Respiratory

The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Request STAT arterial blood gases. 4. Auscultate the client's lung sounds.

2. If the ventilator system malfunctions, the nurse must ventilate the client with a manual resuscitation (Ambu) bag until the problem is resolved. TEST-TAKING HINT: When the question asks the test taker to select the first intervention and the client is in a life-threatening situa- tion, the nurse should select an intervention that directly helps the client.

The nurse and a licensed practical nurse (LPN) are caring for five (5) clients on a medical unit. Which clients would the nurse assign to the LPN? Select all that apply. 1. The 32-year-old female diagnosed with exercise-induced asthma who has a forced vital capacity of 1,000 mL. 2. The 45-year-old male with adult-onset asthma who is complaining of difficulty completing all of the ADLs at one time. 3. The 92-year-old client diagnosed with respiratory difficulty who is beginning to be confused and keeps climbing out of bed. 4. The 6-year-old client diagnosed with intrinsic asthma who is scheduled for discharge and the mother needs teaching about the medications. 5. The 20-year-old client diagnosed with asthma who has a pulse oximetry reading of 95% and wants to sleep all the time.

1. A forced vital capacity of 1,000 mL is considered normal for most females; therefore, the LPN could care for this client. 2. The client should be encouraged to pace the activities of daily living; this is expected for a client diagnosed with asthma, so the LPN could care for this client. 5. A pulse oximetry level of 95% is normal, so this client could be assigned to an LPN. Wrong answers: 3. Confusion could be a sign of decreased oxygen to the brain and requires the RN's expertise. This client should not be assigned to the LPN. 4. The client's mother requires teaching, which is the nurse's responsibility and cannot be assigned to an LPN.

The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler's position.

1. Altered level of consciousness is the earliest sign of hypoxemia. 3. The client is at risk for complications of immobility; therefore, the nurse should turn the client at least every two (2) hours to prevent pressure ulcers. 4. The client is at risk for fluid volume overload, so the nurse should monitor and maintain the fluid intake. 5. Fowler's position facilitates lung expansion and reduces the workload of breathing. TEST-TAKING HINT: The client with ARDSis critically ill, and interventions should address complications of immobility, de- creased cardiac output, and respiratory dis- tress. Remember, how often an intervention is implemented is important when selecting the correct answer for the question. More than one (1) answer is possible in these alternate-type questions. 2. Urine output of less than 30 mL/hr indicates decreased cardiac output, which requires immediate intervention; it should be assessed every one (1) or two (2) hours, not once during a shift.

The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy? 1. Vitamin C, 2,000 mg daily. 2. Strict bedrest. 3. Humidification of the air. 4. Decongestant therapy.

1. Alternative therapies are therapies not accepted as standard medical practice. These may be encouraged as long as they do not interfere with the medical regimen. Vitamin C in large doses is thought to improve the immune system's functions. TEST-TAKING HINT: Only one of the answer options is not common advice for a client with a cold. When all options but one (1) match each other, then the odd option should be selected as the correct answer.

The client admitted for recurrent aspiration pneumonia is at risk for bronchiectasis. Which intervention should the nurse anticipate the healthcare provider to order? 1. Administer intravenous antibiotics for seven (7) days. 2. Insert a subclavian line and initiate total parenteral nutrition. 3. Provide a low-calorie and low-sodium restricted diet. 4. Encourage the client to turn, cough, and deep breathe frequently.

1. Antibiotics should be administered intravenously for seven (7) to 10 days. Bronchiectasis is an irreversible condition caused by repeated damage to the bronchial walls secondary to repeated aspiration of gastric contents and release of inflammatory mediators by the body to combat the foreign substances. Wrong answers: 2. Total parenteral nutrition is not an expected treatment for a client with bronchiectasis. 3. Clients should have a high-calorie and high-protein diet as a result of high expenditure of energy used to breathe and tissue healing. 4. Turning, coughing, and deep breathing are appropriate independent nursing interventions but do not require a healthcare provider's order.

The nurse is planning the care of a client diagnosed with asthma and has written a problem of "anxiety." Which nursing intervention should be implemented? 1. Remain with the client. 2. Notify the health-care provider. 3. Administer an anxiolytic medication. 4. Encourage the client to drink fluids.

1. Anxiety is an expected sequela of being unable to meet the oxygen needs of the body. Staying with the client lets the client know the nurse will intervene and the client is not alone. Wrong answers: 2. Because anxiety is an expected occurrence with asthma, it is not necessary to notify the health-care provider. 3. An anxiolytic medication could decrease respiratory drive and increase the respiratory distress. Also, the medication will require a delayed time period to begin to work. 4. Drinking fluids will not treat an asthma attack or anxiety.

Which action should the nurse implement for the client with a hemothorax who has a right- sided chest tube with excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

1. Checking to see if someone has increased the suction rate is the simplest and a noninvasive action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system. TEST-TAKING HINT: The test taker should always think about assessing the client if there is a problem and the client is not in immediate danger. This would cause the test taker to eliminate options "3" and "4." If the test taker thinks about bubbling, he or she should know it has to do with suctioning.

27. Which information should the nurse include in the teaching plan for the mother of a child diagnosed with cystic fibrosis (CF)? Select all that apply. 1. Perform postural drainage and percussion every four (4) hours. 2. Modify activities to accommodate daily physiotherapy. 3. Increase fluid intake to one (1) liter daily to thin secretions. 4. Recognize and report signs and symptoms of respiratory infections. 5. Avoid anyone suspected of having an upper respiratory infection.

1. Clients and family members should be taught chest physiotherapy, including postural drainage, chest percussion, and vibration and breathing techniques to keep the lungs clear of the copious secretions. 2. Daily activities should be modified to accommodate the client's treatments. 4. Clients should be taught the signs and symptoms of infections to report to the health-care provider. 5. Clients with CF are susceptible to respiratory infections and should avoid anyone who is suspected of having an infection. Wrong answers: 3. Clients should increase fluids up to 3,000 mL each day to thin secretions and ease expectoration.

Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD? 1. "I need to get an influenza vaccine each year, even when there is a shortage." 2. "I need to get a vaccine for pneumonia each year with my influenza shot." 3. "If I reduce my cigarettes to six (6) a day, I won't have difficulty breathing." 4. "I need to restrict my drinking liquids to keep from having so much phlegm."

1. Clients diagnosed with COPD should receive the influenza vaccine each year. If there is a shortage, these clients have top priority. TEST-TAKING HINT: Nurses are expected to serve as community resources. The nurse should be knowledgeable about health- promotion activities such as immunizations. One (1) option describes a desired goal, but the other three (3) do not.

The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bedrest.

4. Bedrest reduces the risk of another clot becoming an embolus leading to a pulmo- nary embolus. Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs. TEST-TAKING HINT: The test taker must be aware of adjectives such as "oral" in option "1," which makes this option incorrect. The test taker should apply the body system of the disease process to eliminate option "2" as a correct answer.

The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse's best response? 1. Close the door and discuss the UAP's action after coming out of the room. 2. Make the UAP come back outside the room and then reenter, closing the door. 3. Say nothing to the UAP but report the incident to the nursing supervisor. 4. Enter the client's room and discuss the matter with the UAP immediately.

1. Closing the door reestablishes the negative air pressure, which prevents the air from entering the hall and contaminating the hospital environment. When correct- ing an individual, it is always best to do so in a private manner. TEST-TAKING HINT: An action must be taken; the test taker must determine which action would have the desired results with the least amount of disruption to client care. Correct- ing the UAP in this manner has the greatest chance of creating a win-win situation.

Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.

1. Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant. 3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. 4. Invasive procedures increase the risk of tissue trauma and bleeding. 5. Stool softeners help prevent constipation and straining, which may precipitate bleeding from hemorrhoids. TEST-TAKING HINT: Thrombolytic therapy is ordered to help dissolve the clot resulting in the PE. Therefore, all nursing interventions should address bleeding tendencies. The test taker must select all interventions applicable in these alternative questions.

The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) L/day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.

1. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE. TEST-TAKING HINT: The test taker must know deep vein thrombosis is the most common cause of pulmonary embolus and preventing dehydration is an important in- tervention. The test taker can attempt to eliminate answers by trying to determine which disease process is appropriate for the intervention.

20. The nurse and an unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? Select all that apply. 1. Keep the head of the bed elevated. 2. Encourage deep breathing exercises. 3. Record pulse oximeter reading. 4. Assess level of conscious. 5. Auscultate breath sounds.

1. Keeping the head of the bed elevated maximizes lung excursion and improves gas exchange and can be delegated. 2. Encouraging breathing exercises can be delegated. 3. Recording pulse oximeter readings can be delegated. Evaluating is the responsibility of the nurse. Wrong answers: 4. Assessment cannot be delegated. Confusion is one of the first symptoms of hypoxia. 5. Auscultation is a technique of assessment and cannot be delegated.

Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital? 1. Avoid smoking and exposure to smoke. 2. Do not receive flu or pneumonia vaccines. 3. Avoid any type of alcohol intake. 4. It will take about one (1) month to recuperate.

1. Not smoking is vital to prevent further lung damage. TEST-TAKING HINT: ARDS means something is wrong with the respiratory system. Therefore, the test taker should select an answer option addressing lungs and possible lung damage. It usually takes about six (6) months to recover maximal respiratory function after ARDS.

The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? Select all that apply. 1. Nursing. 2. Pharmacy. 3. Social work. 4. Occupational therapy. 5. Speech therapy.

1. Nursing is the one discipline remaining with the client around the clock. There- fore, nurses have knowledge of the client that other disciplines might not know. 2. The pharmacist will be able to discuss the medication regimen the client is receiving and make suggestions regard- ing other medications or medication interactions. 3. The social worker may be able to assist with financial information or home care arrangements. Wrong answers: 4. Occupational therapists help clients with activities of daily living and modifications to home environments; nothing in the stem indicates a need for these services. 5. Speech therapists assist clients with speech and swallowing problems; nothing in the stem indicates a need for these services.

The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client? 1. Pleuritic chest discomfort and anxiety. 2. Asymmetrical chest expansion and pallor. 3. Leukopenia and CRT <three (3) seconds. 4. Substernal chest pain and diaphoresis

1. Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever, chills, dyspnea, and cough. Wrong answers: 2. Asymmetrical chest expansion occurs if the client has a collapsed lung from a pneumothorax or hemothorax, and the client would be cyanotic from decreased oxygenation. 3. The client would have leukocytosis, not leukopenia, and a capillary refill time (CRT) of less than 3 seconds is normal. 4. Substernal chest pain and diaphoresis are symptoms of myocardial infarction.

Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD? 1. The client demonstrates the correct way to pursed-lip breathe. 2. The client lists three (3) signs/symptoms to report to the HCP. 3. The client will drink at least 2,500 mL of water daily. 4. The client will be able to ambulate 100 feet with dyspnea.

1. Pursed-lip breathing helps keep the alveoli open to allow for better oxygen and carbon dioxide exchange. TEST-TAKING HINT: The test taker needs to identify the outcome for the client problem cited—namely, "ineffective gas exchange." The only answer option addressing the air- way is option "1," pursed-lip breathing.

23. The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement? 1. Assess respiratory rate and depth. 2. Provide for adequate rest period. 3. Administer oxygen as prescribed. 4. Teach slow abdominal breathing.

1. The assessment of respiratory rate and depth is the priority intervention because tachypnea and dyspnea may be early indicators of respiratory compromise. Wrong answers: 2. Rest reduces metabolic demands, fatigue, and the work of breathing, which promotes a more effective breathing pattern, but it is not priority over assessment. 3. Oxygen therapy increases the alveolar oxygen concentration, reducing hypoxia and anxiety, but it is not priority over assessment. 4. This breathing pattern promotes lung expansion, but it is not priority over assessment.

The charge nurse is making rounds. Which client should the nurse assess first? 1. The 29-year-old client diagnosed with reactive airway disease who is complaining the nurse caring for him was rude. 2. The 76-year-old client diagnosed with heart failure who has 2+ edema of the lower extremities. 3. The 15-year-old client diagnosed with diabetic ketoacidosis after a bout with the flu who has a blood glucose reading of 189 mg/dL. 4. The 62-year-old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at two (2) liters per minute.

1. The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have expected and non- life-threatening situations. Wrong answers: 2. Two (2)+ edema of the lower extremities is expected in a client diagnosed with heart failure. 3. A blood glucose reading of 189 mg/dL is not within normal range, but it is not in a range indicating the client is catabolizing the fats and proteins in the body. No ketones will be produced at this blood glucose level, so the ketoacidosis has resolved itself. 4. Most clients diagnosed with COPD are receiving oxygen at a low level.

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.

1. The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane. TEST-TAKING HINT: If the test taker does not know the signs/symptoms of ARDS, the test taker should eliminate option "2" because this could be any respiratory disorder, op- tion "3" because these are normal data, and option "4" because jugular vein distention usually occurs with heart problems.

Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply. 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.

1. The client diagnosed with COPD has difficulty exchanging oxygen with carbon dioxide, which is manifested by physical signs such as fingernail clubbing and respiratory acidosis as seen on arterial blood gases. 2. The client should avoid extremes in temperatures. Warm temperatures cause an increase in the metabolism and increase the need for oxygen. Cold temperatures cause bronchospasms. 3. The client has increased respiratory effort during activities and can be fatigued. Activities should be timed so rest periods are scheduled to prevent fatigue. 4. The client may have difficulty adapting to the role changes brought about because of the disease process. Many cannot main- tain the activities involved in meeting responsibilities at home and at work. Clients should be assessed for these issues. 5. Clients often lose weight because of the effort expended to breathe. TEST-TAKING HINT: This is an example of an alternate-type question. There may be more than one (1) correct answer. The test taker should consider all options independently and understand that the question is not a trick.

The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. 1. Place the client on oxygen delivered by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1,000 mL/day. 4. Restrict the client's smoking to two (2) to three (3) cigarettes per day. 5. Monitor the client's pulse oximetry readings every four (4) hours.

1. The client diagnosed with pneumonia will have some degree of gas exchange deficit. Administering oxygen would help the client. 2. Activities of daily living require energy and therefore oxygen consumption. Spac- ing the activities allows the client to rebuild oxygen reserves between activities. 5. Pulse oximetry readings provide the nurse with an estimate of oxygenation in the periphery. Wrong answers: 3. Clients are encouraged to drink at least 2,000 mL daily to thin secretions. 4. Cigarette smoking depresses the action of the cilia in the lungs. Any smoking should be prohibited.

The nurse is discharging a client newly diagnosed with restrictive airway disease (asthma). Which statement indicates the client understands the discharge instructions? 1. "I will call 911 if my medications don't control an attack." 2. "I should wash my bedding in warm water." 3. "I can still eat at the Chinese restaurant when I want." 4. "If I get a headache, I should take a nonsteroidal anti-inflammatory drug."

1. The client must be able to recognize a life-threatening situation and initiate the correct procedure. Wrong answers: 2. Bedding is washed in hot water to kill dust mites. 3. Many Chinese dishes are prepared with monosodium glutamate, an ingredient that can initiate an asthma attack. 4. Nonsteroidal anti-inflammatory medications, aspirin, and beta blockers have been known to initiate asthma attacks.

Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die.

1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis. TEST-TAKING HINT: If the test taker reads options "2" and "3" and notices that both reflect the same idea—namely, that deep breaths are not necessary—then both can either be eliminated as incorrect answers or kept as possible correct answers. Option "4" should be eliminated based on being a very rude and threatening comment.

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client into a sitting position at 90 degrees. 2. Administer oxygen at six (6) LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health-care provider about the client's status.

1. The client should be assisted into a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed lean- ing over the bed table. The nurse needs to maintain the client's safety. TEST-TAKING HINT: When a question asks for the test taker to choose the intervention to implement first, the test taker should select an intervention directly caring for the client. Remember: in distress do not assess.

Which information should the nurse teach the client diagnosed with acute sinusitis? 1. Instruct the client to complete all the ordered antibiotics. 2. Teach the client how to irrigate the nasal passages. 3. Have the client demonstrate how to blow the nose. 4. Give the client samples of a narcotic analgesic for the headache

1. The client should be taught to take all antibiotics as ordered. Discontinuing antibiotics prior to the full dose results in the development of antibiotic-resistant bacteria. Sinus infections are difficult to treat and may become chronic and will then require several weeks of therapy or possibly surgery to control. Wrong answers: 2. If the sinuses are irrigated, it is done under anesthesia by a health-care provider. 3. Blowing the nose will increase pressure in the sinus cavities and will cause the client increased pain. 4. The nurse is not licensed to prescribe medi- cations, so this is not in the nurse's scope of practice. Also, narcotic analgesic medications are controlled substances and require writ-ten documentation of being prescribed by the health-care provider; samples are not generally available.

The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine? 1. Elderly and chronically ill clients. 2. Child-care workers and children less than four (4) years of age. 3. Hospital chaplains and health-care workers. 4. Schoolteachers and students living in a dormitory.

1. The elderly and chronically ill are at great- est risk for developing serious complica- tions if they contract the influenza virus. TEST-TAKING HINT: Sometimes the test taker may think the answer is too easy and obvious, but the test taker should not try to second- guess the question. Item writers are not try- ing to trick the test taker; they are trying to evaluate knowledge.

The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client? 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention.

1. The elderly client diagnosed with pneumonia may present with weakness, fatigue, lethargy, confusion, and poor appetite but not have any of the classic signs and symptoms of pneumonia. Wrong answers: 2. Fever and chills are classic symptoms of pneumonia, but they are usually absent in the elderly client. 3. Frothy sputum and edema are signs and symptoms of heart failure, not pneumonia. 4. The client has tachypnea (fast respirations), not bradypnea (slow respirations), and jugular vein distention accompanies heart failure.

The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement? 1. Demonstrate the correct technique for giving a bed bath. 2, Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the UAP.

1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, the nurse should demonstrate the proper way to bathe a client in the bed. TEST-TAKING HINT: Although the test taker should always be concerned with the disease process of the client, many times the answer may be selected based on basic nursing skills not requiring an understanding of the client's disease process.

The client is suspected of having a pulmonary embolus. Which diagnostic test suggests the presence of a pulmonary embolus and requires further investigation? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray (CXR). 4. Magnetic resonance imaging (MRI).

1. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis. This result would require a CT or V/Q scan to then confirm the diagnosis. TEST-TAKING HINT: The key to answering this question is "confirms the diagnosis." The test taker should eliminate options "2" and "3" based on the fact these are diagnostic tests used for many disease processes and conditions.

The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, Pao2 92, Paco2 38, Hco3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one (1) ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.

1. These arterial blood gases are within normal limits, and, therefore, the nurse should not take any action except to continue to monitor the client. TEST-TAKING HINT: This question requires the test taker to know normal arterial blood gas results: pH 7.35 to 7.45, PaO2 80 to100, PaCO2 35 to 45, HCO3 22 to 26. The test taker must know how to evaluate the results.

The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

1. When peak airway pressure is increased, the nurse should implement the intervention least invasive for the client. This alarm goes off with a plugged airway, "bucking" in the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the health- care provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

2. The insertion of a chest tube is an invasive procedure and requires informed consent. Without a consent form, this procedure should not be done on an alert and oriented client. TEST-TAKING HINT: The test taker must know invasive procedures require informed con- sent, and legally it must be obtained first before anyone can touch the client.

The client is diagnosed with bronchiolitis obliterans. Which data indicate the glucocorticoid therapy is effective? 1. The client has an elevation in the blood glucose. 2. The client has a decrease in sputum production. 3. The client has an increase in the temperature. 4. The client appears restless and is irritable.

2. A decrease in sputum production indicates that the client is improving and the medication is effective; long-term use of corticosteroids is indicated for a client with bronchiolitis obliterans. Wrong answers: 1. An elevation in the blood glucose level is a common side effect of corticosteroids and does not indicate effectiveness of the treatment for bronchiolitis obliterans. 3. An elevated temperature indicates the client is becoming worse; therefore, the medication is not effective. 4. Restlessness and irritability can be side effects of treatment with corticosteroids or they could be signs of hypoxemia, which would indicate the medication is not effective.

Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

2. The most common signs of a pulmonary embolism are sudden onset of chest pain when taking a deep breath and shortness of breath. TEST-TAKING HINT: The key to selecting option "2" as the correct answer is sudden onset. The test taker would need to note "left-sided" in option "3" to eliminate this as a possible correct answer, and option "4" is nonspecific for a pulmonary embolism.

The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery? 1. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%. 2. The client has an oral temperature of 100.2 ̊F and a dry cough. 3. There are one (1) to two (2) white blood cells (WBCs) in the urinalysis. 4. The client's current international normalized ratio (INR) is 1.

2. A low-grade temperature and a cough could indicate the presence of an infection, in which case the health-care provider would not want to subject the client to anesthesia and the possibility of further complications. The surgery would be postponed. Wrong answers: 1. The hemoglobin and hematocrit (H&H) given are within normal range. This would not warrant notifying the healthcare provider. 3. One (1) to two (2) WBCs in a urinalysis is not uncommon because of the normal flora in the bladder. 4. The INR indicates that the client's bleeding time is within normal range.

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

2. Assessment of the lung sounds could indicate the client's lung has re-expanded be- cause it has been three (3) days since the chest tube has been inserted. TEST-TAKING HINT: When the stem asks the test taker to identify the first intervention, all four (4) answer options could be interven- tions appropriate for the situation, but only one (1) is the first intervention. Remember to apply the nursing process: the first step is assessment.

Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4. The client is able to deep breathe without any pain.

2. At three (3) days post insertion, no fluctuation (tidaling) indicates the lung has re-expanded, which indicates the treatment has been effective. TEST-TAKING HINT: The test taker must be knowledgeable about chest tubes to be able to answer this question. The test taker must know the normal time frame and what is expected for each compartment of the chest tube drainage system. 1. This is an expected finding in the suction compartment of the drainage system, indicating adequate suctioning is being applied. 3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have re-expanded the lung. 4. Taking a deep breath without pain is good, but it does not mean the lungs have re-expanded.

The nurse is discussing the care of a child diagnosed with asthma with the parent. Which referral is important to include in the teaching? 1. Referral to a dietitian. 2. Referral for allergy testing. 3. Referral to the developmental psychologist. 4. Referral to a home health nurse.

2. Because asthma can be a reaction to an allergen, it is important to determine which substances may trigger an attack. Wrong answers: 1. A child with asthma can eat a regular diet if the child is not allergic to the components of the diet. 3. The stem did not indicate the child is developmentally delayed. 4. The child does not require a home health nurse solely on the basis of asthma; the school nurse or any child-care provider should be informed of the child's diagnosis, and the parents must know the individual caring for the child is prepared to intervene during an attack.

Which task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Feed a client who is postoperative tonsillectomy the first meal of clear liquids. 2. Encourage the client diagnosed with a cold to drink a glass of orange juice. 3. Obtain a throat culture on a client diagnosed with bacterial pharyngitis. 4. Escort the client diagnosed with laryngitis outside to smoke a cigarette

2. Clients with colds are encouraged to drink 2,000 mL of liquids a day. The UAP could do this. Wrong answers: 1. Tonsillectomies cause throat edema and difficulty swallowing; the nurse must observe the client's ability to swallow before this task can be delegated. 3. Throat swabs for culture must be done correctly or false-negative results can occur. The nurse should obtain the swab. 4. Clients with laryngitis are instructed not to smoke. Smoking is discouraged in all health- care facilities. Sending nursing personnel out- side encourages an unhealthy practice, which is not the best use of the personnel.

The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client? 1. Daily inhaled corticosteroids. 2. Use of a "rescue inhaler." 3. Use of systemic steroids. 4. Leukotriene agonists.

2. Clients with intermittent asthma will have exacerbations treated with rescue inhalers. Therefore, the nurse should teach the client about rescue inhalers. Wrong answers: 1. Daily inhaled steroids are used for mild, moderate, or severe persistent asthma, not for intermittent asthma. 3. Systemic steroids are used frequently by clients with severe persistent asthma, not with mild intermittent asthma. 4. Leukotriene agonists are prescribed for clients diagnosed with mild persistent asthma.

The 56-year-old client diagnosed with tuberculosis (Tb) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? 1. "I will take my medication for the full three (3) weeks prescribed." 2. "I must stay on the medication for months if I am to get well." 3. "I can be around my friends because I have started taking antibiotics." 4. "I should get a Tb skin test every three (3) months to determine if I am well."

2. Compliance with treatment plans forTb includes multidrug therapy for six (6) months to one (1) year for the client to be free of the Tb bacteria. TEST-TAKING HINT: The test taker should determine if the time of three (3) weeks in option "1," months in option "2," or im- mediately in option "3" is the correct time interval.

The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube used for bolus feedings. Which intervention should the nurse include in the plan of care? 1. Inspect the insertion line at the naris prior to instilling formula. 2. Elevate the head of the bed (HOB) after feeding the client. 3. Place the client in the Sims position following each feeding. 4. Change the dressing on the feeding tube every three (3) days.

2. Elevating the head of the bed uses gravity to keep the formula in the gastric cavity and help prevent it from refluxing into the esophagus, which predisposes the client to aspiration. TEST-TAKING HINT: The test taker should try to picture the positioning of the client to determine the correct answer. In option "4," the test taker should question if the time given, three (3) days, is the correct time interval for performing this intervention.

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first? 1. Administer oxygen 10 L via nasal cannula. 2. Place the client in high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.

2. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system. TEST-TAKING HINT: The test taker must select the option that will directly help the client breathe easier. Therefore, assessment is not the first intervention and option "4" can be eliminated as the correct answer. When the client is in distress, do not assess.

The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client? 1. Complete blood count. 2. Pulmonary function test. 3. Allergy skin testing. 4. Drug cortisol level.

2. Pulmonary function tests are completed to determine the forced vital capacity (FVC), the forced expiratory capacity in the first second (FEV1), and the peak expiratory flow (PEF). A decline in the FVC, FEV1, and PEF indicates respiratory compromise. Wrong answers: 1. A complete blood count determines the oxygen-carrying capacity of the hemoglobin in the body, but it will not identify the immediate problem. 3. Allergy skin testing will be done to determine triggers for allergic asthma, but it is not done during an attack. 4. Drug cortisol levels do not relate to asthma.

The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription? 1. "These pills will make me feel better fast and I can return to work." 2. "The antibiotics will help prevent me from developing a bacterial pneumonia." 3. "If I had gotten this prescription sooner, I could have prevented this illness." 4. "I need to take these pills until I feel better; then I can stop taking the rest."

2. Secondary bacterial infections often accompany influenza, and antibiotics are often prescribed to help prevent the development of a bacterial infection re- sulting from a weakened client immune system. TEST-TAKING HINT: Knowing drug classifi- cations and how the drugs within the clas- sification work would assist the test taker to determine the correct answer. Antibiotics work to destroy bacterial invasions of the body.

Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS? 1. An aminoglycoside antibiotic. 2. A synthetic surfactant. 3. A potassium cation. 4. A nonsteroidal anti-inflammatory drug.

2. Surfactant therapy may be prescribed to reduce the surface tension in the alveoli. The surfactant helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent atelectasis. TEST-TAKING HINT: Acute respiratory dis- tress syndrome (ARDS) would indicate a problem with the lungs; if the test taker knew surfactant is needed by the lungs to expand, this would be an appropriate selection as the correct answer.

The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The UAP keeps the chest tube below chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of the bed. 4. The UAP uses a bedside commode for the client.

2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the UAP. TEST-TAKING HINT: "Warrants immediate in- tervention" means the test taker must iden- tify the situation in which the nurse should correct the action, demonstrate a skill, or somehow intervene with the UAP's behavior.

The nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement? 1. Praise the UAP because this prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the UAP in front of the client oxygen must be left in place at all times. 4. Discuss the UAP's action with the charge nurse so appropriate action can be taken.

2. The client needs the oxygen, and the nurse should not correct the UAP in front of the client; it is embarrassing for the UAP and the client loses confidence in the staff. TEST-TAKING HINT: The test taker must know management concepts, and the nurse should first address the behavior with the person directly, then follow the chain of command.

12. Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy? 1. "I must avoid hair spray and powders." 2. "I should take a shower instead of a tub bath." 3. "I will need to cleanse around the stoma daily." 4. "I can use an electric larynx to speak."

2. The client should not allow water to enter the stoma; therefore, the client should take a tub bath, not a shower. Wrong answers: 1. The client should not let any spray or powder enter the stoma because it goes directly into the lung. 3. The stoma site should be cleansed to help prevent infection. 4. The client's vocal cords were removed; therefore, the client must use an alternate form of communication.

Which clinical manifestation indicates to the nurse the child has cystic fibrosis? 1. Wheezing with a productive cough. 2. Excessive salty sweat secretions. 3. Multiple vitamin deficiencies. 4. Clubbing of all fingers.

2. The excessive excretion of salt from the sweat glands is specific to cystic fibrosis. Repeated values greater than 60 mEq/L of sweat chloride is diagnostic for CF. Wrong answers: 1. Wheezing and productive coughs are symptoms experienced by clients with respiratory diseases, but they are not specific to cystic fibrosis. 3. Multiple vitamin deficiencies are experienced with some pulmonary diseases, but they are not specific to cystic fibrosis. 4. Clubbing of the fingers is an indicator of chronic hypoxia, but it is not specific to the diagnosis of cystic fibrosis.

35. The nurse is caring for a client on a ventilator and the alarm goes off. Which action should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Check the ventilator to determine the cause. 3. Elevate the head of the client's bed. 4. Assess the client's oxygen saturation.

2. The nurse must determine what is causing the alarm; a high or low alarm will make a difference in the nurse's action. Wrong answers: 1. The nurse needs to notify the respiratory therapist to check the ventilator, but it is not the first intervention. 3. Elevating the head of the bed will help lung expansion, but it is not the first intervention. 4. The ventilator alarm indicates something is wrong, and the nurse must first determine if the problem is with the ventilator or the client.

The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amounts of thick white sputum. 2. Oxygen flowmeter set on eight (8) liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.

2. The nurse should decrease the oxygen rate to two (2) to three (3) liters. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the oxygen level increases, the drive to breathe may be eliminated. TEST-TAKING HINT: This question requires interpreting the data to determine which are abnormal or unexpected and require intervention. Options "1," "3," and "4" are expected for the client's disease process.

38. The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.

2. The nurse should implement the least invasive intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle. Wrong answers: 1. No fluctuation in the water-seal chamber four (4) hours postinsertion indicates the tubing is blocked; the nurse should not milk the chest tube. 3. Coughing may help push a clot in the tubing into the drainage bottle, but the first intervention is to check and see if the client is lying on the tubing or the tube is kinked somewhere. 4. The insertion site can be assessed, but it will not help determine why there is no fluctua- tion in the water-seal drainage compartment.

The client diagnosed with restrictive airway disease (asthma) has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication? 1. Do not abruptly stop taking this medication; it must be tapered off. 2. Immediately rinse the mouth following administration of the drug. 3. Hold the medication in the mouth for 15 seconds before swallowing. 4. Take the medication immediately when an attack starts.

2. The steroids must pass through the oral cavity before reaching the lungs. Allowing the medication to stay within the oral cavity will suppress the normal flora found there, and the client could develop a yeast infection of the mouth (oral candidiasis). Wrong answers: 1. This applies to systemically administered steroids, not to inhaled steroids. 3. Holding the medication in the mouth increases the risk of an oral yeast infection, and the medication is inhaled, not swallowed. 4. Inhaled steroids are not used first; the beta- adrenergic inhalers are used for acute attack.

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

2. The system must be patent and intact to function properly. 4. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and a potential clogging of the tube. 5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site. TEST-TAKING HINT: The test taker should be careful with adjectives. In option "1," the word "low" makes it incorrect; in option "3," the word "strict" makes this option incorrect. 1. The client should be in the high Fowler's position to facilitate lung expansion. 2. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion.

The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output. TEST-TAKING HINT: The test taker must think about which answer option addresses the problem of the heart's inability to pump blood. Decreased blood to the extremities results in cyanosis and cold extremities.

The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first? 1. Suction the client's nares. 2. Turn the client to the side. 3. Place the client in Trendelenburg position. 4. Notify the health-care provider.

2. Turning the client to the side allows for the food to be coughed up and come out of the mouth, rather than be aspirated into the lungs. Wrong answers: 1. The nares are the openings of the nostrils. Suctioning, if done, would be of the posterior pharynx. 3. Placing the client in the Trendelenburg position increases the risk of aspiration. 4. An immediate action is needed to protect the client.

The client is admitted to the emergency department with chest trauma. Which signs/ symptoms indicate to the nurse the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum and consolidation. 4. Barrel chest and polycythemia.

2. Unequal lung expansion and dyspnea indicate a pneumothorax. TEST-TAKING HINT: The test taker can use "chest trauma" or "pneumothorax" to help select the correct answer. Both of these terms should cause the test taker to select option "2" because unequal chest expansion would result from trauma.

The home health-care nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse he has been blowing his nose frequently. Which question should the nurse ask the client? 1. "Have you had the flu shot in the last two (2) weeks?" 2. "Are there any small children in the home?" 3. "Are you taking over-the-counter medicine for these symptoms?" 4. "Do you have any cold sores associated with your sneezing?"

3. A client diagnosed with hypertension should not take many of the over-the-counter medications because they work by causing vasoconstriction, which will increase the hypertension. Wrong answers: 1. Influenza is a viral illness that might cause these symptoms; however, an immunization should not give the client the illness. 2. Coming into contact with small children increases the risk of contracting colds and the flu, but the client has a problem—not just a potential one. 4. Cold sores are actually an infection by the herpes simplex virus. Colds and cold-like symptoms are caused by the rhinovirus or influenza virus. The term "cold sore" is a common term that still persists in the populace.

The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hang the heparin bag on a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

3. A normal PTT is 39 seconds, and for heparin to be therapeutic, it should be 1.5 to 2 times the normal value, or 58 to 78. A PTT of 98 indicates the client is not clot- ting and the medication should be held. TEST-TAKING HINT: This question is asking the test taker to select a distracter with assessment data that are unsafe for admin- istering the medication. The test taker must know normal laboratory values to administer medication safely.

The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? 1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the laboratory. 2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. 3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.

3. A pulse oximetry reading of 92% means that the arterial blood oxygen saturation is somewhere around 60% to 70%. Wrong answers: 1. The specimen needs to be taken to the laboratory within a reasonable time frame, but a UAP can take specimens to the laboratory. 2. Clogged feeding tubes occur with some regularity. Delay in feeding a client will not result in permanent damage. 4. Arterial oxygenation normal values are 80% to 100%.

The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.

3. A therapeutic INR is 2 to 3; therefore, the nurse should administer the medication. TEST-TAKING HINT: The test taker must know normal laboratory values; this is the only way the test taker will be able to answer this question. The test taker should make a list of laboratory values that must be memorized for successful test taking.

Which collaborative intervention should the nurse implement when caring for the client diagnosed with bronchiectasis? 1. Prepare the client for an emergency tracheostomy. 2. Discuss postoperative teaching for a lobectomy. 3. Administer bronchodilators with postural drainage. 4. Obtain informed consent form for chest tube insertion.

3. Administering bronchodilators is a collaborative intervention (requiring an order from a healthcare provider) appropriate for this client. Wrong answers: Other answers are not expected treatments

The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first? 1. Take the client's vital signs. 2. Check the client's pulse oximeter reading. 3. Administer oxygen via a nasal cannula. 4. Notify the respiratory therapist STAT.

3. After elevating the head of the bed, the nurse should administer oxygen to the client who is in respiratory difficulty. Wrong answers: The other actions will not help the client's shortness of breath and difficulty in breathing.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.

3. Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator. TEST-TAKING HINT: The test taker should apply the nursing process, which identifies assessment as the first step. Therefore, if the test taker is not sure of the answer, the best educated choice is to select an option ad- dressing assessment data.

Which assessment data indicate to thenurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100 mL in four (4) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation.

The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication? 1. Muscle weakness. 2. Purulent sputum. 3. Nuchal rigidity. 4. Intermittent loss of muscle control.

3. Nuchal rigidity is a sign/symptom of meningitis, which is a life-threatening potential complication of sinusitis resulting from the close proximity of the sinus cavities to the meninges. Wrong answers: 1. Muscle weakness is a sign/symptom of myalgia, but it is not a life-threatening complication of sinusitis. 2. Purulent sputum would be a sign/symptom of a lung infection, but it is not a life-threatening complication of sinusitis. 4. Intermittent loss of muscle control can be a symptom of multiple sclerosis, but it would not be a life-threatening complication of sinusitis.

The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find? 1. Fever and crepitus. 2. Rales and hives. 3. Dyspnea and wheezing. 4. Normal chest shape and eupnea.

3. During an asthma attack, the muscles surrounding the bronchioles constrict, causing a narrowing of the bronchioles. The lungs then respond with the production of secretions that further narrow the lumen. The resulting symptoms include wheezing from air passing through the narrow, clogged spaces and dyspnea. Wrong answers: 1. Fever is a sign of infection, and crepitus is air trapped in the layers of the skin. 2. Rales indicate fluid in the lung, and hives are a skin reaction to a stimulus such as occurs with an allergy to a specific substance. 4. During an attack, the chest will be expanded from air being trapped and not being exhaled. A chest x-ray will reveal a lowered diaphragm and hyperinflated lungs.

Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen? 1. "I will take Singulair, a leukotriene, every day to prevent allergic asthma attacks." 2. "I need to use my Intal, cromolyn inhaler, 15 minutes before I begin my exercise." 3. "I need to take oral glucocorticoids every day to prevent my asthma attacks." 4. "If I have an asthma attack, I need to use my albuterol, a beta2 agonist, inhaler."

3. Glucocorticoids are administered orally or intravenously during acute exacerbations of asthma, not on a daily basis because of the long-term complications of steroid therapy. Wrong answers: 1. Leukotrienes, such as Singulair, should be taken daily to prevent an asthma attack triggered by an allergen response. 2. Cromolyn inhalers, such as Intal, are used to prevent exercise-induced asthma attacks. 4. Albuterol, a beta2 agonist, is used during attacks because of the fast action.

The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing? 1. The client's first skin test indicates a purple flat area at the site of injection. 2. The client's second skin test indicates a red area measuring four (4) mm. 3. The client's previous skin test was read as positive. 4. The client has never shown a reaction to the tuberculin medication.

3. If the client has ever reacted positively, then the client should have a chest x-ray to look for causation and inflammation. TEST-TAKING HINT: The test taker should note descriptive terms such as "purple," "flat," or "4 mm" before determining the correct answer. Option "4" has the absolute word "never," and absolutes usually indicate incorrect answers.

The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced? 1. Myocardial infarction. 2. Pneumonia. 3. Pulmonary embolus. 4. Pneumothorax.

3. Part of the clot in the deep veins of the legs dislodges and travels up the inferior vena cava, lodges in the pulmonary arterial system, and causes the chest pain; the client often feels as if he or she is going to die. Wrong answers: 1. The nurse would not suspect a myocardial infarction for a client with a DVT who suddenly has chest pain. 2. These signs and symptoms should not make the nurse think the client has pneumonia. 4. Chest pain is a sign of pneumothorax, but it is not a complication of deep vein thrombosis.

Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD? 1. Clubbing of the client's fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough.

3. Sputum production, along with cough and dyspnea on exertion, are the early signs/ symptoms of COPD. TEST-TAKING HINT: The test taker must be observant of terms such as "recently diagnosed," which help to rule out incorrect answers such as option "1." Option "2" has the word "infrequent." The test taker must notice these words.

Which referral is most appropriate for a client diagnosed with end-stage COPD? 1. The Asthma Foundation of America. 2. The American Cancer Society. 3. The American Lung Association. 4. The American Heart Association.

3. The American Lung Association has information helpful for a client with COPD. TEST-TAKING HINT: The test taker should be familiar with organizations, but if the test taker had no idea what the answer was, the only option containing a word referring to respiration—"lung"—is option "3."

The nurse is discharging the client diagnosed with bronchiolitis obliterans. Which priority intervention should the nurse include? 1. Refer the client to the American Lung Association. 2. Notify the physical therapy department to arrange for activity training. 3. Arrange for oxygen therapy to be used at home. 4. Discuss advance directives with the client.

3. The client with bronchiolitis obliterans will need long-term use of oxygen. Wrong answers: 1. The American Lung Association is an excellent resource for educational material, but it is not the priority intervention for the client. 2. Physical therapy is an appropriate intervention, but it is not the priority intervention. 4. Advance directives are an important intervention but are not the priority intervention.

The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care?1. The client has no signs of respiratory distress. 2. The client shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.

3. The expected outcome should be that the client has tolerance for activity; because the client is not meeting the expected out- come, the plan of care needs revision. TEST-TAKING HINT: This question is an "except" question. Three of the options indicate desired outcomes and only one (1) option indicates the need for improvement.

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.

3. The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop. TEST-TAKING HINT: The test taker should apply the nursing process to answer the question correctly. The first step in the nursing process is assessment, and "check" (option "3") is a word that can be used syn- onymously for "assess." Monitoring (op- tion "4") is also assessing, but the test taker should not check a diagnostic test result be- fore caring for the client.

The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, Pao2 95, Paco2 38, Hco3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions (PVCs). 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

3. The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an arterial oxygen level of around 60. TEST-TAKING HINT: This question is asking the test taker to select abnormal, unex- pected, or life-threatening assessment data in relationship to the client's disease process. A pulse oximeter reading of less than 93% indicates severe hypoxia and requires imme- diate intervention.

The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)? 1. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain. 2. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication. 3. The 18-year-old client who had a Caldwell- Luc procedure three (3) days ago and has purulent drainage on the drip pad. 4. The 45-year-old client diagnosed with a peritonsillar abscess who requires VPB antibiotic therapy four (4) times a day.

3. The postoperative client with purulent drainage could be developing an infection. The experienced nurse would be needed to assess and monitor the client's condition. Wrong answers: 1. This client is one (1) day postoperative and has moderate pain, which is to be expected after surgery. A less experienced nurse can care for this client. 2. A child about to go to surgery involving the throat area can be expected to have painful swallowing. This does not require the most experienced nurse. 4. Any nurse who is capable of administering IVPB medications can care for this client.

The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an air- filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life. TEST-TAKING HINT: The test taker must always be clear about what the question is asking before answering the question. If the test taker can eliminate options "1" and "2" and can't decide between options "3" and "4," the test taker must go back to the stem and clarify what the question is asking. 1. This statement describes a spontaneous pneumothorax. 2. This statement describes an open pneumothorax. 4. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but the statement does not describe a tension pneumothorax.

The client who smokes two (2) packs of cigarettes a day develops ARDS after a near- drowning. The client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is most appropriate? 1. "Most people who almost drown end up developing ARDS." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your lungs are filling up with fluid, causing breathing problems." 4. "Smoking has caused your lungs to become weakened, so you got ARDS."

3. This is a basic layperson's terms explanation of ARDS and explains why the client is having trouble breathing. TEST-TAKING HINT: The test taker should se- lect the answer option presenting facts and easiest for the client to understand. The test taker should not select the distracter with medical jargon the client may not under- stand. The test taker as a rule can eliminate any distracter using medical jargon in the answer.

The client diagnosed with a community- acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? 1. Administer the ordered oral antibiotic immediately (STAT). 2. Order the meal tray to be delivered as soon as possible. 3. Obtain a sputum specimen for culture and sensitivity. 4. Have the unlicensed assistive personnel weigh the client.

3. To determine the antibiotic that will effectively treat an infection, specimens for culture are taken prior to beginning the medication. Administering antibiotics prior to cultures may make it impossible to determine the actual agent causing the pneumonia. Wrong answers: 1. Broad-spectrum IV antibiotics are priority, but before antibiotics are administered, it is important to obtain culture specimens to determine the correct antibiotic for the client's infection. Clients are placed on oral medica- tions only after several days of IVPB therapy. 2. Meal trays are not priority over cultures. 4. Admission weights are important to deter- mine appropriate dosing of medication, but they are not priority over sputum collection.

The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching? 1. Take two (2) puffs on the rescue inhaler and wait five (5) minutes before exercise. 2. Warm-up exercises will increase the potential for developing the asthma attacks. 3. Use the bronchodilator inhaler immediately prior to beginning to exercise. 4. Increase dietary intake of food high in monosodium glutamate (MSG).

3. Using a bronchodilator immediately prior to exercising will help reduce bronchospasms. Wrong answers: 1. Rescue inhalers are used to treat attacks, not prevent them, so this should not be administered prior to exercising. 2. Warm-up exercises decrease the risk of developing an asthma attack. 4. Monosodium glutamate, a food preservative, has been shown to initiate asthma attacks.

The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem "altered communication." Which intervention should the nurse implement? 1. Instruct the client to drink a mixture of brandy and honey several times a day. 2. Encourage the client to whisper instead of trying to speak at a normal level. 3. Provide the client with a blank note pad for writing any communication. 4. Explain that the client's aphonia may become a permanent condition.

3. Voice rest is encouraged for the client experiencing laryngitis. Wrong answers: 1. The client with laryngitis is instructed to avoid all alcohol. Alcohol causes increased irritation of the throat. 2. Whispering places added strain on the larynx. 4. Aphonia, or inability to speak, is a temporary condition associated with laryngitis.

Which intervention should the emergency department nurse implement first for the client admitted for an acute asthma attack? 1. Administer glucocorticoids intravenously. 2. Administer oxygen 5 L per nasal cannula. 3. Establish and maintain a 20-gauge saline lock. 4. Assess breath sounds every 15 minutes.

4. Assessment is the first step of the nursing process, but in distress do not assess. Wrong answers: 1. Glucocorticoids are treatment of choice, but they are not the first intervention. 2. The client is in distress so the nurse must do something for the client's airway. 3. A saline lock is needed for intravenous fluids, but it is not the first intervention.

94. The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the licensed practical nurse (LPN)? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hb of 9 g/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post- bronchoscopy procedure.

4. A client two (2) hours post-bronchoscopy procedure could safely be assigned to an LPN. TEST-TAKING HINT: The test taker must understand that the LPN should be assigned the least critical client or the client whois stable and not exhibiting any complications secondary to the admitting disease or condition.

Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required? 1. "I should contact my health-care provider if my sputum changes color or amount." 2. "I will take my bronchodilator regularly to prevent having bronchospasms." 3. "This metered-dose inhaler gives a precise amount of medication with each dose." 4. "I need to return to the HCP to have my blood drawn with my annual physical."

4. Clients should have blood levels drawn every six (6) months when taking bronchodilators, not yearly. This indicates the client needs more teaching. Wrong answers: 1. When sputum changes in color or amount, or both, this indicates infection, and the client should report this information to the healthcare provider. This statement indicates the client understands the teaching. 2. Bronchodilators should be taken routinely to prevent bronchospasms. This statement indicates the client understands the teaching. 3. Clients use metered-dose inhalers because they deliver a precise amount of medication with correct use. This statement indicates the client understands the teaching.

Which diagnostic test should the nurse anticipate the health-care provider ordering to rule out the diagnosis of asthma in clients diagnosed with chronic obstructive pulmonary disease (COPD)? 1. A bronchoscopy. 2. An immunoglobulin E. 3. An arterial blood gas. 4. A bronchodilator reversibility test.

4. During a bronchodilator reversibility test, the client's positive response to a bronchodilator confirms the diagnosis of asthma. It is useful in clients with COPD because airway reversibility is characteristic of asthma but no emphysema or bronchitis. Wrong answers: 1. A bronchoscope visualizes the bronchial tree under sedation, but it does not confirm the diagnosis of asthma. 2. An immunoglobulin E is a blood test for the presence of an antibody protein indicating allergic reactions. 3. Arterial blood gases analyze levels providing information about the exchange of oxygen and carbon dioxide, but they are not diagnostic of asthma.

The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss? 1. Instruct the children to always keep a tissue or handkerchief with them. 2. Explain that children current with immunizations will not get a cold. 3. Tell the children they should go to the doctor if they get a cold. 4. Demonstrate to the students how to wash hands correctly.

4. Hand washing is the single most useful technique for prevention of disease. Wrong answers: 1. It is not feasible for a child to always have a tissue or handkerchief available. 2. There is no immunization for the common cold. Colds are actually caused by at least 200 separate viruses and the viruses mutate frequently. 3. Colds are caused by a virus and antibiotics do not treat a virus; therefore, there is no need to go to a healthcare provider.

The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which is an expected outcome for this problem? 1. Performs chest physiotherapy three (3) times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall several times during each shift. 4. Alert and oriented to person, place, time, and events.

4. Impaired gas exchange results in hypoxia, the earliest sign/symptom of which is a change in the level of consciousness. Wrong answers: 1. Clients do not perform chest physiotherapy; this is normally done by the respiratory therapist. This is a staff goal, not a client goal. 2. This would be a goal for self-care deficit but not for impaired gas exchange. 3. This would be a goal for the problem of activity intolerance.

Which statement indicates to the nurse the client diagnosed with asthma understands the teaching regarding mast cell stabilizer medications? 1. "I should take two (2) puffs when I begin to have an asthma attack." 2. "I must taper off the medications and not stop taking them abruptly." 3. "These drugs will be most effective if taken at bedtime." 4. "These drugs are not good at the time of an attack."

4. Mast cell drugs are routine maintenance medications and do not treat an attack. Wrong answers: 1. Mast cell stabilizers require 10 to 14 days to be effective. Some clients diagnosed with exercise-induced asthma derive benefit from taking the drugs immediately before exercising, but these drugs must be in the system fora period of time before effectiveness can be achieved. 2. Tapering of medications is done for systemic steroids because of adrenal functioning. 3. The drugs are taken daily or before exercise, or both.

The client diagnosed with chronic sinusitis who has undergone a Caldwell-Luc procedure is complaining of pain. Which intervention should the nurse implement first? 1. Administer the narcotic analgesic intravenous push (IVP). 2. Perform gentle oral hygiene. 3. Place the client in semi-Fowler's position. 4. Assess the client's pain.

4. Prior to intervening, the nurse must assess to determine the amount of pain and possible complications occurring that could be masked if narcotic medication is administered. Wrong answers: 1. The client has complained of pain, and the nurse, after determining the severity of the pain and barring any complications in the client, will administer pain medication after completion of the assessment. 2. Oral hygiene helps to prevent the development of infections and promotes comfort, but it will not relieve the pain. 3. Placing the client in the semi-Fowler's position will reduce edema of inflamed sinus tissue, but it will not immediately affect the client's perception of pain.

The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? 1. The client's pulse oximeter reading is 92%. 2. The client's arterial blood gas level is 74. 3. The client has SOB when walking to the bathroom. 4. The client's sputum is rusty colored.

4. Rusty-colored sputum indicates blood in the sputum and requires further assessment by the nurse. TEST-TAKING HINT: The test taker could rule out options "1" and "2" as correct answers because both describe the same data of de- creased oxygen, which is characteristic of COPD.

The nurse is caring for a client with a right- sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation. TEST-TAKING HINT: The words "implement first" in the stem of the question indicate to the test taker that possibly more than one (1) intervention could be warranted in the situ- ation but only one (1) is implemented first. Remember, do not select assessment first without reading the question. If the client is in any type of crisis, then the nurse should first do something to help the client's situation.

The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.

4. The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be one (1) inch above the bifurcation of the bronchi. TEST-TAKING HINT: The test taker must be knowledgeable about ventilator care. Radiation is dangerous; therefore, a daily CXR (option "2") may be eliminated as the correct answer.

Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a Medic Alert band at all times."

4. The client should wear a Medic Alert band at all times so that, if any accident or situation occurs, the healthcare providers will know the client is receiving anticoagulant therapy. The client understands the teaching. TEST-TAKING HINT: This is a higher level question in which the test taker must know clients with a pulmonary embolus are pre- scribed anticoagulant therapy on discharge from the hospital. If the test taker had no idea of the answer, the option stating "wear a Medic Alert band" is a good choice because many disease processes require the client to take long-term medication and a health-care provider should be aware of this.

The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain? 1. Number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medication. 4. Willingness to modify lifestyle.

4. The client's attitude toward lifestyle changes is the most important consideration in health promotion, in this case smoking cessation. The nurse should assess if the client is willing to consider cessation of smoking and carry out the plan. TEST-TAKING HINT: The test taker should read the stem for words such as "health promotion." These words make all the other answer options incorrect because they do not promote health.

The client is admitted with a diagnosis of rule-out tuberculosis. Which type of isolation procedures should the nurse implement? 1. Standard Precautions. 2. Contact Precautions. 3. Droplet Precautions. 4. Airborne Precautions.

4. Tuberculosis bacteria are capable of dis- seminating over long distances on air cur- rents. Clients with tuberculosis are placed in negative air pressure rooms where the air in the room is not allowed to cross- contaminate the air in the hallway. TEST-TAKING HINT: Standard Precautions and Contact Precautions can be ruled out as the correct answer if the test taker is aware that Tb is usually a respiratory illness. This at least gives the reader a 1:2 chance of select- ing the correct answer if the answer is not known.

The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mLof D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour? ________

880 units.If there are 20,000 units of heparin in 500 mL of D5W, there are 40 units in each mL: 20,000 " 500 # 40 unitsIf 22 mL are infused per hour, then 880 units of heparin are infused each hour:40 × 22 # 880