Resp2 nclex

A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?

Take ordered medications as scheduled. Correct Explanation: Although avoiding contact with fur-bearing animals, changing filters on heating and air conditioning units frequently, and avoiding goose down pillows are all appropriate measures for clients with asthma, taking ordered medications on time is the most important measure in preventing asthma attacks.

A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it:

may induce bronchospasm. Acetylcysteine must be used cautiously in a client with asthma because it may induce bronchospasm. The drug isn't a respiratory depressant or stimulant. It's a mucolytic agent that decreases the viscosity of respiratory secretions by altering the molecular composition of mucus. Acetylcysteine doesn't inhibit the cough reflex.

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

"Family members should continue to talk to the client." Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

6 to 12 months Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis. (less)

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy about 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. The nurse's first course of action is to:

Assess the pain systematically with the hospital-approved pain scale. Systematic pain assessment is necessary for adequate pain management in the postoperative client. Even though the client is receiving morphine sulfate by PCA, assessment is needed if he is experiencing pain. Encouraging the client to rest or to ignore pain without further assessment is not a sufficient intervention. (less)

Outcome criteria for evaluating the effectiveness of airway suctioning should include which of the following?

Breath sounds clear on auscultation. Correct Explanation: Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning. Auscultation should also be done to determine whether or not the client needs suctioning. Assessing for labored respirations is not as accurate in evaluating the effectiveness of tracheobronchial suctioning. A client may have labored breathing that is not affected by the presence or absence of tracheobronchial secretions. Percussion of the chest is useful for detecting masses or dense consolidation of lung tissue. It is not an accurate method for assessing the effectiveness of suctioning. Suctioning clears mucus but does not decrease its production.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate?

Position in high Fowler's position and administer an albuterol sulfate inhaler. Following an asthma attack, it is important to ensure optimal positioning (Fowler's) and adequate oxygen levels. The client is still experiencing wheezing, so coughing to remove secretions is important. A bronchodilator would also help by enlarging the size of the bronchioles. Asking the client to calm down is incorrect because it does not explore concerns. Semi-prone positioning would not assist with breathing. (

An adult with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused client assessment for:

dyspnea Dyspnea is a distressing symptom in clients with advanced cancer including metastatic carcinoma of the lung, previous radiation therapy, and coexisting COPD. Ascites does occur in clients with metastatic carcinoma; however, in the client with COPD and lung cancer, dyspnea is a more common finding. A pleural friction rub is usually associated with pneumonia, pleurisy, or pulmonary infarct.