NURS Chapter 19

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? A) A resident who suffered a severe stroke several weeks ago B) A resident with mid-stage Alzheimers disease C) A 92-year-old resident who needs extensive help with ADLs D) A resident with severe and deforming rheumatoid arthritis

A) A resident who suffered a severe stroke several weeks ago

The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? A) Administer intradermal injections into the childrens inner forearms. B) Administer intramuscular injections into each childs vastus lateralis. C) Administer a subcutaneous injection into each childs umbilical area. D) Administer a subcutaneous injection at a 45-degree angle into each childs deltoid.

A) Administer intradermal injections into the childrens inner forearms.

While planning a patients care, the nurse identifies nursing actions to minimize the patients pleuritic pain. Which intervention should the nurse include in the plan of care? A) Avoid actions that will cause the patient to breathe deeply. B) Ambulate the patient at least three times daily. C) Arrange for a soft-textured diet and increased fluid intake. D) Encourage the patient to speak as little as possible

A) Avoid actions that will cause the patient to breathe deeply.

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds

A) Diminished or absent breath sounds on the affected side

The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)? A) Early ambulation B) Increased dietary intake of protein C) Maintaining the patient in a supine position D) Administering aspirin with warfarin

A) Early ambulation

The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? A) Incentive spirometry B) Intermittent positive-pressure breathing (IPPB) C) Positive end-expiratory pressure (PEEP) D) Bronchoscopy

A) Incentive spirometry

A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? A) Increase oral fluids unless contraindicated. B) Call the nurse for oral suctioning, as needed. C) Lie in a low Fowlers or supine position. D) Increase activity.

A) Increase oral fluids unless contraindicated.

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration

A) Pneumothorax If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia.

A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate? A) Preparing to assist with intubating the patient B) Setting up oxygen at 5 L/minute by nasal cannula C) Performing deep suctioning D) Setting up a nebulizer to administer corticosteroids

A) Preparing to assist with intubating the patient

An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize? A) The importance of adhering closely to the prescribed medication regimen B) The fact that the disease is a lifelong, chronic condition that will affect ADLs C) The fact that TB is self-limiting, but can take up to 2 years to resolve D) The need to work closely with the occupational and physical therapists

A) The importance of adhering closely to the prescribed medication regimen

16. The nurse is assessing a client who has a 35 pack-year history of cigarette smoking.In light of this known risk factor for lung cancer, which statement by the client should prompt the nurse to refer the client for further assessment? A. "Lately, I have this cough that just never seems to go away." B. "I find that I don't have nearly the stamina that I used to." C. "I seem to get nearly every cold and flu that goes around my workplace." D. "I never used to have any allergies, but now I think I'm developing allergies to dust and pet hair."

A. "Lately, I have this cough that just never seems to go away."

15. The school nurse is presenting a class on smoking cessation at the local high school.A participant in the class asks the nurse about the risk of lung cancer in those who smoke.What response related to risk for lung cancer in smokers is most accurate? A. "The younger you are when you start smoking, the higher your risk of lung cancer." B. "The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays." C. "The risk for lung cancer is determined mostly by what type of cigarettes you smoke." D. "The risk for lung cancer depends primarily on the other risk factors for cancer that you have."

A. "The younger you are when you start smoking, the higher your risk of lung cancer."

40. The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A. 20 cm H2O B. 15 cm H2O C. 10 cm H2O D. 5 cm H2O

A. 20 cm H2O

8. An x-ray of a trauma client reveals rib fractures, and the client is diagnosed with as mall flail chest injury. Which intervention should the nurse include in the client's plan of care? A. Initiate chest physiotherapy. B. Immobilize the ribs with an abdominal binder. C. Prepare the client for surgery. D. Immediately sedate and intubate the client.

A. Initiate chest physiotherapy.

38. A critical care nurse is caring for a client with an endotracheal tube who is on aventilator. The nurse knows that meticulous airway management of this client isnecessary. What is the main rationale for this? A. Maintaining a patent airway B. Preventing the need for suctioning C. Maintaining the sterility of the client's airway D. Increasing the client's lung compliance

A. Maintaining a patent airway

39. The critical care nurse and the other members of the care team are assessing the client to see if the client is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A. Stable vital signs and arterial blood gases (ABGs) B. Pulse oximetry above 80% and stable vital signs C. Stable nutritional status and ABGs D. Normal level of consciousness

A. Stable vital signs and arterial blood gases (ABGs)

24. The occupational health nurse is assessing an employee who has just had respiratoryexposure to a toxin. What should the nurse assess? Select all that apply. A. Time frame of exposure B. Type of respiratory protection used C. Immunization status D. Breath sounds E. Intensity of exposure

A. Time frame of exposure B. Type of respiratory protection used D. Breath sounds E. Intensity of exposure

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A) Administration of prophylactic antibiotics B) Administration of pneumococcal vaccine to vulnerable individuals C) Obtaining culture and sensitivity swabs from all newly admitted patients D) Administration of antiretroviral medications to patients over age 65

B) Administration of pneumococcal vaccine to vulnerable individuals

A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what complication? A) Acute respiratory distress syndrome (ARDS) B) Atelectasis C) Aspiration D) Pulmonary embolism

B) Atelectasis A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis.

The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patients symptoms from those of a cardiac etiology? A) Carboxyhemoglobin level B) Brain natriuretic peptide (BNP) level C) C-reactive protein (CRP) level D) Complete blood count

B) Brain natriuretic peptide (BNP) level

A new employee asks the occupational health nurse about measures to prevent inhalation exposure to toxic substances. What should the nurse recommend? A. "Position a fan blowing toxic substances away from you to prevent you from being exposed." B. "Wear protective attire and devices when working with a toxic substance." C. "Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins." D. "Always wear a disposable paper face mask when you are working with inhalable toxins."

B. "Wear protective attire and devices when working with a toxic substance."

A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A. A chest tube B. A tracheostomy C. An endotracheal tube D. A feeding tube

B. A tracheostomy

34. The nurse is preparing to wean a client from the ventilator. Which assessmentparameter is most important for the nurse to assess? A. Fluid intake for the last 24 hours B. Arterial blood gas (ABG) levels C. Prior outcomes of weaning D. Electrocardiogram (ECG) results

B. Arterial blood gas (ABG) levels

11. The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology? A. Carboxyhemoglobin level B. Brain natriuretic peptide (BNP) level C. C-reactive protein (CRP) level D. Complete blood count

B. Brain natriuretic peptide (BNP) level

27. A client is brought to the emergency department by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, intubated, and transferred to the intensive care unit (ICU). Which assessment parameters should the nurse monitor most closely? Select all that apply. A. Coping B. Level of consciousness C. Oral intake D. Arterial blood gases E. Vital signs

B. Level of consciousness D. Arterial blood gases E. Vital signs

22. A client is receiving thrombolytic therapy for the treatment of pulmonary emboli.What is the best way for the nurse to assess the client's oxygenation status at the bedside? A. Obtain serial ABG samples. B. Monitor pulse oximetry readings. C. Perform chest auscultation. D. Monitor incentive spirometry volumes.

B. Monitor pulse oximetry readings.

26. A client who was involved in a workplace accident sustained a penetrating wound of the chest that led to acute respiratory failure. Which goal of treatment should the care team prioritize when planning this client's care? A. Facilitation of long-term intubation B. Restoration of adequate gas exchange C. Attainment of effective coping D. Self-management of oxygen therapy

B. Restoration of adequate gas exchange

36. While caring for a client with an endotracheal tube, the nurse should normally providesuctioning how often? A. Every 2 hours when the client is awake B. When adventitious breath sounds are auscultated C. When there is a need to prevent the client from coughing D. When the nurse needs to stimulate the cough reflex

B. When adventitious breath sounds are auscultated

A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he just cant breathe enough. The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem? A) Pneumoconiosis B) Pleural effusion C) Acute respiratory failure D) Pneumonia

C) Acute respiratory failure Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure.

The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client? A) Coumadin will continue to break up the clot over a period of weeks B) Coumadin must be taken concurrent with ASA to achieve anticoagulation. C) Anticoagulant therapy usually lasts between 3 and 6 months. D) He should take a vitamin supplement containing vitamin K

C) Anticoagulant therapy usually lasts between 3 and 6 months.

The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic? A) Assess the patients level of consciousness (LOC). B) Assess the patients extremities for signs of cyanosis. C) Assess the patients oxygen saturation level. D) Review the patients hemoglobin, hematocrit, and red blood cell levels.

C) Assess the patients oxygen saturation level.

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? A) Older adults have less compliant lung tissue than younger adults. B) Older adults are not normally candidates for pneumococcal vaccination. C) Older adults often lack the classic signs and symptoms of pneumonia. D) Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.

C) Older adults often lack the classic signs and symptoms of pneumonia.

The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing? A) Traumatic pneumothorax B) Empyema C) Pleuritic pain D) Myocardial infarction

C) Pleuritic pain

The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patients history is most likely to have caused the empyema? A) Smoking B) Asbestosis C) Pneumonia D) Lung cancer

C) Pneumonia

A client presents to the walk-in clinic complaining of a dry, irritating cough and production of a minute amount of mucus-like sputum. The patient complains of soreness in her chest in the sternal area. The nurse should suspect that the primary care provider will assess the patient for what health problem? A) Pleural effusion B) Pulmonary embolism C) Tracheobronchitis D) Tuberculosis

C) Tracheobronchitis

28. A client has just been diagnosed with lung cancer. After the health care providerdiscusses treatment options and leaves the room, the client asks the nurse how thetreatment is decided upon. What would be the nurse's best response? A. "The type of treatment depends on the client's age and health status." B. "The type of treatment depends on what the client wants when given theoptions." C. "The type of treatment depends on the cell type of the cancer, the stage of thecancer, and the client's health status." D. "The type of treatment depends on the discussion between the client and thehealth care provider of which treatment is best."

C. "The type of treatment depends on the cell type of the cancer, the stage of thecancer, and the client's health status."

20. A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem? A. Pneumoconiosis B. Pleural effusion C. Acute respiratory failure D. Pneumonia

C. Acute respiratory failure

19. When assessing for substances that are known to harm workers' lungs, the occupational health nurse should assess their potential exposure to which of the following? A. Organic acids B. Solvents C. Asbestos D. Gypsum

C. Asbestos

41. The nurse is preparing to discharge a client after thoracotomy. The client is goinghome on oxygen therapy and requires wound care. As a result, the client will receivehome care nursing. Which information should the nurse include in discharge teaching forthis client? A. Safe technique for self-suctioning of secretions B. Technique for performing postural drainage C. Correct and safe use of oxygen therapy equipment D. How to provide safe and effective tracheostomy care

C. Correct and safe use of oxygen therapy equipment

6. The nurse in the intensive care unit is caring for a client with pulmonary hypertension.Which finding should the nurse expect to assess? A. Pulmonary artery pressure greater than 20 mm Hg B. Flat neck veins C. Dyspnea at rest D. Enlarged spleen

C. Dyspnea at rest

21. The nurse is caring for an adult client recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating clients with non-small cell tumors is what method? A. Chemotherapy B. Radiation C. Surgical resection D. Bronchoscopic opening of the airway

C. Surgical resection

35. While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach? A. The system is functioning normally. B. The client has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed.

C. The system has an air leak.

An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patients plan of care? A) Nasogastric intubation B) Administration of probiotic supplements C) Bedrest D) Cautious hydration

D) Cautious hydration

A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor most closely on a patient who is postoperative following an embolectomy? A) Pupillary response B) Pressure in the vena cava C) White blood cell differential D) Pulmonary arterial pressure

D) Pulmonary arterial pressure

The home care nurse is monitoring a patient discharged home after resolution of a pulmonary embolus. For what potential complication would the home care nurse be most closely monitoring this patient? A) Signs and symptoms of pulmonary infection B) Swallowing ability and signs of aspiration C) Activity level and role performance D) Residual effects of compromised oxygenation

D) Residual effects of compromised oxygenation

32. The medical nurse is creating the care plan of a client with a tracheostomy requiring mechanical ventilation. Which nursing action is most appropriate? A. Keep the client in a low Fowler position B. Perform tracheostomy care at least once per day. C. Maintain continuous bed rest. D. Monitor cuff pressure every 8 hours.

D. Monitor cuff pressure every 8 hours.

37. The nurse is discussing activity management with a client who is postoperativefollowing thoracotomy. What instructions should the nurse give to the client regardingactivity immediately following discharge? A. Walk 1 mile (1.6 km) 3 to 4 times a week. B. Use weights daily to increase arm strength. C. Walk on a treadmill 30 minutes daily. D. Perform shoulder exercises five times daily.

D. Perform shoulder exercises five times daily.

33. A nurse is educating a client in anticipation of a procedure that will require awater-sealed chest drainage system. What should the nurse tell the client and the familythat this drainage system is used for? A. Maintaining positive chest-wall pressure B. Monitoring pleural fluid osmolarity C. Providing positive intrathoracic pressure D. Removing excess air and fluid

D. Removing excess air and fluid

25. A client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for the cancer. Which fact about lung cancer treatment should inform the nurse's response? A. The cells in small cell cancer of the lung are not large enough to visualize in surgery B. Small cell lung cancer is self-limiting in many clients, and surgery should bedelayed. C. Clients with small cell lung cancer are not normally stable enough to survivesurgery. D. Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

D. Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

4. The nurse caring for a client recently diagnosed with lung disease encourages the client not to smoke. What is the primary rationale behind this nursing action? A. Smoking decreases the amount of mucus production. B. Smoke particles compete for binding sites on hemoglobin. C. Smoking causes atrophy of the alveoli. D. Smoking damages the ciliary cleansing mechanism.

D. Smoking damages the ciliary cleansing mechanism

3. The nurse is caring for a client who has been in a motor vehicle accident and is suspected of having developed pleurisy. Which assessment finding would best corroborate this diagnosis? A. The client is experiencing painless hemoptysis. B. The client's arterial blood gases (ABGs) are normal, but the client demonstrates increased work of breathing. C. The client's oxygen saturation level is below 88%, but the client denies shortness of breath. D. The client's pain intensifies when the client coughs or takes a deep breath.

D. The client's pain intensifies when the client coughs or takes a deep breath.

31. The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as adisadvantage of endotracheal tubes? A. Cognition is decreased. B. Daily arterial blood gases (ABGs) are necessary. C. Slight tracheal bleeding is anticipated. D. The cough reflex is depressed.

D. The cough reflex is depressed.