nu260 quiz 2

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Don't go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

A, D, E

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client's face is puffy and the eyelids are swollen. What action by the nurse takes best? a. Assess the client's oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

A

A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Replaces the oxygen tubing with a different type. d. Turn the client every 2 hours or as needed.

A

A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

A

An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best? a. Assess the client's lung sounds. b. Assign a different AP to the client. c. Report the AP to the manager. d. Request thicker liquids for meals.

A

Which arterial blood gas (ABG) values from an 86-year-old client does the nurse consider to be normal? A. pH 7.32, PaO2 94 mm Hg, PaCO2 42 mm Hg B. pH 7.35, PaO2 90 mm Hg, PaCO2 52 mm Hg C. pH 7.45, PaO2 88 mm Hg, PaCO2 48 mm Hg D. pH 7.47, PaO2 98 mm Hg, PaCO2 30 mm Hg

A

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home. f. No alcohol-based hand sanitizers are present.

A, B, C

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Alveolar recruitment e. Toxicity

A, B, C, E

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision f. Upper arm range of motion

A, B, D, E, F

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

A, C, D, F

Which respiratory changes does the nurse expect to find in an 82-year-old client who has no indicators for respiratory disease? Select all that apply. A. Exhalation is twice as long as inhalation B. Wheezing on arising every morning C. Decreased force of cough D. Increased anteroposterior diameter E. Shortness of breath at rest F. Softer voice

A, C, D, F

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Applying water-soluble lip balm to the client's lips b. Ensuring that the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy f. Holding the new tracheostomy tube while the RN changes the ties

A, D

When the SpO2 of a client with very dark skin reads 91%, which additional assessments will the nurse perform to determine the client's gas exchange adequacy? Select all that apply. A. Examine the color of oral mucosa. B. Ask the client to rate his or her dyspnea. C. Reapply the pulse oximeter to the earlobe. D. Use capnography to assess end-tidal CO2 levels. E. Examine the color of the sclera closest to the iris. F. Compare the temperature of the right foot to that of the left.

A, D

Which statements indicate to the nurse that client has a strong addiction to cigarette smoking. Select all that apply. A. "I smoke a cigarette when I wake up before I make coffee." B. "To reduce my children's exposure, I only smoke outdoors." C. "I used to just 'burn' cigarettes but now I buy a pack daily for myself." D. "I only watch movies on television rather than at a theater because I can smoke at home." E. "Last night I woke up at 2:00 a.m. and 5:00 a.m. to smoke two cigarettes each ti

A, D, E

Which assessment findings on a client who had a bronchoscopy using the local anesthetic benzocaine spray along with light sedation are most important to report to the health care provider who performed the procedure? Select all that apply. A. Oxygen saturation is 60% and does not increase with supplemental oxygen. B. Twenty minutes after the procedure, the client remains drowsy. C. Client coughed on first being awake but is no longer coughing. D. The client reports having a sore throat. E. O

A, E, F

Which client conditions does the nurse recognize as most likely to cause a "left shift" of the oxyhemoglobin dissociation curve? Select all that apply. A. Alkalosis B. Increased body temperature C. Reduced blood and tissue pH D. Increased metabolic demands E. Reduced blood and tissue levels of oxygen F. Reduced blood and tissue levels of diphosphoglycerate (DPG)

A, F

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

ANS: A

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

ANS: A

The nurse should assess a child who has had a tonsillectomy for which of the following as the priority? a. Frequent swallowing b. Inspiratory stridor c. Swelling of the throat d. Abnormal lung sounds

ANS:

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

ANS: A

A 5-year-old child is brought to the emergency department with copious drooling and a croaking sound on inspiration. Her mother states that the child is very agitated and only wants to sit upright. What action by the nurse takes priority? a. Prepare intubation equipment and call the provider. b. Examine the child's oropharynx and call the provider. c. Obtain a throat culture for respiratory syncytial virus (RSV). d. Obtain vital signs and listen to breath sounds.

ANS: A

11. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 liters per nasal cannula d. Complete bedrest with frequent repositioning

ANS: A

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

ANS: A

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

ANS: A

14. A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowlers position. d. Administer prescribed albuterol.

ANS: A

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

ANS: A

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

ANS: A

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

ANS: A

21.A nurse admits a client from the emergency department. Client data are listed below: History 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Physical Assessment Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only Laboratory Values WBC: 5,200/mm3 PaO2 on room air 65mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. b. Begin br

ANS: A

A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase of respiration. What action by the nurse is most appropriate? a. Prepare to administer a bronchodilator. b. Give ordered antibiotics on time. c. Provide oxygen via face tent. d. Assess the airway for a foreign body.

ANS: A

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

ANS: A

A nurse auscultates a client's lung fields. Which action should the nurse take based on the lung sounds? (Click the media button to hear the audio clip.) a. Assess for airway obstruction. b. Initiate oxygen therapy. c. Assess vital signs. d. Elevate the client's head.

ANS: A

A nurse auscultates a client's lung fields. Which pathophysiologic process should the nurse associate with this breath sound? (Click the media button to hear the audio clip.) a. Inflammation of the pleura b. Constriction of the bronchioles c. Upper airway obstruction d. Pulmonary vascular edema

ANS: A

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

ANS: A

A nurse is caring for four infants. Which one should the nurse assess first? a. Nasal flaring b. Respiratory rate of 55 breaths/min c. Irregular respiratory pattern d. Abdominal breathing

ANS: A

An infant has laryngomalacia. What assessment finding correlates with this condition? a. Stridor b. High-pitched cry c. Nasal congestion d. Spasmodic cough

ANS: A

An infant's parents ask the nurse about preventing OM. What should be recommended? a. Avoid tobacco smoke. b. Use nasal decongestant. c. Avoid children with OM. d. Bottle feed or breastfeed in supine position.

ANS: A

The nurse expects the initial plan of care for a 9-month-old child with an acute otitis media infection to include a. symptomatic treatment and observation for 48 to 72 hours after diagnosis. b. an oral antibiotic, such as amoxicillin, five times a day for 7 days. c. pneumococcal conjugate vaccine. d. myringotomy with tympanoplasty tubes.

ANS: A

The nurse getting an end-of-shift report on a child with status asthmaticus should question which intervention? a. Administer oxygen by nasal cannula to keep oxygen saturation at 100%. b. Assess intravenous (IV) maintenance fluids and site every hour. c. Notify provider for signs of increasing respiratory distress. d. Organize care to allow for uninterrupted rest periods.

ANS: A

The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additio

ANS: A

The nurse should teach parents of a child with cystic fibrosis to adjust enzyme dosage according to which indicator? a. Stool formation b. Vomiting c. Weight d. Urine output

ANS: A

What explanation should the nurse give to the parent of a child with asthma about using a peak flow meter? a. It is used to monitor the child's breathing capacity. b. It measures the child's lung volume. c. It will help the medication reach the child's airways. d. It measures the amount of air the child breathes in.

ANS: A

What is the earliest recognizable clinical manifestation(s) of CF? a. Meconium ileus b. History of poor intestinal absorption c. Foul-smelling, frothy, greasy stools d. Recurrent pneumonia and lung infections

ANS: A

Which assessment finding after tonsillectomy should be reported to the surgeon? a. Vomiting bright red blood b. Pain at surgical site c. Pain on swallowing d. The ability to only take small sips of liquids

ANS: A

Which classification of drugs is used to relieve an acute asthma episode? a. Short-acting beta2-adrenergic agonist b. Inhaled corticosteroids c. Leukotriene blockers d. Long-acting bronchodilators

ANS: A

2.A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin) d. Ethambutol (Myambutol) e. Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

ANS: A, B, C

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? (Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Increase carbohydrate intake for energy."

ANS: A, B, C

What information should the nurse teach families about reducing exposure to pollens and dust? (Select all that apply.) a. Replace wall-to-wall carpeting with wood and tile floors. b. Use an air conditioner. c. Put dust-proof covers on pillows and mattresses. d. Keep humidity in the house above 60%. e. Keep pets outside.

ANS: A, B, C

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

ANS: A, B, C, D

The nurse is assessing a child for epiglottitis. What findings are consistent with this condition? (Select all that apply.) a. Drooling b. Dysphagia c. Dysphonia d. Distressed inspiratory efforts e. Decreased oxygenation

ANS: A, B, C, D

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

ANS: A, B, C, D, F

We have an expert-written solution to this problem! 3. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the assistive personnel (AP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E

A nurse is planning care for an asymptomatic child with a positive tuberculin test. What should the nurse include in the plan? (Select all that apply.) a.Administration of daily isoniazid (INH) b.Instructing family members about administration of INH to all close contacts of the child c.Administration of the bacillus Calmette-Guérin vaccine d.Reporting the case to the health department e.Administration of INH and rifampin (Rifadin) simultaneously

ANS: A, B, D

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

ANS: A, B, D

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

ANS: A, B, D, E

The mother of a newborn asks the nurse what causes the baby to begin to breathe after delivery. What changes in the respiratory system stimulating respirations postnatally can the nurse explain to the mother? (Select all that apply.) a. Low oxygen levels in the infant's blood b. Rubbing the newborn with a towel or blanket c. Surfactant, a special lubricant in the lungs d. Increased blood flow to the infant's lungs e. Cold environment in the delivery room

ANS: A, B, E

2. A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. e. Administer acetaminophen (Tylenol) twice daily.

ANS: A, C, D

1.A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 253 when administering the pneumonia vaccination? (Select all that apply.) a. 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabet

ANS: A, C, D, E

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

ANS: A, C, E

The nurse should implement which interventions for an infant experiencing apnea? (Select all that apply.) a. Stimulate the infant by gently tapping the foot. b. Shake the infant vigorously. c. Have resuscitative equipment available. d. Suction the infant. e. Maintain a neutral thermal environment.

ANS: A, C, E

1. A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Impaired judgment e. Increased thirst

ANS: A, D

3. While obtaining a clients health history, the client states, I am allergic to avocados. Which responses by the nurse are best? (Select all that apply.) a. What response do you have when you eat avocados? b. I will remove any avocados that are on your lunch tray. c. When was the last time you ate foods containing avocados? d. I will document this in your record so all of your providers will know. e. Have you ever been treated for this allergic reaction?

ANS: A, D, E

4. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. I held the clients morning bronchodilator medication. b. The client is ready to go down to radiology for this examination. c. Physical therapy states the client can run on a treadmill. d. I advised the client not to smoke for 6 hours prior to the t

ANS: A, D, E

5. A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Find an activity that you enjoy and will keep your hands busy. b. Keep snacks like potato chips on hand to nibble on. c. Identify a punishment for yourself in case you backslide. d. Drink at least eight glasses of water each day. e. Make a list of reasons you want to stop smoking.

ANS: A, D, E

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

ANS: B

13. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the clients peripheral pulses. d. Obtain blood and sputum cultures.

ANS: B

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

ANS: B

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

ANS: B

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

ANS: B

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

ANS: B

17.A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a. Arrange for immediate hospitalization. b. Facilitate polymerase chain reaction testing. c. Have the client produce a sputum sample. d. Obtain two sets of blood cultures.

ANS: B

19.A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a. Ask the client what foods cause trouble swallowing. b. Assess the client for pain when swallowing. c. Determine if the client can swallow saliva. d. Palpate the clients jaw while swallowing.

ANS: B

3.Which teaching point is most important for the client with bacterial pharyngitis? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.

ANS: B

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

ANS: B

4. A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first? a. Encourage the client to increase fluid intake. b. Assess the clients level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.

ANS: B

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

ANS: B

5.The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the clients on Contact Precautions. b. Cohort the clients in the same area of the unit. c. Do not allow pregnant caregivers to care for these clients. d. Place the clients on enhanced Droplet Precautions.

ANS: B

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

ANS: B

6. A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding? a. Are you taking any medications or herbal supplements? b. Do you have any chronic breathing problems? c. How often do you perform aerobic exercise? d. What is your occupation and what are your hobbies?

ANS: B

7. A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action? a. Increased temperature b. Absent breath sounds c. Productive cough d. Incisional discomfort

ANS: B

7.An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. Chest x-rays are always ordered when we suspect pneumonia. b. Older people often have vague symptoms, so an x-ray is essential. c. The x-ray can be done and read

ANS: B

A home health care nurse is doing a home assessment for a family whose child is oxygen dependent. What finding by the nurse requires intervention? a. Tanks are stored only in an upright position. b. Oxygen tank is placed 3 feet away from the heater. c. Smoking is not allowed in the house. d. Fire extinguisher expires at the end of the month.

ANS: B

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. Bronchodilator - Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators b. Cholinergic antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system c. Corticosteroid - Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors d. Cromone - Dis

ANS: B

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

ANS: B

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes Reports feeling frightened "Can't catch my breath" Laboratory Analysis pH: 7.32 PaCO2: 28 mm Hg PaO2: 78 mm Hg Physical Assessment SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathi

ANS: B

A parent of a child with asthma asks if his child can still participate in sports. What response by the nurse is best? a. "Children with asthma are usually restricted from physical activities." b. "Children can usually play any type of sport if their asthma is well controlled." c. "Avoid swimming because exhaling underwater is dangerous for people with asthma." d. "Even with good asthma control, I would advise limiting the child to one athletic activity per school year."

ANS: B

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

ANS: B

A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. What home care measure does the nurse educate parents about? a. Taking the full course of antibiotics b. Providing humidity and increased fluids c. Treating any fever with aspirin d. Isolation from family until symptoms resolve

ANS: B

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

ANS: B

The nurse encourages the mother of a toddler with acute LTB to stay at the bedside as much as possible. Which of the following best explains the nurse's rationale? a. Mothers of hospitalized toddlers often experience guilt. b. The mother's presence will reduce anxiety and ease the child's respiratory efforts. c. Separation from the mother is a major developmental threat at this age. d. The mother can provide constant observations of the child's respiratory efforts.

ANS: B

The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Nursing actions should include which of the following? a. Forcing fluids b. Monitoring pulse oximetry c. Instituting seizure precautions d. Encouraging a high-protein diet

ANS: B

The nurse is caring for an infant with bronchopulmonary dysplasia (BPD) who has RSV. Which treatment measure does the nurse prepare to provide? a. Pancreatic enzymes b. Cool humidified oxygen c. Erythromycin intravenously d. Intermittent positive pressure ventilation

ANS: B

The parent of a toddler calls the nurse, asking about croup. What is a distinguishing manifestation of spasmodic croup? a. Wheezing is heard audibly. b. It has a harsh, barky cough. c. It is bacterial in nature. d. The child has a high fever.

ANS: B

What intervention can be taught to the parents of a 3-year-old child with pneumonia who is not hospitalized? a. Offer the child only cool liquids. b. Offer the child favorite warm liquid drinks. c. Use a warm mist humidifier. d. Report a respiratory rate less than 28 breaths/min.

ANS: B

Which statement indicates that a parent of a toddler needs more education about preventing foreign body aspiration? a. "I keep objects with small parts out of reach." b. "My toddler loves to play with balloons." c. "I won't permit my child to have peanuts." d. "I never leave coins where my child could get them."

ANS: B

Which statement made by a parent indicates an understanding about the genetic transmission of cystic fibrosis (CF)? a. "Only one parent carries the cystic fibrosis gene." b. "Both parents are carriers of the cystic fibrosis gene." c. "The presence of the disease is most likely the result of a genetic mutation." d. "The mother is usually the carrier of the cystic fibrosis gene."

ANS: B

Which type of croup is always considered a medical emergency? a. Laryngitis b. Epiglottitis c. Spasmodic croup d. Laryngotracheobronchitis (LTB)

ANS: B

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique.

ANS: B

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

ANS: B, C

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage of 75 mL/hr

ANS: B, C

A child has allergies to animal dander but is distraught at having to give away the family dog. What actions could the nurse suggest that might avoid this? (Select all that apply.) a. Choose a dander-free pet like a lizard. b. Keep the dog outside as much as possible. c. Install air cleaners in the house. d. Use dust-proof pillow covers. e. Keep the windows closed in the summer.

ANS: B, C, D

Which vitamin supplements are necessary for children with cystic fibrosis? a.Vitamin C b.Vitamin D c.Vitamin A d.Vitamin E e.Vitamin K

ANS: B, C, D, E

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

ANS: B, C, E

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

ANS: B, D, E

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

ANS: B, D, E, F

1. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d.

ANS: C

1.A nurse working in a geriatric clinic sees clients with cold symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor- Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

ANS: C

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

ANS: C

10. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? a. Call the physician and request a prescription for food and water. b. Provide the client with ice chips instead of a drink of water. c. Assess the clients gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

ANS: C

10.A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

ANS: C

12. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this clients teaching? a. Make a list of reasons why smoking is a bad habit. b. Rise slowly when getting out of bed in the morning. c. Smoking while taking this medication will increase your risk of a stroke. d. Stopping this medication suddenly increases your risk for a heart attack.

ANS: C

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

ANS: C

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

ANS: C

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

ANS: C

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

ANS: C

2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client states he is dizzy. Nurse applies oxygen and pulse oximetry. b. Clients heart rate is 55 beats/min. Nurse withholds pain medication. c. Client has reduced breath sounds. Nurse calls physician immediately. d. Clients respiratory rate is 18 breaths/min. Nurse decreases oxygen flow rate.

ANS: C

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

ANS: C

20.A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a few days ago and shows the nurse the results of what the client calls an allergy test, as shown below: What action by the nurse takes priority? a. Assess the client for possible items to which he or she is allergic. b. Call the primary care providers office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration

ANS: C

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

ANS: C

5. A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention? a. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate. b. Crackles are heard in bases. The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. The nurse has the client breathe d

ANS: C

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

ANS: C

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

ANS: C

A child has had cold symptoms for more than 2 weeks, a headache, nasal congestion with purulent nasal drainage, facial tenderness, and a cough that increases during sleep. The nurse plans to teach the parents about which treatment regime? a. Antihistamine use b. Cold washcloths on the face for comfort c. Antibiotic treatment with amoxicillin d. Referral for a sinuplasty

ANS: C

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

ANS: C

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

ANS: C

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

ANS: C

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

ANS: C

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. "There are a variety of support groups for people who have COPD." b. "I will ask your provider to prescribe you with an antianxiety agent." c. "Share any thoughts and feelings that cause you to limit social activities." d. "Friends can be a good support system for clients with chronic disorders."

ANS: C

A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How should the nurse respond? a. "Since many of your family members are carriers, your children will also be carriers of the gene." b. "Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder." c. "Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." d

ANS: C

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

ANS: C

A small child with cystic fibrosis cannot swallow pancreatic enzyme capsules. The nurse should teach parents to mix enzymes with which food? a. Macaroni and cheese b. Tapioca c. Applesauce d. Hot chocolate

ANS: C

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

ANS: C

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

ANS: C

For which problem should the child with chronic otitis media with effusion be evaluated? a. Brain abscess b. Meningitis c. Hearing loss d. Perforation of the tympanic membrane

ANS: C

Once an allergen is identified in a child with allergic rhinitis, the treatment of choice the nurse educates the parents about is which of the following? a. Using appropriate medications b. Beginning desensitization injections c. Eliminating the allergen d. Removing the adenoids

ANS: C

Teaching safety precautions with the administration of antihistamines is important because of what common side effect? a. Dry mouth b. Excitability c. Drowsiness d. Dry mucous membranes

ANS: C

The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. "Press down firmly on the canister to release one dose of medication." 2. "Breathe in slowly and deeply." 3. "Shake the whole unit vigorously three or four times." 4. "Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer." 5. "Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece." 6. "Remove the m

ANS: C

The nurse is caring for a client with lung cancer who states, "I don't want any pain medication because I am afraid I'll become addicted." How should the nurse respond? a. "I will ask the provider to change your medication to a drug that is less potent." b. "Would you like me to use music therapy to distract you from your pain?" c. "It is unlikely you will become addicted when taking medicine for pain." d. "Would you like me to give you acetaminophen (Tylenol) instead?"

ANS: C

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? a. "I plan to wear my oxygen when I exercise and feel short of breath." b. "I will use my portable oxygen when grilling burgers in the backyard." c. "I plan to use cotton balls to cushion the oxygen tubing on my ears." d. "I will only smoke while I am wearing my oxygen via nasal cannula."

ANS: C

What is a common trigger for asthma attacks in children? a. Febrile episodes b. Dehydration c. Exercise d. Seizures

ANS: C

What should the nurse teach a child about using an albuterol metered-dose inhaler for exercise-induced asthma? a. Take two puffs every 6 hours around the clock. b. Use the inhaler only when the child is short of breath. c. Use the inhaler 30 minutes before exercise. d. Take one to two puffs every morning upon awakening

ANS: C

Which child requires a Mantoux test? a. The child who has episodes of nighttime wheezing and coughing b. The child who has a history of allergic rhinitis c. The child whose babysitter has received a tuberculosis diagnosis d. The premature infant who is being treated for apnea of infancy

ANS: C

Which finding confirms a diagnosis of cystic fibrosis? a. Chest radiograph shows alveolar hyperinflation. b. Stool analysis indicates significant amounts of fecal fat. c. Sweat chloride is greater than 60 mEq/L. d. Liver function levels are abnormal.

ANS: C

Which intervention for treating croup at home should be taught to parents as possibly helpful? a. Have a decongestant available. b. Have the child sleep in a dry room. c. Take the child outside. d. Give the child an antibiotic at bedtime.

ANS: C

Which statement made by a parent indicates an understanding about treatment of streptococcal pharyngitis? a. "I guess my child will need to have his tonsils removed." b. "A couple of days of rest and some ibuprofen will take care of this." c. "I should give the penicillin three times a day for 10 days." d. "I am giving my child prednisone to decrease the swelling of the tonsils."

ANS: C

Which statement made by parents of a child with cystic fibrosis indicates that they understood the nurse's teaching on pancreatic enzyme replacement? a. "Enzymes will improve my child's breathing." b. "I should give the enzymes 1 hour after meals." c. "Enzymes should be given with meals and snacks." d. "The enzymes are stopped if my child begins wheezing."

ANS: C

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

ANS: C, D, E

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

ANS: C, E

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

ANS: D

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

ANS: D

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

ANS: D

18.A client has the diagnosis of valley fever accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on? a. Intravenous amphotericin B b. Long-term antiinflammatories c. No specific treatment d. Oral fluconazole (Diflucan)

ANS: D

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

ANS: D

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

ANS: D

3. A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain? a. Average daily fluid intake b. Neck circumference c. Height and weight d. Occupation and hobbies

ANS: D

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

ANS: D

8. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.

ANS: D

9. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 liters of oxygen. d. The trachea is deviated toward the opposite side of the neck.

ANS: D

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

ANS: D

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who has a longer expiratory phase than inspiratory phase d. A 27-year-old client with a heart rate of 120 beats/min

ANS: D

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

ANS: D

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. When the insertion site becomes red and warm to the touch b. When the tube drainage decreases and becomes sanguineous c. When the client experiences pain at the insertion site d. When the tube becomes disconnected from the drainage system

ANS: D

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

ANS: D

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3- = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client wit

ANS: D

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, "The medication is too expensive to use every day. I only use my inhaler when I have an attack." How should the nurse respond? a. "You are using the inhaler incorrectly. This medication should be taken daily." b. "If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks." c. "Tell me more about your fears related to feelings of breathlessness." d.

ANS: D

What information should the nurse teach workers at a daycare center about RSV? a. RSV is transmitted through particles in the air. b. RSV can live on skin or paper for up to a few seconds after contact. c. RSV can survive on nonporous surfaces for about 60 minutes. d. Frequent handwashing can decrease the spread of the virus.

ANS: D

What is an appropriate beverage for the nurse to give to a child who had a tonsillectomy earlier in the day? a. Chocolate ice cream b. Orange juice c. Fruit punch d. Apple juice

ANS: D

Which intervention is appropriate for the infant hospitalized with bronchiolitis? a. Position on the side with neck slightly flexed. b. Administer antibiotics as ordered. c. Restrict oral and parenteral fluids if tachypneic. d. Give cool, humidified oxygen.

ANS: D

Which statement is characteristic of acute otitis media (AOM)? a. The etiology is unknown. b. Permanent hearing loss often results. c. It can be treated by intramuscular (IM) antibiotics. d. It is treated with a broad range of antibiotics.

ANS: D

Why do infants and young children quickly have respiratory distress in acute and chronic alterations of the respiratory system? a. They have a widened, shorter airway. b. There is a defect in their sucking ability. c. The gag reflex increases mucous production. d. Mucus and edema obstruct small airways.

ANS: D

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

B

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure that informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

B

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the client's oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

B

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client's decrease in self-esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

B

A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%

B

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days

B

How will the nurse categorize a client's level of dyspnea who reports no shortness of breath (SOB) at rest, fair to moderate SOB with activity, some SOB while dressing, and has to stop to catch his breath when going up a flight of stairs? A. Class II B. Class III C. Class IV D. Class V

B

The nurse assessing a client's respiratory status finds fremitus has increased from the assessment performed yesterday. For which possible respiratory problem will the nurse assess further? A. Pneumothorax B. Pneumonia C. Pleural effusion D. Emphysema

B

What is the priority or most relevant medical-surgical concept for the nurse when performing an assessment of a client's respiratory system? A. Perfusion B. Gas exchange C. Acid-base balance D. Cellular regulation

B

Which precaution to prevent harm is most important for the nurse to teach a client who is newly prescribed to take varenicline? A. Avoid crowds and people who are ill because your immunity is reduced while on this drug. B. Immediately report any change in thought process or suicide ideation because this drug can alter behavior. C. Be sure to remain in an upright position for an hour after taking the drug to avoid esophageal reflux and ulceration. D. Do not smoke cigarettes or use nicotine in

B

Which are the nurse's priority actions when caring for a client who has labored, shallow respirations and a respiratory rate of 32 breaths/min with a pulse oximetry reading of 85%? Select all that apply. A. Notify the respiratory therapist to give the client a breathing treatment. B. Start oxygen using a nasal cannula at a rate of 2 L/min. C. Assess other indicators of adequate gas exchange. D. Obtain an order for a stat arterial blood gas (ABG). E. Assist with coughing and deep-breathing ex

B, C, F

Which findings noted during assessment of a client who reports a respiratory problem will the nurse document as abnormal? Select all that apply. A. Moveable trachea B. Use of pursed-lip breathing C. Intercostal space two finger-breadths wide D. Flat percussive sound in the upper center chest E. No breath sounds heard below the diaphragm F. Rough scratching sounds over the right lower lobe

B, C, F

Which client descriptions of sputum production alert the nurse to the possibility of a current respiratory problem? Select all that apply. A. Totals about 2 ounces daily B. Is streaked with mucous C. Is clear and thin D. Is frothy and pink E. Has a foul odor F. Is colorless

B, D, E

Which statements made by a client indicate to the nurse the need for additional eduction regarding smoking-related health risks? Select all that apply. A. "I have heard that cigarette smoking can cause both lung problems and heart problems." B. "I don't worry about lung problems because, unlike my wife, I don't smoke daily." C. "I worry about lung disease because I borrow cigarettes when I'm out with friends." D. "I use a hookah when I smoke, but I'm trying to quit because I know it's not goo

B, E, F

A nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

C

How will the nurse document the respiratory assessment findings on auscultation that are heard as squeaky, musical continuous sounds when the client inhales and exhales? A. Fine crackles B. Coarse crackles C. Wheezes D. Rhonchi

C

What is the nurse's best response to a client who says he is afraid to have pulmonary function testing (PFTs) because it may reveal that he has lung cancer? A. "This test can establish whether lung cancer is present at a very early state when the disease is more curable." B. "Because this test is noninvasive, it is less likely to cause you pain or increase your risk for infection." C. "These tests only determine whether your breathing is normal and cannot diagnose lung cancer." D. "There is

C

What type of assessment information does the nurse expect to gather when asking a client who has a respiratory problem whether the symptoms are worse at work or at home? A. Exposure to respiratory infections B. Presence of inherited predisposition C. Possible particulate matter exposure D. Possible continuation of a childhood respiratory problem

C

Which description of respiratory physiology 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

C

Which end-tidal carbon dioxide level in a client being monitored with capnography after anesthesia indicates to the nurse a possible early problem affecting gas exchange? A. 28 mm Hg B. 40 mm Hg C. 58 mm Hg D. 80 mm Hg

C

Which question will the nurse ask first when a client reports a persistent, nagging cough? A. "Have you been running a fever?" B. "Do you have pain when coughing?" C. "How long has your cough been present?" D. "Do you have a family history of lung cancer?"

C

With which client will the nurse expect to find a "barrel chest" on respiratory assessment? A. 22-year-old with mild, intermittent asthma B. 28-year-old with cystic fibrosis C. 55-year-old with chronic emphysema D. 60-year-old with bilateral pneumonia

C

Which factor does the nurse teach clients as the most common cause of chronic respiratory problems and physical limitations? A. Annual chest x-ray exposure to ionizing radiation B. Age-related decreased strength of respiratory muscles C. Failure to receive influenza and pneumonia vaccinations D. Smoking cigarettes or chronic exposure to cigarette smoke

D

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the clie

D

How will the nurse document the pack-year smoking history for a client who reports smoking a pack of cigarettes a day for 10 years, quitting for 4 years, and then smoking 2 packs a day for the last 25 years? A. 30 years B. 35 years C. 45 years D. 60 years

D

What is the priority action to prevent harm for a nurse to take before allowing a client who had a flexible bronchoscopy 2 hours ago to drink or eat? A. Assessing pulse oximetry to be sure oxygen saturation has returned to normal B. Measuring the client's end-tidal carbon dioxide level C. Asking whether the client has any nausea D. Checking for return of the gag reflex

D

Which client assessment finding does the nurse recognize as an immediate gas exchange and perfusion problem? A. Pursed-lip breathing B. Clubbed fingers C. Barrel chest D. Cyanosis

D

Which client will the nurse assess most often for the possibility of a post procedure pneumothorax? A. Pulmonary function testing B. Flexible bronchoscopy C. Laryngoscopy D. Thoracentesis

D

Nasal Cannula

Flow rates of 1-6 L/min O2 concentration of 24%-44%

Simple Facemask

deliver oxygen concentrations of 40% to 60% for short-term oxygen therapy or in an emergency A minimum flow rate of 5 L/min is needed to prevent rebreathing of exhaled air

Venturi Mask

deliver the most accurate oxygen concentration without intubation

Partial rebreather masks

provide oxygen concentrations of 60% to 75% with flow rates of 6 to 11 L/min. These masks have a reservoir bag but no flaps

Nonrebreather mask

provide the highest oxygen level of the low-flow systems and can deliver an FiO2 greater than 90%, depending on the patient's breathing pattern has flaps over exhalation ports (one-way)

High-flow nasal cannulas (HFNCs)

widely used for better temperature and oxygen control along with humidification. a precise FiO2 an be maintained at liter flows of 30-60 L/min