immediate assessment and intervention to improve blood and tissue oxygenation.The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed. There is no evidence the client who had a bronchoscopy 3 hours ago is unstable and therefore does not require attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion.

The home health nurse is assigned to visit these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule? a. Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% b. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test c. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment d. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

a. Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% The best client for the nurse to reschedule for a home visit is the client with chronic emphysema who is on home oxygen and who has an appropriate SpO2 level. A SpO2 level of between 89% and 92% is appropriate and satisfactory.The client with a positive Mantoux test, in addition to a history of cough, weight loss, and night sweats, is highly suspicious for tuberculosis and needs to be seen that day. The nurse needs to perform follow-up assessment and coordinate follow up testing. The nurse may need to provide reporting to the public health department and to develop a plan for close personal contacts. A client with a newly diagnosed pleural effusion needs a complete and thorough admission and intake assessment to ensure that oxygenation and underlying needs are addressed. A percutaneous lung biopsy may be performed as an outpatient procedure. The client who had a percutaneous lung biopsy and is experiencing increased dyspnea needs to be assessed that day to determine whether a life-threatening pneumothorax or hemothorax has developed.

A client with respiratory failure has been intubated and placed on a ventilator with 100% oxygen delivery to maintain adequate saturation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds. The most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. What action will the nurse take next? a. Collaborate with the provider to lower the FiO2 level. b. Discuss the need for extubation due to the need for 100% oxygen. c. Suggest noninvasive positive airway pressure techniques with oxygen. d. Prepare to suction the client.

a. Collaborate with the provider to lower the FiO2 level. Prompt identification and correction of the underlying disease process and potential oxygen toxicity may require delivery of a lower FiO2. The HCP needs to be notified when PaO2 levels are greater than 90 mmHg. Preventing oxygen toxicity and absorptive atelectasis (new onset of crackles and decreased breath sounds) are essential. Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung tissue present.The need for 100% oxygen delivery indicates that the client continues to require intubation and mechanical ventilation. Noninvasive positive airway pressure techniques are not used for clients requiring 100% oxygen. Suction is performed for rhonchi or noisy breath sounds on the anterior chest below the sternal notch (upper airway). Crackles and diminished breath sounds will be heard posteriorly reflecting fluid or poor exchange in the lower airway.

The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath sounds will the nurse assess? a. Crackles b. Rhonchi c. Pleural friction rub d. Wheeze

a. Crackles When caring for a client with heart failure and acute kidney disease, the nurse would assess for crackles. Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways or areas of fluid.Rhonchi are low-pitched, coarse snoring sounds caused by thick secretions in larger airways. A pleural friction rub sounds grating, loud, or scratchy as inflamed surfaces of the pleura rub together. Wheezes are frequently referred to as musical or squeaky sounds caused by bronchospasm. They may occur on inspiration or on expiration as air rushes through narrowed airways.

When caring for a client who had a lobectomy the nurse notes small bubbles in the water seal chamber of the disposable chest drainage device during coughing. Which of these reflects the appropriate action by the nurse? a. Document the finding in the medical record. b. Check the tube for blood clots. c. Briefly increase the amount of suction. d. Add additional sterile water to the water seal chamber.

a. Document the finding in the medical record. The nurse recognizes that gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. This indicates air is leaving the pleural space which is the intended purpose of the chest drain.Bubbling in the water seal chamber is absent if a kink or a blockage is present because air would not be able to escape from the chest cavity. Increasing the amount of suction without an order could damage lung tissue. There is no indication that the level of fluid in the water seal chamber is low.

A client is admitted to the medical floor with a new diagnosis of lung cancer. How will the nurse initially assist the client in managing the anxiety associated with the new diagnosis? a. Encourage the client to ask questions and verbalize concerns. b. Provide privacy for the client to be alone to deal with his or her own feelings. c. Medicate the client with diazepam for anxiety every 8 hours. d. Provide journals about cancer treatment.

a. Encourage the client to ask questions and verbalize concerns. The best way for the nurse to initially assist the client in managing anxiety related to a new diagnosis of cancer is to encourage the client to ask questions and voice concerns. The availability of the nurse to answer questions and listen to the client's concerns will help to decrease anxiety.The client may choose to be alone, although this may be a maladaptive coping behavior. Diazepam every 8 hours will reduce the client's anxiety but not help to manage its cause such as fear of the unknown or fear of death. It is more important to work with the client to assist him or her in dealing with those issues first. Knowledge about cancer diagnosis and treatment may help relieve anxiety but the nurse must first assess the client's needs as well as the plan of care.

A client who has a "do not resuscitate" (DNR) prescription has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? a. Ensure that the tubing is patent and that oxygen flow is high. b. Notify the chaplain and the family member of record. c. Call the Rapid Response Team (RRT) and prepare to intubate. d. Comfort the client.

a. Ensure that the tubing is patent and that oxygen flow is high. The nurse needs to first ensure that the tubing is patent and that the O2 flow is high. Labored breathing and ultimately suffocation can occur if the reservoir bag on a non-rebreather mask kinks, or if the oxygen source disconnects or is not set to high flow levels.The chaplain and the family member of record would not be notified until assessment confirms that death is imminent at this time. The RRT team can be called but the client may not want to be intubated, as indicated in the DNR orders. The RRT needs to know the client's wishes when they arrive. Comforting the client must be done but is not the first action by the action.

A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest? a. Expiratory wheezing not cleared by coughing b. Bronchial breath sounds over the trachea c. Crackles throughout the lung fields d. Bronchovesicular breath sounds in the lung bases

a. Expiratory wheezing not cleared by coughing In a client with asthma and shortness of breath, the nurse expects to hear expiratory wheezing not cleared by coughing. Wheezes are squeaky, musical, continuous sounds associated with bronchospasm, typical with asthma. They may be heard without a stethoscope and usually do not clear with coughing.Bronchial breath sounds are normal breath sounds, heard over the trachea and larynx. Crackles, an adventitious breath sound, will sound like popping, discontinuous sounds caused by air moving into previously deflated airways or coarse rattling sounds caused by fluid. Bronchovesicular breath sounds are normal breath sounds heard over major bronchi where fewer alveoli are located. They are best heard between the scapula and anterior chest.

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device will the nurse select? a. Face tent b. Venturi mask c. Nasal cannula d. Non-rebreather mask

a. Face tent The nurse will initially select a fact tent for this client. A client with smoke inhalation and facial burns who requires high-flow oxygen must initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue.Although a Venturi mask and a non-rebreather mask are high-flow oxygen delivery devices, they are snugly fitted on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? a. Fluconazole (Diflucan) b. Trimethoprim/sulfamethoxazole (Bactrim) c. Rifampin (Rifadin) d. Acyclovir (Zovirax)

a. Fluconazole (Diflucan) Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. Candidiasis is a fungal infection.Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. Rifampin (Rifadin) is used for treatment of tuberculosis. Acyclovir (Zovirax) is an antiviral agent.

The nurse on a pulmonary unit is caring for a client who has had a tracheostomy placed earlier today. Which of these techniques representing best practice will use the nurse use when suctioning the client's tracheostomy tube? a. Hyperoxygenate before and after suctioning. b. Repeat suctioning until the tube is clear. c. Apply suction during insertion of the tube. d. Suction through the tracheostomy tube for 30 seconds.

a. Hyperoxygenate before and after suctioning. The client needs to be preoxygenated/hyperoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client needs to be hyperoxygenated for 1 to 5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits.Repeat suctioning can be performed as needed for up to three total suction passes. Any additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult and is traumatic to the airway. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; a suction pass should last 10 to 15 seconds.

The nurse in the medical clinic is performing an assessment on an older adult client. Which finding requires further assessment by the nurse? a. Inability to state name and date of birth b. Slight kyphoscoliosis c. Soft speaking voice d. Need to rest after activity

a. Inability to state name and date of birth The nurse would further assess the client who is unable to state name and date of birth. The older adult has a higher risk for hypoxemia than a younger client. The older adult can become confused during acute respiratory conditions, which requires additional investigation.Progressive Kyphoscoliosis occurs with aging because the thorax becomes shorter. With aging, laryngeal muscles lose elasticity, and airways lose cartilage causing the client's voice to become soft and difficult to understand. This is due to age-related changes in chest wall compliance and elasticity. Increased need for rest periods during exercise may occur.

A registered nurse (RN) from the orthopedic unit has been assigned to the medical unit for the day. Which client assignment for the reassigned RN is the best? a. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula b. The client with chronic lung disease who is being evaluated for possible home oxygen use c. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar d. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

a. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula The best client to assign this RN is the client with a pulmonary embolism. Orthopedic nurses are familiar with pulmonary emboli, a common complication of fractures and orthopedic surgery, as well as administration of oxygen through nasal cannulas.Orthopedic nurses do not specialize in chronic lung conditions. These clients are best assigned to an RN with experience in caring for clients with chronic lung diseases who require the use of home oxygen delivery devices and equipment. Orthopedic nurses generally do not have specific experience with airway surgery clients and clients being treated for chronic bronchitis. Care of these clients is best assigned to an RN with skills in postoperative tracheostomy care and chronic respiratory disease clients.

Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)? a. The dietary worker hands the disposable meal trays to the LPN assigned to the client. b. The social worker encourages the client to verbalize about stressors at home. c. A member of the housekeeping staff thoroughly cleans and disinfects the hallways near the client's room. d. The health care provider orders vital signs, including temperature, every 8 hours.

a. The dietary worker hands the disposable meal trays to the LPN assigned to the client. The dietary worker giving the meal tray to the LPN limits the number of health care personnel entering the room, thus reducing the risk for infection.Verbalizing stressors does not reduce the risk for infection. Cleaning of bathrooms, not hallways, at least once daily by housekeeping staff reduces risk for infection. Vital signs, including temperature, should be taken every 4 hours to detect potential infection, but this does not reduce the risk of infection.

Which statement accurately explains otitis media? a. The inflammatory response is triggered by the invasion of foreign proteins. b. Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders. c. It is caused by a left shift or increase in immature neutrophils. d. Many immune system cells released into the blood have specific effects.

a. The inflammatory response is triggered by the invasion of foreign proteins. The inflammatory bacterial response of otitis media is stimulated by invading foreign proteins caused by infection.Macrophages and neutrophils are involved in the process of inflammation, but otitis media is an inflammation caused by infection. It is not caused by a left shift or increase in immature neutrophil forms. The change in form is caused by infection, such as sepsis. The action of immune system cells occurs when encountering a non-self or foreign protein to neutralize, destroy, or eliminate a foreign invader. This does not cause inflammation.

A client with COPD calls the pulmonary clinic reporting the last 24 hours the peak flow meter readings have been in the yellow range. Which of these interventions by the nurse is appropriate at this time? a. Use your prescription for rescue medication and retest yourself. b. This is a satisfactory reading, continue your present regimen. c. Go to the nearest emergency department. d. Increase your controller medication dose.

a. Use your prescription for rescue medication and retest yourself. The nurse would tell the client to use the rescue medication and then retest. This instruction by the nurse is appropriate. Reliever drugs (also called "rescue" drugs) are used to stop an attack once it has started or when the peak flow meter is in the yellow range or 50%-80% of personal best range.The reading is not satisfactory. Frequent readings in the yellow zone indicate the need to reassess the asthma plan and the need to possibly change controller drugs. Satisfactory readings are in the green zone and are at least 80% of or better than the personal best readings. The client needs to seek care in the ED when the readings are in the red zone or below 50% of the personal best reading. Nurses do not prescribe medications or change dosing.

The nurse in the community health clinic is planning education related to tuberculosis (TB). Which of these groups will the nurse target? Select all that apply. a. Breast cancer survivors b. Those in the local prison c. Homeless adults d. Recent immigrants to the United States e. Those who have received bacille Calmette-Guérin (BCG) vaccine

b, c, d The groups the nurse plans to educate include those adults who live in crowded areas such as prisons and homeless shelters, and those who are recent immigrants to the USA. Other groups at higher risk for tuberculosis include those who abuse injection drugs or alcohol and those groups of lower socioeconomic status.Breast cancer survivors who are no longer undergoing immunocomprising therapy have the same risk as the general population. Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.

The nurse is planning to provide tracheostomy care for a client with a soiled tracheostomy dressing. Which of these actions would be included in the plan of care? Select all that apply. a. Cut a sterile 4 × 4 gauze to fit around the tracheostomy tube. b. Suction the client if needed. c. Cleanse the inner cannula with a mixture of peroxide and saline. d. Replace the dressing with a sterile, folded 4 × 4 gauze. e. Provide clean tracheostomy ties that fit snugly against the neck.

b, c, d The nurse needs to first suction the tracheostomy tube if necessary. Use half-strength hydrogen peroxide to clean the inner cannula and sterile saline to rinse it. Alternatively, remove a disposable inner cannula and replace it with a new one.Never cut tracheostomy tube dressings because small bits of gauze could then be aspirated through the tube. If specific tracheal tube dressings are not available, then fold a sterile 4 × 4 gauze to fit around the tube. Also, make sure tracheal ties do not fit snuggle to the neck. Secure new ties in place before removing soiled ones. Tie a square knot that is visible on the side of the neck which is snug against one finger placed between the tie tape and the neck.

The emergency department nurse is assessing a client who believes he has sustained a pneumothorax after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess? Select all that apply. a. Slowing heart rate b. Sensation of air hunger c. Tracheal deviation d. Pain on the unaffected side e. Blue discoloration of the lips

b, c, e The nurse would assess for a pneumothorax if the client has a sensation of air hunger, tracheal deviation, and blue discoloration of the lips. All clients need to be taught to go to the ED for symptoms of a pneumothorax after a thoracentesis. Symptoms include pain on the affected side, rapid heart rate, rapid, shallow respirations, sensation of air hunger, prominence of the affected side that does not move in and out with respiratory effort, tracheal deviation to the unaffected, new onset of "nagging" cough and cyanosis. Tachycardia, rather than bradycardia, is consistent with a pneumothorax. Pain occurs on the affected side, not the unaffected side.

A client recently diagnosed with asthma has a prescription to use an inhaled medication with a spacer. The nurse evaluates the client has correct understanding of the use of an inhaler with a spacer when the client states which of these? Select all that apply. a. "I don't have to wait a minute between the two puffs if I use a spacer." b. "If the spacer makes a whistling sound, I am breathing in too rapidly." c. "I should rinse my mouth and then swallow the water to get all of the medicine." d. "I should shake the canister when I want to see whether it is empty." e. "I should hold my breath for at least ten seconds after inhaling the medication."

b, e Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client should hold the breath for at least 10 seconds, however attempting to hold the breath for a minute is unnecessary and could pose a threat to oxygenation.The client must wait 1 minute between puffs regardless of the method of delivery of the medication. The client should rinse the mouth but not swallow the water. The mouth needs to be rinsed after using an inhaler with or without a spacer. This is especially important if the inhaled medication is a corticosteroid; rinsing will help prevent the development of an oral fungal infection. An empty inhaler will float on its side in water while a full inhaler will sink. Shaking an inhaler helps ensure that the medication is dispersed and the same dose is delivered in each puff.

The nurse is providing teaching for a client who has been newly diagnosed with lung cancer and will be undergoing radiation therapy. Which of these points would be covered in the teaching session? Select all that apply. a. Hair loss will occur. b. Do not expose the site to sun. c. Loss of appetite may develop. d. Pain in the area is expected. e. Fatigue may occur. f. Changes in taste may occur.

b, e, f Skin in the path of radiation is more sensitive to sun damage. Clients must avoid direct skin exposure to the sun during treatment and for at least 1 year after radiation is completed. Side effects also include skin irritation and peeling, fatigue, nausea, and taste changes. Some clients have esophagitis during therapy, making nutrition more difficult.Alopecia, or hair loss, is a side effect of chemotherapy, not of radiation to the chest. Loss of appetite is not specific to radiation therapy. Radiation therapy itself is painless and sensation-free.

When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? a. "Condoms should be used when lesions are present on the penis." b. "Always position the condom with a space at the tip of an erect penis." c. "Make sure it fits loosely to allow for penile erection." d. "Use adequate lubrication, such as petroleum jelly."

b. "Always position the condom with a space at the tip of an erect penis." Positioning the condom with a space at the tip of the erect penis allows for the collection of semen at the tip of the condom.Condoms must be used by HIV-infected people at all times for sexual activity, with or without the presence of lesions. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. Lubricants should be water-based only. Oil-based lubricants, for example, petroleum-based lubricants (such as petroleum jelly), can increase the likelihood of breakage and slipping of latex condoms due to loss of elasticity caused by these lubricants. Oil may also create tiny holes in the latex. Oil-based lubricants may be considered desirable for people who are in relationships not requiring condom use and who wish to avoid certain additives and preservatives often found in other lubricants.

A client diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The client asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? a. "This will not make any difference in the viral load." b. "Blood concentrations will be decreased, which will lead to increased viral replication." c. "If only one dose of medication is missed, this will not make a difference." d. "This will cause an increase in opportunistic infections."

b. "Blood concentrations will be decreased, which will lead to increased viral replication." When doses are missed, blood concentrations become lower than what is needed for inhibition of viral replication (often called the inhibitory concentration). Teach clients the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART.When the inhibitory concentration is too low, the organism can replicate and produce new organisms that are resistant to the drugs being used. It does not cause an increase in opportunistic infections but places the client at increased risk for developing one. Therefore, it does make a difference and is critical to ensure that highly active antiretroviral therapy (HAART) doses are not missed, delayed, or administered in lower-than-prescribed dosages in the inpatient setting.

A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? a. "But you know you need this to breathe, right?" b. "Do you have a light scarf that you could place over it?" c. "Your family and friends probably won't even care." d. "It won't take you long to learn to manage."

b. "Do you have a light scarf that you could place over it?" The nurse's best response is to suggest some strategies to cover the tracheostomy. This statement recognizes the client's concerns and explores options for dealing with the effects of the procedure.Reiterating the reason for the tracheostomy, suggesting that the client's loved ones won't care, and telling the client that he or she will learn to live with the tracheostomy are insensitive responses and minimize the client's concerns.

The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery of his AIDS by his family? a. "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" b. " Is there somewhere private in the home where we can go and talk?" c. "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick." d. "It is your duty to protect your family members from getting AIDS."

b. "Is there somewhere private in the home where we can go and talk?" A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. The nurse needs to have a private conversation with the client to discover the client's wishes.The client has a right to privacy and can make the decision whether to post handwashing signs; caution signs invade the client's right to privacy. Protection from infection is important, but stating that the family members should know about the disease is not respectful of the client's right to privacy. The nurse suggesting that it is the client's responsibility to protect his or her family from getting AIDS is an intimidating statement. It is the client's right to make the decision whether to inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently.

Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? a. "I told family members they need to wash their hands when they enter and leave the room." b. "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." c. "Yes, I understand the reasons why I have to wear gloves when I bathe the client." d. "The client's spouse told me she got HIV from a blood transfusion."

b. "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse.Instruction on handwashing to family members or friends is not a breach of confidentiality. Understanding the reasons for wearing gloves recognizes Standard Precautions in direct care and is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.

The client says, "I hate this stupid COPD." What is the best response by the nurse? a. "Stopping smoking will help your lungs heal." b. "You sound fed up with managing your illness." c. "Does anyone in your family have COPD?" d. "Most clients get used to it after a few months."

b. "You sound fed up with managing your illness." The best response by the nurse is "You sound fed up with managing your illness." This response encourages the client to express his or her feelings about the disease and its challenges.Lecturing the client regarding his smoking habits disregards the client's need for support. "Why" questions can seem accusatory and may make a client less likely to talk about what he or she is feeling. Asking the client if anyone in the family has COPD is a "yes" or "no" question and does not encourage the client to talk about his or her feelings. The client's feelings should never be minimized.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? a. "You will not spread the disease unless you stop taking your medication." b. "You will not pose an increased risk of disease to the people you have been living with." c. "You will have to take these medications for at least 1 year." d. "Your sputum may turn a rust color as your condition gets better."

b. "You will not pose an increased risk of disease to the people you have been living with." The nurse tells the client that he/she will not be contagious to the people he/she lives with. The people the client has been living with have already been exposed and need to be tested. They cannot become at higher risk simply because the diagnosis has now been confirmed.The client with active tuberculosis is contagious, even while taking medication. However, the risk for transmission is reduced after the infectious person has received proper drug therapy for 2 to 3 weeks, clinical improvement occurs, and acid-fast bacilli (AFB) in the sputum are reduced. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

Which nursing activity can the nurse delegate to a home health aide? a. Changing the dressing for a client with a low absolute neutrophil count b. Assisting with bathing for a client with chronic rejection of a liver transplant c. Teaching a client with bacterial pneumonia how to take the prescribed antibiotic d. Assessing incisional tenderness for a client who had a recent kidney transplant

b. Assisting with bathing for a client with chronic rejection of a liver transplant Assisting with bathing for a client with chronic rejection of a liver transplant can be delegated to the home health aide.Changing the dressing for a client with a low absolute neutrophil count requires strict sterile technique by a licensed RN and should not be delegated because of the high risk for infection. Teaching about medications and assessments is within the scope of practice of the professional RN.

An older client presents to the emergency department with a 2-day history of cough, pain, wheezing, and dyspnea. The medical record states the client has not received the pneumococcal vaccine. While collaborating with the interprofessional team, which one of these medications does the nurse anticipate the health care provider will recommend as the priority? a. Corticosteroid b. Beta agonist c. Pneumococcal vaccine d. Antibiotic

b. Beta agonist The priority medication the nurse would expect the HCP to order is a beta-2 agonist or bronchodilator to help decrease bronchospasm and wheezing. This medication allows for adequate oxygenation by relaxing bronchial smooth muscle in the airways, and acts quickly to maintain airway patency.A corticosteroid will decrease airway swelling but takes many hours to days to become effective. A diagnosis of pneumonia has not been validated. However, if documented, the client should receive pneumococcal vaccine as an inpatient The anti-infective medication may be ordered after the cause of the symptoms is determined, but restoring adequate airway patency and reducing dyspnea take priority.

Which assessment finding in the client with exacerbation of emphysema requires intervention by the nurse? a. Barrel-shaped chest b. Bronchial breath sounds heard at the bases c. Hyperresonance to percussion of the chest d. Ribs lying horizontal

b. Bronchial breath sounds heard at the bases The client with bronchial breath sounds needs intervention by the nurse. These sounds are not normally heard in the periphery and may indicate atelectasis or increased lung density, as might present with a tumor or an infectious process such as pneumonia.The anteroposterior diameter is the same as the lateral-to-lateral or side-to-side diameter in a client with emphysema, so the client will generally have a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to percussion. Air trapping causes the ribs in a client with emphysema to lie in a more horizontal direction.

The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32 years. How does the nurse document pack-year history of smoking in the medical record? a. Client has a 32 pack-year history b. Client has a 96 pack-year history c. Client smoked 3 packs for years d. Client was a passive smoker for 32 years

b. Client has a 96 pack-year history This client has a 96-year pack history. Pack-year history refers to the number of packs per day multiplied by the number of years the client smoked.Pack-year history refers to the number of packs per day multiplied by the number of years the client smoked.

The nurse is assigned to care for four clients. Which client does the nurse assess first? a. Client with human immune deficiency virus (HIV) and Kaposi's sarcoma who has increased swelling of a sarcoma lesion on the right arm b. Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature c. Client who has been admitted to receive a monthly dose of serum immune globulin to treat Bruton's agammaglobulinemia d. Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count

b. Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature The temperature elevation of the client with a history of liver transplantation indicates that infection may be occurring, and is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated.Information regarding the HIV-positive client with Kaposi's sarcoma and the client with Bruton's agammaglobulinemia indicates that these clients' physiologic statuses are relatively stable. It is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count.

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first? a. Client with chronic obstructive pulmonary disease (COPD) who is ready for discharge, but is unable to afford prescribed medications. b. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. c. Hospice client with end-stage pulmonary fibrosis and an oxygen saturation level of 89%. d. Client with lung cancer who needs an IV antibiotic administered before going to surgery.

b. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. The client with CF with an elevated temperature and respiratory rate of 38 breaths/min is exhibiting signs of an exacerbation/infection and needs to be assessed first.The nurse will need to speak with the client who has COPD to help find a plan that will enable the client to obtain his or her prescribed medications. This may involve contacting case management or social services and discussing the discharge with the discharge health care provider. An oxygen saturation of 89% may be normal and expected for a hospice client with end-stage pulmonary fibrosis. There is no indication that this client is in distress. The nurse can delegate administration of the IV antibiotic to another RN, or it could be administered before the client is brought to the operating room.

The registered nurse receives report on four clients on a medical-surgical unit. Which of these clients will the charge nurse assign to the LPN/LVN? a.Client with group A beta-hemolytic streptococcal pharyngitis who has stridor b. Client with pulmonary tuberculosis who is receiving multiple medications c. Client with sinusitis who has just arrived after having endoscopic sinus surgery d. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

b. Client with pulmonary tuberculosis who is receiving multiple medications The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Each state designates which tasks may be safely delegated and assigned to nursing team members. Depending on the state's nurse practice act, licensed practical/vocational nurses (LPNs/LVNs) and technicians may be trained and undergo competency verification related to the skill of peripheral IV insertion and assistance with infusions. The RN is ultimately accountable for all aspects of infusion therapy and delegation of associated tasks (Infusion Nurses Society [INS], 2016; Weinstein & Hagle, 2014).Stridor, a harsh respiratory sound, is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful swallowing and respiratory assessment and monitoring by the RN.

The nurse is reviewing the admission assessment of an elderly client with pneumonia. For which symptom of pneumonia, typical to older adults, does the nurse assess? a. Bradycardia b. Confusion c. Eupnea d. Pale skin

b. Confusion The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present.Symptoms of pneumonia include flushing, not pale skin, anxiety, chest pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, not bradycardia, dyspnea, tachypnea not eupnea, hemoptysis, and sputum production. Severe chest muscle weakness also may be present from sustained coughing. Crackles, wheezing may be heard over areas of fluid, decreased breath sounds are present and wheezing may be heard where the airways are narrowed by exudate.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the inner cannula and the tracheostomy tube. Which action should the nurse take first? a. Auscultate the client's breath sounds while applying a nasal cannula. b. Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask. c. Apply a 100% non-rebreather mask while administering high-flow oxygen. d. Replace the obturator while reinserting the tracheostomy tube.

b. Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask. The nurse must first have someone call the RRT while attempting to resuscitate the client. Because a fresh tracheostomy stoma will collapse and airway patency lost, the nurse needs to ventilate the client through the mouth and nose while awaiting assistance to recannulate the client. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client.Auscultation of the client's breath sounds at this time will not improve the client's respiratory status. Effective use of a 100% non-rebreather mask requires a patent airway. During the first 72 hours following a tracheostomy, reinsertion of the tube is difficult and should not be attempted by the nurse but rather by the surgeon or an expert in this area such as a member of the RRT. The obturator aids in insertion of the tube and must be removed immediately or it will obstruct the airway.

A client with aspiration pneumonia occurring after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? a. Administer levofloxacin (Levaquin) 500 mg IV. b. Draw aerobic and anaerobic blood cultures. c. Give lorazepam (Ativan) as needed for agitation. d. Refer to social worker for alcohol counseling.

b. Draw aerobic and anaerobic blood cultures. The nurse would first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed. Getting cultures to identify the causative organism before initiating an antibiotic could affect the results of the culture and the type of antibiotic used.Levofloxacin, an antibiotic, is a priority intervention, and would be done after cultures are drawn. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action. Other interventions to help control the agitation may be tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.

The community health nurse is collaborating with the local health department on containment of an anticipated pandemic influenza outbreak. The nurse advises the health department that the best method to prevent outbreaks of pandemic influenza is which of these? a. Avoiding public gatherings at all times b. Early recognition and quarantine of affected persons c. Vaccinating community members with pneumonia vaccine d. Widespread distribution of antiviral drugs

b. Early recognition and quarantine of affected personsEarly recognition and quarantine of affected persons is the best way to prevent outbreaks of pandemic influenza. The recommended approach to disease prevention consists of quick recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus.Public gatherings need to be avoided only in the case of widespread outbreak of influenza in the community. A vaccine (Vepacel) is available in case of H5N1 outbreaks, but is stockpiled and not part of general influenza vaccination. The pneumonia vaccine is recommended for high-risk populations because pneumonia may be a complication of influenza. The current influenza vaccine is updated, re-evaluated, and changed yearly to meet anticipated changes in the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.

The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential for the nurse to perform prior to the procedure? a. Obtain informed consent. b. Ensure the client has had nothing by mouth. c. Review dietary and medication allergies. d. Perform aggressive chest physiotherapy.

b. Ensure the client has had nothing by mouth. When preparing a client for a diagnostic bronchoscopy, it is essential for the nurse to make sure the client is NPO for 4 to 8 hours before the procedure to reduce the risk for aspiration.It is important to verify allergies, however ensuring NPO status is maintained is essential to prevent aspiration, which can be life threatening. The nurse will verify that consent for the procedure was obtained. Until the client has a gag reflex and is fully alert, he or she should be maintained on NPO status to prevent aspiration. Aggressive chest physiotherapy is not indicated in a client who has had a bronchoscopy and may cause bleeding if biopsies have been obtained.

Which factor relates most directly to a diagnosis of primary immune deficiency? a. History of viral infection b. Full-term infant surfactant deficiency c. Contact with anthrax toxin d. Corticosteroid therapy

b. Full-term infant surfactant deficiency Genetic mutation causes surfactant deficiency; this is a primary immune deficiency. Primary immunodeficiencydiseases (PI) are a group of more than 250 rare, chronic disorders in which part of the body'simmunesystem is missing or functions improperly.Viral infection can cause a secondary immune deficiency. Anthrax and medical therapy are examples of a secondary immune deficiency.

Which postoperative kidney transplantation client does the nurse assess first for signs and symptoms of hyperacute rejection? a. Older adult with Parkinson disease receiving a donation from an identical twin b. Grand multipara female with a history of subsequent blood transfusions c. Middle-aged man with a 20-pack-year history d. Young adult with type 1 diabetes

b. Grand multipara female with a history of subsequent blood transfusions The grand multipara female with a history of subsequent blood transfusions should be assessed first because multiple pregnancies and blood transfusions greatly increase the risk of a hyperacute rejection. Hyperacute rejection occurs mostly in transplanted kidneys but is less common now with better HLA matching. Symptoms of rejection are apparent within minutes of attachment of the donated organ to the recipient's blood supply. The process usually cannot be stopped once it has started, and the rejected organ must be removed as soon as hyperacute rejection is diagnosed.The older adult with Parkinson disease receiving a donation from an identical twin has less chance of hyperacute rejection because his donor is an identical twin. Smoking places the middle-aged man with a 20-pack-year history at higher risk for postoperative respiratory difficulties, but not for hyperacute rejection. Type 1 diabetes requires close postoperative monitoring of blood sugar, but does not predispose the client to a hyperacute rejection.

Because of a flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner? a. Older adult client with a history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 150,000 mm3 (15.5 × 109/L), segmented neutrophils (segs) (8.0 × 109/L), bands 5% (0.5 × 109/L), lungs with slight crackles in bases, able to assist with activities of daily living, and afebrile b. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, WBC count 9,500 mm3 (9.5 × 109/L), segs (6.0 × 109/L), bands 1.0% (0.1 × 109/L), oxygen saturation of 93% on room air, and afebrile c. Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, WBC count 20,000 mm3 (20.0 × 109/L), segs (7.0 × 109/L), bands 10.0% (1.1 × 109/L), oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4°F (38°C) d. Older adult client with recent history of right hip replacement, with productive cough, WBC count 3,400 mm3 (3.4 × 109/L), segs (6.2 × 109/L), bands 5% (0.5 × 109/L), lungs with crackles right mid-lobe posterior chest wall, oxygen saturation of 89% with O2 at 2 L, and afebrile

b. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, WBC count 9,500 mm3 (9.5 × 109/L), segs (6.0 × 109/L), bands 1.0% (0.1 × 109/L), oxygen saturation of 93% on room air, and afebrile The client most ready for discharge is the middle-aged client with history of multiple sclerosis because the complete blood count (CBC) is within normal limits.The older adult client with a history of congestive heart failure and elevated WBC and segs and slight crackles in lung bases is not ready for discharge. The young adult client with crackles in all lung lobes is not ready for discharge because of elevated WBCs, left shift, and febrile status. The older adult client with recent history of right hip replacement is not ready for discharge because the WBC is below normal even though the other parts of the differential are within normal limits. This client may have a viral infection with crackles in the lungs and low oxygen saturation.

A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? a. Collaborate with the client to select foods that are high in calories. b. Provide oral care to the client before meals to enhance appetite. c. Assess the perianal area every 8 hours for signs of skin breakdown. d. Discuss the need to avoid foods that are spicy or irritating.

b. Provide oral care to the client before meals to enhance appetite. Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants.Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice, and would be done by licensed staff.

The nurse is educating the client with COPD who requires home oxygen therapy for discharge. Which of these teaching points takes the highest priority? a. Correct performance when setting up the oxygen delivery system b. Removing combustion hazards present in the home c. Understanding the signs and symptoms of hypoxemia d. Demonstrating how to use a pulse oximetry device

b. Removing combustion hazards present in the home The highest priority of education is that oxygen is highly combustible. The nurse must ensure that no open flames or combustion hazards are present in a room where oxygen is in use.The oxygen delivery system in the home will be different than in the hospital. Therefore, this skill may be verified by the visiting nurse or company providing the oxygen. The client must be able to state signs and symptoms of hypoxemia, although safety is the priority. Pulse oximetry may be useful for monitoring the client's oxygenation status and the visiting nurse or respiratory therapy partner can assess this. The client needs to be able to state the signs and symptoms of hypoxemia and when to notify the health care provider.

When caring for a client who has just undergone thoracentesis, which of these interventions does the nurse perform first? a. Encourage coughing and deep breathing. b. Schedule an immediate chest x-ray. c. Document the volume of removed fluid in the medical record. d. Set up a water seal drainage unit.

b. Schedule an immediate chest x-ray. After thoracentesis, the nurse first makes sure a chest x-ray is performed to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures toward one side).Coughing and deep breathing is done to promote lung expansion as part of the treatment for the underlying disorder. This can wait until a chest x-ray is completed. The volume of fluid will be recorded in the medical record, after the nurse schedules the x-ray to ensure a pneumothorax did not occur. Pigtail drain catheters may be left in place to a waterseal drainage system, rather than performing thoracentesis aspiration on a recurring basis, but this action is not standard.

A client who is exposed to invading organisms recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client? a. Intact skin and mucous membranes b. Self-tolerance c. Inflammatory response against invading foreign proteins d. Antibody-antigen interaction

b. Self-tolerance Self-tolerance is the process of recognizing and distinguishing between the body's own healthy self cells and non-self proteins and cells. The presence of different proteins on cell membranes makes the process of self-tolerance possible.The body has some defenses to prevent organisms from gaining access to the internal environment, such as intact skin and mucous membranes; however, they are not perfect—invasion of the body's internal environment by organisms often occurs. Inflammation provides immediate protection against the effects of tissue injury and invading foreign proteins. The inflammatory response is immediate but short-term against injury or invading organisms; it does not provide true immunity. Seven steps, known as phagocytosis (See Figure 17-6), are needed to produce a specific antibody directed against a specific antigen. These steps are necessary whenever the person is exposed to that antigen.

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? a. Complete the referral form for a home health agency. b. Suction the tracheostomy using sterile technique. c. Teach the client and spouse about tracheostomy care. d. Consult with the health care provider (HCP) about using a fenestrated tube.

b. Suction the tracheostomy using sterile technique. An experienced LPN/LVN can perform complex sterile procedures such as suctioning a tracheostomy tube using sterile technique.Completion of client referral forms, client and family teaching, and consulting with the (HCP) are all actions that must be performed by an RN

A client with pneumonia is receiving 100% oxygen via a non-rebreather mask. Which of these situations requires immediate intervention by the nurse? a. The client's skin has pink color. b. The oxygen reservoir deflates during inspiration. c. The client has crackles at the lung bases. d. The client is expectorating rust colored sputum.

b. The oxygen reservoir deflates during inspiration. The nurse intervene immediately if the reservoir bag is deflated. Suffocation can occur if the reservoir bag deflates, kinks, or if the oxygen source disconnects. The nurse needs to remove the device, refill the reservoir, and then reapply the mask.It is anticipated that the client's color is now pink. The client's color is expected to improve (from ashen or gray to pink) because of an increase in PaO2 level. Crackles in lung bases are an expected finding in a client with pneumonia, as is expectorating rust-colored sputum. Monitoring for adventitious breath sounds is important for the nurse to assess.

The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority? a. Administer antibiotics as prescribed. b. Transfuse ordered packed red blood cells. c. Teach pursed-lip breathing. d. Encourage increased fluid intake.

b. Transfuse ordered packed red blood cells. Packed red blood cells increase hemoglobin molecules and increases sites at which oxygen can attach and improves gas exchange.Antibiotics treat infection and do not improve oxygenation. Mouth breathing does not improve oxygenation related to anemia. Fluid intake does not have an effect on improving oxygenation.

The nurse in a life care community for geriatric clients is providing education to a group of residents on expected changes during aging. Which of these activities does the nurse encourage the older adult to perform to maintain respiratory function? a. Stay in bed to prevent fatigue. b. Walk as tolerated each day. c. Consume adequate calcium. d. Perform oral hygiene twice daily.

b. Walk as tolerated each day. The best activity for the older adult to perform in order to maintain respiratory function is to try and walk each day. Ambulation to the client's ability is easily performed in an older adult facility as it does not require special equipment. Health and fitness help keep losses in respiratory functioning to a minimum.Older clients have less tolerance for exercise and may need increased rest periods during exercise. However, bedrest is not necessary or desirable. Encouraging adequate calcium intake to prevent osteoporosis is more helpful prior to menopause, and is less helpful with elderly clients. Oral hygiene aids in the removal of secretions when present, but is not the best intervention to maintain respiratory function.

When caring for the client with chronic bronchitis, which of these interventions will assist the client in mobilizing secretions? a. Elevate the head of the bed 45 degrees b. consume at least 2 liters of fluid daily c. avoid triggers which cause coughing d. assume the tripod position

b. consume at least 2 liters of fluid daily Clients with chronic bronchitis tend to have thick secretions. Hydration with at least 2 liters of fluid daily thins tenacious (sticky) secretions, making them easier to expectorate. The goal is to consume fluid to thin secretions and perform controlled coughing. If health issues require fluid restriction, the client would attempt to consume the total amount permitted.Head of bed elevation may promote oxygenation and lung expansion, but does not promote secretion mobilization. Clients need to sit with both feet on the floor when performing controlled coughing. The tripod position is assumed during episodes of hypoxemia, but will not facilitate mobilization of fluid.

A local hunter is admitted to the intensive care unit with a diagnosis of fulminant stage inhalation anthrax. Which assessment findings does the nurse anticipate is present? Select all that apply. a. Sore throat b. Rhinorrhea c. Harsh cough d. Stridor e. Low grade fever

c, d The ICU nurse expects to find this client exhibiting a harsh cough and stridor. Inhalation anthrax has two stages: prodromal (or incubation period) and fulminant (with active disease). The fulminant phase of inhalation anthrax begins after the client feels a little better and includes high fever, sudden onset of severe illness, including respiratory distress, hematemesis (bloody vomit), dyspnea, diaphoresis, stridor, chest pain, and cyanosis. When infection occurs through the lungs, the disease is nearly 100% fatal without treatment (CDC, 2015b). Inhalation anthrax has two stages: prodromal (or incubation period) and fulminant (with active disease). Symptoms take up to 8 weeks to develop after exposure (Chart 31-4).The prodromal stage occurs early in the course of illness and includes low-grade fever, fatigue, mild chest pain, and a dry, harsh cough. It is not accompanied by upper respiratory symptoms of sore throat or rhinitis.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What primary assessment will the nurse make while preparing the client for a computed tomography (CT) scan? a. "Do you have any metal anywhere in your body?" b. "Do you have diabetes?" c. "Are you allergic to iodine or shellfish?" d. "Do you drink alcohol regularly?"

c. "Are you allergic to iodine or shellfish?" While preparing the client for a CT scan, the nurse's primary assessment would be to determine whether the client has any sensitivity to the contrast material by asking if the client has a known allergy to contrast, iodine or shellfish. CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli.Assessing for any metal in the body is done when clients undergo MRI. Diabetes is not a contraindication for CT with contrast. However, if the client receives metformin, the drug is stopped at least 24 hours before contrast dye is used and withheld until adequate kidney function is confirmed. Assessing regular alcohol intake is important, but is not the primary assessment.

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions? a. "All asthma drugs help everybody breathe better." b. "I must carry my emergency inhaler when activity is anticipated." c. "I must have my emergency inhaler with me at all times." d. "Preventive drugs can stop an attack."

c. "I must have my emergency inhaler with me at all times." The statement by the client that indicates a correct understanding of the instructions is that the emergency inhaler must be with the client at all times. Because asthma attacks cannot always be predicted, clients with asthma must always carry a rescue inhaler such as a short-acting beta agonist (e.g., albuterol).Asthma medications are specific to the disease and to the client and should never be shared or used by anyone other than the person for whom they are prescribed. They are not always good for everyone and, in fact, may do harm. An emergency inhaler should be carried all the time and not just when activity is anticipated. Preventive drugs are those that are taken every day to help prevent an attack from occurring, and do not stop an attack once it begins.

The nurse is teaching a client about cyclosporine (Sandimmune) therapy after liver transplantation. Which client statement indicates the need for further teaching? a. "I will be on this medicine for the rest of my life." b. "I must undergo regular kidney function tests." c. "I must regularly monitor my blood sugar." d. "My gums may become swollen because of this drug.

c. "I must regularly monitor my blood sugar." Further teaching is needed when the client says, "I must regularly monitor my blood sugar." Blood sugar is not affected by taking cyclosporine, so the client has no need to monitor blood sugar.The client must take cyclosporine for the rest of his or her life. (See chart 17-2) Kidney dysfunction is a side effect of cyclosporine, so regular monitoring is required. Swollen gums are a side effect of taking cyclosporine.

The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address? a. "When I injected heroin, I was exposed to HIV." b. "I don't understand how the antiretroviral drugs work." c. "I remember to take my antiretroviral drugs almost every day." d. "My sex drive is weaker than it used to be since I started taking my antiretroviral medications."

c. "I remember to take my antiretroviral drugs almost every day." It is important that clients take these drugs consistently, because inconsistent use of antiretroviral medications can lead to unsuccessful therapy and the development of drug-resistant HIV strains. The nurse would immediately assess the reasons why the client does not take the medications daily and then would implement a plan to improve adherence.The nurse would assess whether the client is still injecting drugs and would make certain the client understands the risks for infection with another strain of HIV or other blood borne pathogens and the risk for spreading HIV, but this does not need to be addressed immediately. The nurse must provide further education about how the medications work and assess how the lack of knowledge or decreased libido influences compliance, but this does not need to be addressed immediately.

The nurse is evaluating understanding of the treatment regimen for a client newly diagnosed with asthma. Which of these statements by the client indicates understanding of the regimen? a. "I will take albuterol when I go to sleep." b. "I will keep the rescue medication readily accessible on the first floor of my home." c. "I will take the long acting beta agonist even when my breathing seems OK." d. "I will immediately take the anti-inflammatory medication for an acute asthma attack."

c. "I will take the long acting beta agonist even when my breathing seems OK." The client indicates understanding of the dosing regimen when stating, "I will take the long-acting beta agonist even when my breathing seems OK." Long-acting medications are useful in preventing an asthma attack but cannot stop an acute attack.Short-acting beta2 agonists (SABAs) provide rapid, short-term relief. These "rescue" type inhaled drugs are most useful when an attack begins (as relief) or as premedication when the client is about to begin an activity that is likely to induce an attack. They are not used on a regular schedule. The client must always carry the relief drug inhaler with him or her and ensure that they do not run out of this medication. Anti-inflammatory medications decrease airway inflammation and are considered controller medications. They are not used for acute attacks.

The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? a. "I need to know my HIV status, so I must get tested before caring for any clients." b. "Putting on a gown and gloves will cover up the itchy sores on my elbows." c. "Washing my hands and putting on a gown and gloves is what I must do before starting care." d. "I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client's genitals."

c. "Washing my hands and putting on a gown and gloves is what I must do before starting care."Standard Precautions include hand hygiene and whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes.Knowing HIV status is important for preventing transmission of HIV, but is not part of the Standard Precaution Protocol. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of a gown and gloves. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.

A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? a. Suction as needed. b. Clean the tracheostomy inner cannula and stoma. c. Auscultate lung sounds. d. Change the tracheostomy dressing as needed.

c. Auscultate lung sounds.The first step of the nursing process and nursing action for a client following an airway procedure is to assess for a patent airway by auscultating the client's lungs and assessing the client's respiratory status.Suction is not needed if the lungs are clear to auscultation. Although cleanliness is important, the PACU nurse will not typically perform this procedure immediately after the tracheotomy is created, unless copious secretions are blocking the tube.Performing a dressing change is done every 8 hours or per hospital policy. The PACU nurse will perform this if the dressing is soiled or bloody, but assessment of airway must be performed first.

The school nurse is teaching a group of adolescents about risk factors for lung cancer and lung disease. Which of these would be included in the discussion? Alcohol consumption Cocaine use Cigarette smoking Heroin use

c. Cigarette smoking Cigarette smoking is highly addictive and is the number-one risk factor for lung cancer and chronic obstructive pulmonary disease.Alcohol can cause some cancers and liver disease and can increase risky behaviors, but it is not a major cause of lung cancer. Cocaine use, while highly addictive, poses a risk for cardiovascular disorders such as ACS, MI, or stroke. Heroin use does not increase one's risk of developing lung disease or lung cancer.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? a. Client with bacterial pneumonia and a cough productive of green sputum b. Client with neutropenia and pneumonia caused by Candida albicans c. Client with possible H5N1 influenza who currently has epistaxis d. Client with right empyema who has a chest tube and a fever of 103.2° F (39.6°C)

c. Client with possible H5N1 influenza who currently has epistaxis A client with possible tuberculosis or H5N1 avian influenza would be admitted to the negative-airflow room to prevent airborne transmission of organisms from the client room to other clients/staff and areas of the hospital.A client with bacterial pneumonia does not require a negative-airflow room but should have airborne or Droplet Precautions in place. A client with neutropenia may be in a regular room with an emphasis on handwashing. The client with a right empyema who also has a chest tube and a fever would have Contact Precautions in place but does not require a negative-airflow room.

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? a. Completing the antibiotic medication regimen b. Taking pain medications every 4 to 6 hours c. Contacting the health care provider (HCP) if drooling occurs d. Using warm saline gargles and irrigations

c. Contacting the health care provider (HCP) if drooling occurs The most important point to teach the client is to notify the HCP if signs of drooling develop. Clients with peritonsillar abscesses are at risk for airway obstruction due to swelling, manifested by drooling.It is also important to tell the client to complete the antibiotics to treat the infection, and to adhere to comfort measures such as analgesic medications and saline gargles, but these are not priority issues.

The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced respiratory depression does the nurse recommend? a. Continuous pulse oximetry b. Serial arterial blood gas measurements c. Continuous capnography d. Apnea monitoring

c. Continuous capnography For early detection of opioid-induced respiratory depression, the nurse recommends continuous capnography. Capnography detects exhaled carbon dioxide which increases during opioid-induced respiratory depression.Capnography, to detect opioid-induced respiratory depression, has been proven to be superior for early detection of respiratory changes and is a more sensitive indicator of respiratory depression than pulse oximetry. Arterial blood gas measurement is painful and expensive, and is not practical to use this methodology on a continuous basis. Apnea monitoring will detect a lack of breathing, but capnography will alert the nurse to respiratory depression prior to that time.

The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize? a. Administer bronchodilator medication on call. b. Encourage clear fluid intake 12 hours before the procedure. c. Ensure the client does not smoke for 6 hours before the test. d. Provide supplemental oxygen.

c. Ensure the client does not smoke for 6 hours before the test. The essential nursing intervention for a client being prepared for a PFT is to make sure that the client does not smoke for 6 hours before the test. Smoking can alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results.Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Encouraging fluid intake does not have an effect on PFT testing. Supplemental oxygen is not required and will alter the results of PFT. However, oxygen may be given if the client develops distress during testing.

The nurse on a medical surgical unit is caring for an adult client who has type 2 diabetes and is now admitted for pneumonia. The nurse must ensure the Joint Commission's National Client Safety Goals for this client are met and therefore follows up on which of these? a. Hemoglobin A1C b. Culture and Sensitivity report c. Evaluating pneumonia vaccine status d. Ensuring education to cough into the upper sleeve

c. Evaluating pneumonia vaccine statusThe Joint Commission's National Client Safety Goals (NPSGs) and core measures are client-safety oriented and recommends that all inpatients need to have their pneumonia vaccination status evaluated and, if needed, be vaccinated during that admission.It is important to provide diabetes education and assist the client in understanding the role of A1C in diabetes management, but that is not a core measure related to this situation. A culture and sensitivity may be performed, but is not a requirement or core measure. Coughing into the upper sleeve is a technique the center for disease control (CDC) recommends to prevent transmission and reduce the spread of disease.

The nurse in the clinic is following up on diagnostic testing for a client recently diagnosed with metastatic lung cancer and back pain. Which of these findings does the nurse expect to uncover? a. Hyperkalemia b. Hyperglycemia c. Hypercalcemia d. Hypernatremia

c. Hypercalcemia Hypercalcemia is the result of increasing parathyroid hormone as a paraneoplastic complication of cancer as well as bone metastasis. Bone metastasis should be suspected in the presence of back pain.Paraneoplastic syndromes are manifested by Cushing's syndrome, weight gain and dilution of electrolytes (SIADH) with resulting hyponatremia. Gynecomastia and hypoglycemia may also occur. Hyperkalemia most typically occurs with tumor lysis syndrome where multiple electrolyte imbalances develop impaired renal function and oliguria.

A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first? a. Obtain a 12-lead electrocardiogram (ECG). b. Call for a portable chest x-ray. c. Obtain blood cultures from two sites. d. Give cefazolin (Kefzol) 500 mg IV.

c. Obtain blood cultures from two sites. Antibiotics should be given as soon as possible to immunocompromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic.A 12-lead ECG can be obtained and calling for a portable chest x-ray can be done after other priority requests have been carried out.

The adult client with degenerative arthritis is admitted for surgery to create a tracheostomy. What is the best communication method for this client during the postoperative period? a. Computer keyboard b. Magic Slate c. Picture board d. Pen and paper

c. Picture board A picture board is the best communication strategy for this client. It does not require very much dexterity for someone who has degenerative arthritis.A computer keyboard, Magic Slate, and pen and paper require dexterity that may be difficult and/or painful for a client with degenerative arthritis.

A client who has recently relocated to the United States from Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? a. Contact the health care provider for tuberculosis (TB) medications. b. Perform a TB skin test. c. Place a respiratory mask on the client. d. Test all family members for TB.

c. Place a respiratory mask on the client. The nurse's first action is to place a respiratory mask on the client. The concern is that this client has a high risk for TB having recently immigrated from overseas. Client with symptoms consistent with TB should be considered infectious until the disease is ruled out.Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. Tell the client that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.

In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? a. Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma b. Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency c. Potential for infection transmission related to recurring opportunistic infections d. High risk for inadequate nutrition related to acquired secondary immune deficiency and Candida albicans

c. Potential for infection transmission related to recurring opportunistic infections Protecting the client from further opportunistic infection such as Candida albicans is a priority. Secondary immune deficiencies are common and acquired as part of another disease or as a consequence of certain medications. The most common secondary immune deficiencies are caused by aging, malnutrition, certain medications, and some infections, such as HIV. The most common medications associated with secondary immune deficiencies are chemotherapy agents and immune suppressive medications, cancer, transplanted organ rejection, or autoimmune diseases.Loss of social contact is not a priority problem with an opportunistic infection. Mouth sores would be secondary concern because Candida Albicans causes the mouth sores. Nutrition will be affected because of Candida Albicans; however, it is not a priority.

The interprofessional team is collaborating about using noninvasive positive-pressure ventilation (NPPV) for a confused client with pneumonia. What information is essential for the nurse to share with the team while making this decision? a. The client requires frequent respiratory assessment. b. NPPV uses positive pressure to keep the alveoli open. c. The client is unable to cough and protect the airway. d. A full face mask may not fit this client's small face well.

c. The client is unable to cough and protect the airway. It is most essential to determine the client's respiratory status including ability to cough and presence of a gag reflex before beginning NPPV. NPPV may cause gastric insufflation that can lead to vomiting or aspiration. NPPV must only be used on clients who have the ability to protect their own airway.NPPV uses positive pressure to keep the alveoli open; function of the devices is not the most important consideration in this scenario. If NPPV is used, full face masks, nasal pillows, and nasal-oral masks are available in a variety of sizes. One may provide a better seal and comfort than the other.

The nurse is caring for four clients who came to the emergency department with a productive cough. Which of these clients requires immediate intervention by the nurse? a. The client with blood in the sputum b. The client with mucoid sputum c. The client with pink, frothy sputum d. The client with yellow sputum

c. he client with pink, frothy sputum The nurse would immediately assess and interview the client with a productive cough and pink, frothy sputum. Pink, frothy sputum is common with pulmonary edema, a life-threatening exacerbation of heart failure. This client requires immediate assessment and intervention.Blood in the sputum may occur with chronic bronchitis or lung cancer. These conditions develop over time and therefore do not require immediate attention. Mucoid sputum may be related to smoking and does not require immediate attention. Although yellow sputum may indicate an infection that requires treatment, the condition is not life threatening.

The nurse is developing the plan of care to reduce risk for aspiration for a client with a tracheostomy. Which nursing interventions would be included in the plan of care? Select all that apply. a. Encourage frequent sipping from a cup. b. Encourage water with meals. c. Inflate the tracheostomy cuff during meals. d. Maintain the client upright for 30 minutes after eating. e. Provide small, frequent meals. f. Teach the client to "tuck" the chin down in the forward position to swallow.

d, e, f Interventions that must be noted in the client's plan of care include having the client remain upright for at least 30 minutes after eating to reduce the chance of aspiration. Also, making sure that small frequent meals are available for the client. Shorter and more frequent intervals of eating tire the client less and also reduce the chance of aspiration. Teaching the client how to tuck the chin down in the forward position helps to open the upper esophageal sphincter and again reduces the risk of aspiration.Sipping from a cup is contraindicated. Liquids are consumed using a spoon to ensure that the client is attempting to swallow only small volumes of liquid. Controlled small amounts of thickened liquids are given. Thin liquids such as water should be avoided because they are easily aspirated. The tracheostomy cuff needs to be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? a. "You can quit when you are ready." b. "It's never too late to quit." c. "For safety, turn off your oxygen when you smoke." d. "Let's discuss why smoking around oxygen is dangerous."

d. "Let's discuss why smoking around oxygen is dangerous." The nurse best response is to ask the client to discuss why smoking around oxygen is dangerous. The nurse would use this opportunity to educate the client about the dangers of smoking in the presence of oxygen, as well as the benefits of quitting.Telling the client it is okay to quit when ready, or that it's never too late to quit, does not address the safety issue of smoking in the presence of oxygen. Recommending that the client turn off the oxygen when smoking also puts the client at risk for harm.

The clinic nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? a. "Handwashing is the best way to prevent transmission." b. "I should avoid kissing and shaking hands." c. "It is best to cough and sneeze into my upper sleeve." d. "The intranasal vaccine can be given to everybody in the family."

d. "The intranasal vaccine can be given to everybody in the family."Further teaching is needed when the client states that the intranasal vaccine can be given to everybody in the family. The intranasal flu vaccine is approved for adult clients up to age 49 who are not pregnant.Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A recommendation from the Centers for Disease Control and Prevention for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand. Question 23 of 23

The nurse on a medical surgical unit is planning bed assignments for a new admission who has cystic fibrosis (CF) and is infected with Burkholderia cepacia. Which of these room assignments is most appropriate for this client? a. A room with laminar air flow b. A room with a client who has c. Down syndrome and pneumonia d. A room with another client who has cystic fibrosis e. A private room with a bathroom

d. A private room with a bathroom The most appropriate room for this client is a private room and separate bathroom. This provides maximum protection from organisms which can easily cause infection in the client with CF. A serious bacterial infection for clients with CF is Burkholderia cepacia, which is spread by casual contact from one CF client to another. To reduce spread of infection, measures include separating infected CF clients from noninfected CF clients on hospital units and seeing them in the clinic on different days.Laminar air flow is used in operating rooms and other areas where removing circulating air will provide for infection prevention. This is not required for those with CF. A client with Down syndrome may be unable to be careful with covering the mouth when coughing, using tissues, and handwashing, and would not be cohorted with a client who has high risk for infection.

The nurse is assessing a client admitted with status asthmaticus. The nurse finds a sudden absence of wheezing in the lung fields and sets which of these as the priority action? a. Education to prevent future exacerbations b. Administration of a bronchodilator c. Measures to reduce anxiety d. Activation of the rapid response team to secure an airway

d. Activation of the rapid response team to secure an airway Sudden absence of wheezing in a client having an asthma attack indicates complete airway obstruction and requires immediate action; a tracheotomy may be required.This is an emergency and educating the client is not appropriate. A bronchodilator is given when breath sounds are present and the client can inhale. Reducing anxiety is not a consideration in an emergency situation.

The nurse is caring for a client who has had a tracheostomy placed yesterday. Which of these assessments is essential for the nurse to make? a. Measure the cuff pressure. b. Assess the color and consistency of secretions. c. Ensure a second tracheostomy tube is available. d. Assess for tachypnea.

d. Assess for tachypnea. It is essential for the nurse to assess the client for tachypnea. Tachypnea can indicate hypoxia.Assessing secretions, ensuring a second tube is available in case of accidental extubation, and measuring cuff pressure are all appropriate interventions, after assessing airway and breathing.

Which statement best exemplifies a client's protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos? a. Cytotoxic and cytolytic T cells destroy cells that contain the major histocompatibility complex of a processed antigen. b. Helper and inducer T cells recognize self cells versus non-self cells and secrete lymphokines that can enhance the activity of white blood cells. c. Suppressor T cells prevent hypersensitivity when a client is exposed to non-self cells or to proteins. d. Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1.

d. Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1. After exposure to asbestos, a client's protection from cancer depends on a balance between helper and inducer T cells and suppressor T cells. This balance occurs when helper and inducer T cells outnumber suppressor T cells by a ratio of 2:1.The activity of cytotoxic and cytolytic T cells is most effective against self cells infected by parasites. Overreactions can cause tissue damage if an imbalance exists between helper and inducer T cells. When suppressor T cells are increased, immune function is suppressed and the client is at risk for infection.

A complete blood count with differential is performed on a client with chronic sinusitis. Which finding does the nurse expect? a. Segmented neutrophils, 62% b. Lymphocytes, 28% c. Bands, 5% d. Basophils, 4%

d. Basophils, 4% The normal count for basophils (basos) is 0.5%; an elevated count indicates inflammation. This is common with chronic sinusitis.62% is a normal segmented neutrophil and refers to mature neutrophils, which, along with macrophages, eliminate invaders (infection) by phagocytosis. For lymphocytes, 28% is a normal count in the differential. For bands, 4% is a normal count. Bands are elevated only when an infection is present and the bone marrow cannot keep up with mature segmented neutrophils.

The nurse is caring for a client with COPD who has a prescription for supplemental oxygen. Which situation will cause the nurse to further assess the need to increase the fraction of inspired oxygen (FiO2)? a. Client's last ECG showed atrial fibrillation at a rate of 82 b. Client's blood pressure is 106/80 c. Client has been cooperative with all treatments d. Client has developed restlessness over the last hour

d. Client has developed restlessness over the last hour The nurse needs to assess the client who has recently become restless for the need to increase this client's FiO2. This client may be exhibiting symptoms of hypoxemia including restlessness. Additional symptoms of hypoxemia include increased heart rate and blood pressure, oxygen desaturation, cyanosis, restlessness, and dysrhythmias.A client with controlled or treated atrial fibrillation with a pulse of 82 beats per minute is stable and not cause for alarm or a change in FiO2. A client with a blood pressure of 106/80 and a client cooperating with the treatment plan indicate positive outcomes to oxygen therapy. The nurse will continue to observe these clients.

The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client needs to be evaluated first by the nurse? a. Client who is short of breath after walking up two flights of stairs b. Client with a 10 mm area of redness on the arm after receiving purified protein derivative (Mantoux) skin test c. Client with sore throat and fever of 102.2°F (39°C) oral d. Client who is speaking in three-word sentences and has an SpO2 of 90%

d. Client who is speaking in three-word sentences and has an SpO2 of 90% The client that requires first and immediate evaluation by the nurse is the client who is speaking in three-word sentences and displaying dyspnea. This, coupled with an SpO2 of 90%, indicates hypoxemia.The client displaying shortness of breath after walking up two flights of stairs may be displaying signs/symptoms of underlying cardiopulmonary disease. This is not an emergency as there is no indication of dyspnea at rest. Induration, not redness, reflects a positive Mantoux test with possible TB. This develops slowly and will not take priority over airway and breathing. Sore throat and fever are symptoms of infection that require further evaluation, but not emergently.

An HIV positive client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? a. Therapeutic highly active antiretroviral therapy (HAART) level b. Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot c. Positive Papanicolaou (Pap) test d. Improved CD4+ T-cell count and reduced viral load

d. Improved CD4+ T-cell count and reduced viral load Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication.Therapeutic HAART level is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. ELISA and Western blot, if positive, indicate that the client is HIV positive (a fact already known for this client) and do not indicate response to prescribed medication. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication.

A client has returned to the medical surgical unit after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP)? a. Assess breath sounds. b. Offer clear liquids when gag reflex returns. c. Determine level of consciousness. d. Monitor blood pressure and pulse.

d. Monitor blood pressure and pulse. The best nursing task for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP) is monitoring blood pressure and pulse. An experienced UAP would have experience in taking client vital signs after procedures requiring conscious sedation or anesthesia.Evaluating breath sounds, gag reflex, and determining level of consciousness are considered nursing assessments and require the skill and knowledge of a higher-level provider or professional nurse.

The nurse is providing education to a client with chronic bronchitis who has a new prescription for a mucolytic. Which of these will the nurse teach the client about the purpose of the medication? a. Mucolytics decrease secretion production. b. Mucolytics increase gas exchange in the lower airways. c. Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease. d. Mucolytics thin secretions, allowing for easier expectoration.

d. Mucolytics thin secretions, allowing for easier expectoration. Client with chronic bronchitis typically produces large amounts of thick mucus interfering with gas exchange. Mucolytic means "breaking down mucus," resulting in thinner secretions which are easier to expectorate.Mucolytics do not decrease secretion production. Mucolytics may increase gas exchange as secretions are cleared, but this is an indirect property and is not the main function. Mucolytics do not have any bronchodilation properties.

The RN and the LPN/LVN are working together to provide care for a group of clients on a medical surgical unit. Which of these actions is most appropriate for the RN to perform? a. Administer purified protein derivative (PPD) for tuberculosis testing. b. Assess vital signs and the puncture site one day post thoracentesis. c. Monitor oxygen saturation using pulse oximetry every 4 hours. d. Plan client and family teaching regarding upcoming pulmonary function testing.

d. Plan client and family teaching regarding upcoming pulmonary function testing. The most appropriate action for the RN to perform is developing the teaching plan for upcoming pulmonary function test. These skills are complex, requiring use of the nursing process, and are not in the scope of practice of the LPN/LVN.Medication administration and monitoring of vital signs and client status after procedures can be accomplished by the LPN/LVN. Monitoring of oxygen saturation by pulse oximetry can also be included in the vital signs assessment.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? a. Ensures that the client is wearing a mask b. Informs the visitor that the client cannot receive visitors at this time c. Provides a particulate air respirator to the visitor d. Provides the visitor with a surgical mask

d. Provides the visitor with a surgical mask Because the visitor is entering the client's isolation environment, the visitor must wear a mask.The client typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator which is typically used for TB, H5N1 influenza, or SARS.

Which home health nurse should the nurse manager assign to care for an 18-year-old client with a kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)? a. RN who has worked for the home health agency for 5 years in maternal-child health b. RN who has extensive critical care nursing experience and has worked in home health for a year c. RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit d. RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency

d. RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency The RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency has the experience and understanding of the needs of a posttransplantation client, as well as knowledge of cyclosporine, and would be the best choice.An RN who has worked for the home health agency for 5 years in maternal-child health, an RN who has extensive critical care nursing experience and has worked in home health for a year, and an RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit would not have specific knowledge and information on the care provided and medications used in posttransplantation clients.

The nurse is preparing to assess an adult client who was just admitted with pertussis. Which symptom does the nurse anticipate finding in this client? a. "Whooping" after a cough b. Hemoptysis c. Mild cold-like symptoms d. Severe coughing spasms

d. Severe coughing spasms Clients with pertussis will have severe coughing spasms. Paroxysms of coughing will often be followed by changes in color and/or vomiting.Adults do not usually have the characteristic whooping sound associated with coughing exhibited by children with pertussis. Hemoptysis may occur after the acute phase when changes in the respiratory mucosa occur. Mild, cold-like symptoms occur in the initial stages of pertussis and generally do not require hospitalization.

An elderly client is admitted to the emergency department (ED) with symptoms of possible seasonal influenza accompanied by vomiting and high fever. Which of these actions is the nurse's first priority? a. Ensure that ED staff members receive oseltamivir (Tamiflu). b. Administer IM influenza vaccination. c. Place the client in a negative air pressure room. d. Start an IV line and begin intravenous hydration.

d. Start an IV line and begin intravenous hydration. The nurse's first priority is to start an IV line and begin intravenous hydration. Elderly clients with influenza symptoms can develop dehydration quickly because of fever, vomiting and possible diarrhea. Initiating intravenous rehydration is a priority to maintain tissue perfusion.The ED staff would have received annual seasonal influenza vaccine, however if not, they can be given antiviral agents. A negative airflow room is not required in the ED, however a mask would be worn. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority as it takes weeks for full immunity to develop.

The home care nurse is caring for an elderly client with streptococcal pneumonia. Which of these findings indicate a positive outcome to treatment? Select all that apply. a. The client states she will complete the entire dose of antibiotic prescribed. b. The client reports fatigue and malaise. c. White blood cell count is 16, 000 cells/cubic mm (16 × 109/L). d. The client has been afebrile for 48 hours.

d. The client has been afebrile for 48 hours. A positive outcome been afebrile for 48 hours.Expected outcomes to treatment include negative blood and sputum cultures, normal WBC count and differential, and absence of fever.Fatigue may persist for several weeks. The normal WBC count is 5000-10,000 mm3 (5-10 × 109/L). A WBC count of 16,000 mm3 (16 × 109/L) indicates infection. The client stating compliance with treatment is positive, but is not an objective measurement of eradicating the infecting organism.

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who has hypoxemia and hypercarbia. The nurse recognizes that a positive outcome to therapy has been achieved by which of these findings? a. The pCO2 is within normal range. b. The client's face is very pink. c. The client reports decreased distress. d. The oxygen saturation is between 88% and 90%.

d. The oxygen saturation is between 88% and 90%. Clients with hypoxemia, even those with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and maintain SpO2 levels between 88% and 92%.Gases diffuse independently, therefore applying oxygen will not decrease the carbon dioxide level; hypoxemia may still be present. Flushing of the face can be a symptom of hypercarbia. A report of less distress is appropriate. The nurse, in any case, needs to use an objective measure of oxygenation such as pulse oximetry or blood gas results.

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? a. Combination medication therapy is effective in eliminating cough and fever. b. Combination medication therapy improves adherence. c. Combination medication therapy has fewer side effects, particularly liver damage. d. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.

d. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms. The nurse tells the client that multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Combination drug therapy is the most effective method for treating TB and preventing transmission.As the disease responds to treatment, the symptoms will decrease, but they are not eliminated. Combination drug therapy does not improve adherence to drug therapy. Isoniazid, rifampin, and pyrazinamide may cause liver damage.

The nurse is caring for a client with severe acute respiratory syndrome (SARS). What is the most important infection control precaution that the nurse takes when preparing to suction this client? a. Keeping the door to the client room closed b. Performing oral care after suctioning the oropharynx c. Washing hands and donning gloves prior to the procedure d. Wearing a disposable particulate mask respirator

d. Wearing a disposable particulate mask respirator The most important infection control precaution the nurse must take before suctioning a client is to wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms.The door to the room needs to be closed during care of the client with SARS and other instances of airborne precautions. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure.