Respiratory

The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? a. Albuterol b. Salmeterol c. Beclomethasone d. Ipratropium bromide

A Option a: Albuterol is a short-acting bronchodilator that is used to treat acute asthma exacerbations. Option b: Salmeterol is a long-acting bronchodilator that is used to prevent asthma exacerbations. Option c: Beclomethasone is a corticosteroid inhaler used for long term asthma management. Option d: Ipratropium is an anticholinergic agonist that is used for acute asthma exacerbations if a patient cannot tolerate short-acting bronchodilators.

When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication? a. Antibiotic b. Corticosteroid c. Bronchodilator d. Cough suppressant

A Pertussis (whooping cough) is caused by the bacteria Bordella pertussis. It causes rhinorrea, congestion, sneezing, low grade fever, and intense coughing.

When initially teaching a patient the supraglottic swallow following a radical neck dissection, with which food or fluid should the nurse begin? a. Cola b. Apple sauce c. French fries d. White grape juice

A A radical neck dissection is a surgical procedure in which cancerous lateral neck nodes and tissues are removed. A supraglottic swallow is a swallowing technique in which a person coughs right at the end of a swallow to help prevent any swallowed food or liquid from going down into the trachea. When learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration.

A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? a. Oxygen tent b. Venturi mask c. Nasal cannula d. Oxygen-conserving cannula

B Patients with COPD need to receive precise amounts of oxygen. Respiratory rate/depth is controlled by the medulla, which monitors CO2 in blood (↑ CO2 = ↓ RR). In patients with chronic respiratory conditions, the medulla acclimates to a higher CO2 level. If this CO2 level suddenly drops (due to increased O2 from supplemental oxygen), the respiratory drive may halt, leading to hypoxemia. The venturi mask is the most accurate method of O2 delivery.

The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation? a. Thoracentesis b. Bronchoscopy c. Arterial blood gases d. Pulmonary function tests

C Option a: Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Option b: Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens. Option c: ABGs assess efficiency of gas transfer between lungs and blood, and assess blood oxygenation. Option d: Pulmonary function tests measure lung volumes and airflow in and out of the lungs.

What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? a. Chest excursion b. Spinal curvatures c. Respiratory pattern d. Fingernails and their base

D Clubbing is a sign of long term hypoxemia.

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? Select all that apply. 1. "I can apply Vaseline to my nose when my nostrils feel dry from the oxygen." 2. "I can cook on my gas stove as long as I have a fire extinguisher in the kitchen." 3. "I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath." 4. "I should not polish my nails when using my oxygen." 5. "I should not use a wool blanket on my bed."

1, 2, 3 Option 1: Vaseline is an oil-based product, therefore it is flammable and should be avoided Option 2: Oxygen canisters need to be kept at least 5 feet from open flames Option 3: Higher rates of O2 with patients with COPD can decrease their respiratory drive, so it shouldn't be raised. Also, nasal cannula should never run at a flow rate of >4 L/min, as this can blow out your sinuses Option 4: True; nail polish is flammable Option 5: True; synthetic and wool fabrics should be avoided because they can build up static electricity and cause a spark

A client with obesity is diagnosed with pulmonary embolism (PE). Which assessment data would the nurse expect to find? Select all that apply. 1. Bradycardia 2. Chest pain 3. Chills and fever 4. Hypoxemia 5. Tachypnea 6. Tracheal deviation

2, 4, 5 A pulmonary embolism is a blood clot or air bubble that obstructions a pulmonary artery. • S/S dyspnea, chest pain, tachycardia, tachypnea, hypoxemia, anxiety • Impaired gas exchange (hypoxemia) occurs • Occurs due to DVT 90% of the time • Risk factors: Virchow's Triad (hypercoagulability, venous stasis, and endothelial damage) prolonged immobilization, obesity, recent surgery, varicose veins, HF, smoking ↑ age, prior DVT Option 1: PE causes tachycardia, not bradycardia Option 3: chills and fever are signs of an infection Option 6: tracheal deviation is a symptom of a tension pneumothorax (deviates toward unaffected side)

A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? Laboratory results PH 7.25 PO2 79 mmHg PaCO2 35 mmHg HCO3- 12 mEq/L 1. Decrease in bicarbonate reabsorption 2. Decrease in respiratory rate 3. Increase in bicarbonate reabsorption 4. Increase in respiratory rate

4 The client is in metabolic acidosis (pH: acid 7.35 - 7.45 basic); we know this because their pH is acidic and their bicarb is also in the acidic range. Option 1: Decreased bicarb would result in metabolic acidosis, which is already what we are in Option 2: Decreased RR would result in respiratory acidosis, as CO2 would increase (CO2: acidic 45 - 35 basic); we are already acidotic, so this wouldn't help Option 3: Increased bicarb would result in metabolic alkalosis (acidic 22 - 26 basic); in this case, the metabolic component is causing the acidosis, so the respiratory component must be the one to "compensate" Option 4: Because pH and bicarb are acidic, respiratory rate would increase to blow off CO2 (acidic) and bring the pH up to a more neutral level

The patient's arterial blood gas results show the PaO2 at 65 mmHg and the SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? a. Restlessness, tachypnea, tachycardia, and diaphoresis b. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis c. Combativeness, retractions with breathing, cyanosis, and decreased output d. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

A A PaO2 of 65 mmHg indicates mild hypoxia (↓ O2 to tissues). Early manifestations of hypoxia include tachypnea, restlessness, tachycardia, diaphoresis, and fatigue. All other symptoms are indicative of later stages of hypoxia. SaO2: Measures the percentage of hemoglobin in arterial blood that are saturated with oxygen. Normal range: 90-100%. SpO2: Measures SaO2 via a pulse oximeter. Normal range: 90-100%. PaO2: Measures the pressure of oxygen dissolved in blood; it reflects how well oxygen is able to move from the lungs to the blood. Normal range: 75-100 mmHg.

A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure? a. Monitor the patient for laryngeal edema. b. Assess the patient's level of consciousness. c. Monitor and manage the patient's level of pain. d. Assess the patient's heart rate and blood pressure.

A Airway, airway, airway! Bronchoscopy is an endoscopic technique, completed under sedation, to visualize the inside of the airways for diagnostic purposes. A bronchoscope is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy.

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? Pulse rate of 72/minute Temperature of 98.4° F Oxygen saturation 96% Respiratory rate of 18/minute

A Albuterol is a beta 2 agonist that causes bronchodilation and is used to treat and prevent asthma and COPD. It can have adverse cardiovascular effects such as tachycardia.

When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included? a. Increasing dyspnea b. Temperature below 98.6° F c. Decreased sputum production d. Unable to drink 3 L low-sodium fluids

A Bronchiectasis is a condition where the bronchial tubes of your lungs are permanently damaged, widened, and thickened. These damaged air passages allow bacteria and mucus to build up and pool in your lungs. This results in frequent infections and blockages of the airways. Option a: When there is a flare up, it can cause dyspnea, fever, chills, increased sputum production, and chest pain. Option b: An infection would cause an increase in temp. Option c: Sputum production would increase and clog the airway, not decrease. Option d: Patients with bronchiectasis are encouraged to drink 3 L of fluid to help liquefy secretions for easier expectoration.

The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. What should the nurse do first? a. Test the drainage for the presence of glucose. b. Suction the nose to maintain airway clearance. c. Document the findings and continue monitoring. d. Apply a drip pad and reassure the patient this is normal.

A Cerebrospinal fluid is clear and contains glucose. Due the nature of the injury (head trauma), CSF needs to be ruled out. Suctioning should not be done on the nose, as there could be trauma in the nasal cavity and suctioning to make it worse.

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease? a. An overproduction of the antiprotease α1 -antitrypsin b. Hyperinflation of alveoli and destruction of alveolar walls c. Hypertrophy and hyperplasia of goblet cells in the bronchi d. Collapse and hypoventilation of the terminal respiratory unit

A Common causes of COPD are long term exposure to pollutants and irritants, such as smoking. In COPD, there are structural changes that include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity.

The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? a. Cough sound, sputum production, pattern b. Frequency, a family history, hematemesis c. Smoking, medications, residence location d. Weight loss, activity tolerance, orthopnea

A Cough severity needs to be determined first, which can be assessed via cough sound, sputum production (and color), and pattern (acute vs chronic. All the other answers are questions used to diagnose the cause of the cough.

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? a. Hypersensitivity to eggs b. Age greater than 80 years c. History of upper respiratory infections d. Chronic obstructive pulmonary disease (COPD)

A Eggs are involved in the process of making vaccinations, so the influenza vaccine would be contraindicated with an egg allergy. The elder and patients with respiratory disorders are encouraged to get annual influenza vaccines, as they are at a higher risk of complications if they contract the flu.

The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? a. Motion b. Anemia c. Dark skin color d. Thick acrylic nails

A Motion can affect pulse oximetry accuracy. Patients with Parkinson's tend to have tremors, which would affect the pulse ox reading.

Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? a. Basilar crackles b. Respiratory rate of 28 c. Oxygen saturation of 85% d. Presence of greenish sputum

A Option a: Crackles in the base of the lungs indicates fluid accumulation, which supports the nursing diagnosis of ineffective airway clearance, as the patient is unable to expectorate the secretions to clear the airway. Options b, c: An RR of 28 and O2 sat of 85% both indicate respiratory distress, but they are nonspecific and can have many causes. Option d: Presence of greenish sputum indicates effective airway clearance, as the patient has to have been able to expel those secretions for us to identify the color.

A male patient with COPD becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? a. Arterial pH 7.26 b. PaCO2 50 mm Hg c. Patient in tripod position d. Increased sputum expectoration

A Option a: Normal pH is 7.35-7.45, so this patient has become even more acidotic. Acidosis supports an exacerbation of COPD, as O2 decreases and CO2 increases. Option b: Normal PaCO2 is 35-45 mmHg, so this patient's CO2 has decreased/remains acidic (↑ CO2 = ↑ acidity). However, it has decreased from baseline. Option c: Normal PaO2 is 80-100 mmHg, so this patient's PaO2 is below normal, indicating they are hypoxemic. The tripod position indicates the patient is in respiratory distress. Option d: Increased sputum expectoration indicates the client's symptoms are resolving.

A client is on Advair (fluticasone and salmeterol) for asthma. What is an important piece of information they should know? A. That it can increase the risk of death B. That it contains a short acting beta agonist C. It can increase the risk of lactic acidosis D. It is best used only several times a week

A Option a: Salmeterol is a long-acting beta agonist that is used to control asthma and prevent bronchospasm when other medications do not work. Fluticasone is a corticosteroid that decreases inflammation in the airway. While Advair can reduce the risks of having an asthma attack, it can make any asthma attack that does occur much more severe. Option b: Salmeterol is a long-acting beta agonist. Option c: Advair can cause lactic acidosis, but this is not the most important piece of information. Option d: Advair should be taken twice a day on a strict regimen.

The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? a. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." b. "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." c. "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." d. "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."

A Option a: The breath during an inhaler dose needs to be deep and quick to ensure the medicine goes into the lungs. Option b: DPIs do not require spacers. A spacer (pictured) is a holding chamber for the medicine that attaches to the inhaler and holds the medication until you can breathe it in. This device ensures more medicine gets into the lungs and not just in the mouth. Option c: Inhaler meds cannot always be tasted or sensed. Option d: The inhaler needs to be in the mouth to be effective, or else the medicine is lost to the atmosphere.

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based upon this assessment? a. Hyperthermia related to infectious illness b. Ineffective thermoregulation related to chilling c. Ineffective breathing pattern related to pneumonia d. Ineffective airway clearance related to thick secretions

A Option a: The patient is hyperthermic related to infection (pneumonia) as evidenced by a temperature of 101.4 F. Option b: Chills were not noted in the assessment. Also, the patient has a fever, and chills would be evidence of a low temperature, not a high temperature. Option c: The patient's breathing pattern is within normal limits. Option d: The assessment does not indicate whether the secretions are thick.

During the assessment in the ED, the nurse is palpating the patient's chest. Which finding is a medical emergency? a. Trachea moved to the left b. Increased tactile fremitus c. Decreased tactile fremitus d. Diminished chest movement

A Option a: Tracheal deviation indicates a tension pneumothorax, a life-threatening condition that develops when air is trapped in the pleural cavity, preventing the lung from expanding. Every inhalation forces more air into the pleural space, constricting the lung further. Option b: Tactile fremitus is the low-frequency vibration of a patient's chest when they speak, which is used as an indirect measure of the amount of air and density (fluid) in lung tissues. Tactile fremitus increases with pneumonia or pulmonary edema. Option c: Tactile fremitus decreases with pleural effusion (fluid surrounding lungs) or lung hyperinflation, as there is decreased fluid within lung tissue. Option d: Diminished chest movement occurs from chronic accessory muscle use (barrel chest) or neuromuscular diseases.

The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? a. Wheezing becomes louder. b. Cough remains nonproductive. c. Vesicular breath sounds decrease. d. Aerosol bronchodilators stimulate coughing.

A The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange due to bronchoconstriction. Option a: Wheezing is caused by a narrowing of the airway. As the airway dilates, the wheezing will become louder until it turns into normal breath sounds. Option b: Swelling of the bronchi leads to mucus production. As swelling decreases, the patient should be able to cough out the mucus. Option c: Vesicular breath sounds (normal, low pitched breath sounds) should increase. Option d: Bronchodilators should not cause coughing; if coughing occurs, there may be a problem with the inhaler.

The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis? a. Work of breathing b. Fear of suffocation c. Effects of medications d. Anxiety and restlessness

A When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity.

When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers (select all that apply)? a. Exercise b. Allergies c. Emotional stress d. Decreased humidity e. Upper respiratory infections

A, B, C, E Potential asthma triggers include exercise, allergens and pollutants, URIs, foods/food additives, stress, and GERD. Humidity (increased or decreased) does not exacerbate asthma.

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)? a. Maintain adequate fluid intake. b. Splint the chest when coughing. c. Maintain a 30-degree elevation. d. Maintain a semi-Fowler's position. e. Instruct patient to cough at end of exhalation.

A, B, D, E Option a: Adequate fluid intake (2-3 L per day) will liquefy secretions (↓ viscosity), allowing for easier expectoration. Option b: Splinting when coughing is done when there is a surgical incision at risk of dehiscence from increased strain (such as coughing). Splinting the incision will ease pain, allowing for a stronger/more effective cough. Options c: 30 degree HOB elevation is not elevated enough. The patient should be in a high fowler's position. Option d: Maintaining an severely elevated HOB will concentrate lung secretions in one area to ease breathing. Option e: Coughing at the end of exhalation promotes a more effective/productive cough.

When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which risk factors (select all that apply)? a. Obesity b. Pneumonia c. Malignancy d. Cigarette smoking e. Prolonged air travel

A, C, D, E Pneumonia does not increase the risk of a pulmonary embolism.

When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient about (select all that apply)? a. Have trouble falling asleep? b. Need to urinate during the night? c. Awaken abruptly during the night? d. Sleep more than 8 hours per night? e. Need to sleep with the head elevated?

A, C, E Options a, c: Patients with sleep apnea may awaken abruptly or have insomnia. Option b: Nocturia is related to bladder function, not respiratory health. Option d: Sleeping for >8 hours a night can have many causes, such as depression. It is unrelated to respiratory health. Option e: Needing to sleep with the HOB elevated (orthopnea) can be caused by cardiovascular disease, which can affect respiratory health.

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? a. 2 minutes b. 5 minutes c. 10 minutes d. 15 minutes

B

After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? a. Bronchospasm b. Pneumothorax c. Pulmonary edema d. Respiratory acidosis

B A thoracentesis is an invasive procedure of inserting a needle into the the pleural space to remove fluid (pleural effusion) or air and is completed for diagnostic or therapeutic purposes. Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax (collapsed lung).

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient? a. Orthostatic blood pressures b. Sputum culture and sensitivity c. Pulmonary function evaluation d. Serum laboratory studies ordered for AM

B Cefuroxime is an antibiotic. The organisms causing this particular pneumonia infection need to be identified to provide the most effective treatment.

Which test result identifies that a patient with asthma is responding to treatment? An increase in CO2 levels A decreased exhaled nitric oxide A decrease in white blood cell count An increase in serum bicarbonate levels

B Option a: Although CO2 levels may initially be decreased due to hyperventilation, the body will then begin secreting mucus in the airway to prevent further CO2 loss. An increase in CO2 may mean the airway has become so constricted that breathing is no longer effective. Option b: Patients with asthma release increased nitrous oxide during an exacerbation due to inflammation. When inflammation begins to resolve, nitrous oxide levels will decrease. Option c: Not every type of asthma causes an increase in WBC count (inflammation due to increased eosinophils attempting to attack an allergen). Option d: Asthma causes respiratory alkalosis, so any metabolic compensation would be an increase in hydrogen or a decrease in bicarbonate levels. Metabolic compensation also takes days to occur.

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? a. "I will pay less for medication because it will last longer." b. "More of the medication will get down into my lungs to help my breathing." c. "Now I will not need to breathe in as deeply when taking the inhaler medications." d. "This device will make it so much easier and faster to take my inhaled medications."

B Option a: Although a spacer does increase the amount of medication lost to the mouth rather than going into the lungs, this is not an instruction when its use. Option b: A spacer holds the medicine and ensures more of it goes into the lungs. Option c: The patient will still need to breathe deeply to get the medicine into the lungs. Option d: A spacer does not affect the speed at which medication needs to be inhaled.

The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes have decreased. The nurse knows this could be due to what occurring? a. Pain b. Atelectasis c. Pneumonia d. Pleural effusion

B Option a: Pain (on inspiration) could cause diminished lung sounds, but it would be bilateral and all lobes would be diminished. Option b: Atelectasis (collapsed alveoli) prevent air from entering that space, which decreases lung sounds. Option c: Pneumonia (lung infection due to build up of secretions in the lungs) is a complication of surgery due to shallow breathing and immobilization, but doesn't occur that quickly after surgery. Option d: Pleural effusion (fluid in pleural cavity around the lungs) would prevent the lungs from fully expanding and would decrease breath sounds, but it's caused by blocked lymphatic drainage or oncotic pressure imbalances, which isn't likely to be the case after surgery.

The nurse is teaching a patient how to self-administer ipratropium (Atrovent) via a metered dose inhaler (MDI). Which instruction given by the nurse is most appropriate to help the patient learn the proper inhalation technique? a. "Avoid shaking the inhaler before use." b. "Breathe out slowly before positioning the inhaler." c. "Using a spacer should be avoided for this type of medication." d. "After taking a puff, hold the breath for 30 seconds before exhaling."

B Option a: The inhaler should be shaken well before use. Option b: The patient should breathe out slowly to ensure as much air as possible is out of the lungs, to be able to take a deeper breath and enhancing the effectiveness of the dose. Option c: A spacer ensures more of the medication gets into the lungs and not just in the mouth. Option d: Breath should be held after taking a puff to ensure medication stays in the lungs, but 30 seconds is excessive.

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? a. Assessing the need for suctioning b. Suctioning the patient's oropharynx c. Assessing the patient's swallowing ability d. Maintaining appropriate cuff inflation pressure

B Options a, c: Assessments (need for suction, swallowing ability) can only be performed by the RN. b. The UAP can suction the oropharynx (mouth, upper throat) only. Other types of suctioning (NG, trach, etc.) can only be performed by the RN. Option d: This patient has an inflated cuff that seals against the inside walls of the trachea. This prevents air from escaping out the nose/mouth (when mechanical ventilation is in use) or prevents aspiration if the patient has difficulty swallowing.

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when he coughs and expels the tracheostomy tube. How should the nurse respond? a. Suction the tracheostomy opening. b. Maintain the airway with a sterile hemostat. c. Use an Ambu bag and mask to ventilate the patient. d. Insert the tracheostomy tube obturator into the stoma.

B Options a, c: Unless the patient is showing signs of respiratory distress, there is no need to suction the tracheostomy opening or ventilate the patient. Option b: A hemostat can be used to keep the stoma open until a new (sterile) tracheostomy tube can be inserted. Option d: An obturator is a device that's used to ease insertion of a tracheostomy tube into the patient's stoma.

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters? a. Apical pulse b. Daily weight c. Bowel sounds d. Deep tendon reflexes

B Oral prednisone can cause weight gain (fluid retention) and hypocalcemia. Hypocalcemia can cause a diminished deep tendon reflexes, but this is a late sign. serum calcium labs should be monitored instead.

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient? a. Order fruits and fruit juices to be offered between meals. b. Order a high-calorie, high-protein diet with six small meals a day. c. Teach the patient to use frozen meals at home that can be microwaved. d. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.

B Patients with COPD may be underweight due to increased effort to breathe (accessory muscle use) and dyspnea preventing adequate intake of food. Option a: Although fruits will provide extra vitamins and minerals, it is not high calorie and the patient will still be at a deficit in macronutrients. Option b: A full stomach impairs the diaphragm from descending fully during inspiration, which can make dyspnea worse. Frequent, small meals prevent this. Option c: Frozen meals can be high in sodium, and doesn't address the issue of decreased food intake due to COPD. Option d: Carbohydrates can be bulky in the stomach and can prevent the diaphragm from expanding completely. Protein is more important than carbs.

When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of: a. cough reflex. b. mucociliary clearance. c. reflex bronchoconstriction. d. ability to filter particles from the air.

B The function of cilia in the trachea and bronchi is to protect the airways from being damaged or infected by particles of dust or foreign matter and facilitate expectoration. Smoking destroys the cilia, making the lungs susceptible to infection and damage, as the trachea/bronchi can no longer filter particles and cannot get the particles out of the lungs.

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after what occurs? a Hypertension and pulmonary edema b. Oropharyngeal candidiasis and hoarseness c. Elevation of blood glucose and calcium levels d. Adrenocortical dysfunction and hyperglycemia

B The patient needs to rinse their mouth after inhaled corticosteroid use to prevent an overgrowth of organisms in the mouth. Corticosteroids can cause increased blood glucose, but they also cause decreased calcium levels. Also, inhaled steroids are not very systemic, so they will not affect other body systems are readily as they affect the lungs.

In an assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply)? a. Cyanosis b. Tripod position c. Kussmaul respirations d. Accessory muscle use e. Increased AP diameter

B, D Option a: Cyanosis is a bluish discoloration of the skin resulting from poor circulation (↓ cardiac output) or inadequate oxygenation of the blood (anemia, ↓ gas exchange). Therefore, it is a nonspecific finding and does not always directly indicate respiratory distress. Option b: "Tripoding" takes advantage of accessory muscles and facilitates expansion of the lungs. Option c: Kussmaul respirations are rapid, deep breaths seen in patients with DKA, in a compensatory attempt to "blow off" CO2 and reduce blood acidity. Option d: Accessory muscle use (other muscles besides diaphragm and intercostal muscles, such as sternocleidomastoid) are used in an attempt to take deeper breaths. Option e: Increased anteroposterior chest diameter indicate disorders such as emphysema, in which the patient chronically struggles for breath.

A patient is being discharged from the emergency department after being treated for epistaxis. In teaching the family first aid measures in the event the epistaxis would recur, what measures should the nurse suggest (select all that apply)? a. Tilt patient's head backwards. b. Apply ice compresses to the nose. c. Tilt head forward while lying down. d. Pinch the entire soft lower portion of the nose. e. Partially insert a small gauze pad into the bleeding nostril.

B, D, E Epistaxis is acute hemorrhage from the nostril, nasal cavity, or nasopharynx (bloody nose). Option a: Tilting the patient's head back increases the risk of blood entering the nasopharynx and causing aspiration. Option b: Ice packs cause vasoconstriction, which will help stop the bleeding. Option c: Tilting the head forward does not help a nose bleed, and lying down increases the risk of aspiration of blood. Options d, e: Pinching the lower portion of the nose or inserting gauze will promote hemostasis, which will facilitate clot formation.

When the patient is diagnosed with a lung abscess, what should the nurse teach the patient? a. Lobectomy surgery is usually needed to drain the abscess. b IV antibiotic therapy will be used for a prolonged period of time. c. Oral antibiotics will be used when the patient and x-ray shows evidence of improvement. d. No further culture and sensitivity tests are needed if the patient takes the medication as ordered.

C An abscess is a infected area within tissue, containing an accumulation of pus. Option a: A lobectomy is a surgical procedure that removes a lobe of a lung. Option b: IV antibiotics are used short term until there is X-ray evidence of improvement of the abscess. Option c: After initial improvement, oral antibiotics will be used for long term therapy. Option d: Further culture tests are needed during the course of antibiotic therapy to ensure the pathogen causing the absence is not becoming resistant to the drug.

Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? a. Acute respiratory failure b. Secondary respiratory infection c. Fluid volume excess resulting from cor pulmonale d. Pulmonary edema caused by left-sided heart failure

C Cor pulmonale is right-sided heart failure due to high blood pressure in the lungs from COPD. Blood backs up from the right side of the heart and flow is decreased from the venae cavae into the right atrium. This back up causes increased deoxygenated blood in the body, as it struggles to enter the heart.

When teaching the patient with cystic fibrosis about the diet and medications, what is the priority information to be included in the discussion? a. Fat soluble vitamins and dietary salt should be avoided. b. Insulin may be needed with a diabetic diet if diabetes mellitus develops. c. Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. d. Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.

C Cystic fibrosis affects the cells that produce mucus, sweat, and digestive juices. It causes these fluids to become thick and sticky. They then plug up tubes, ducts, and passageways, and the lungs. Option a: Patients with CF are at risk of malabsorption and require extra vitamin and mineral intake. Avoiding vitamins increases the risk of malnutrition. Patients with cystic fibrosis also lose excess salt from sweat and require a higher intake, as well. Option b: Cystic fibrosis can scar the pancreas from excess mucus production, which can decrease insulin production and cause diabetes. However, this is not priority information at the moment. Option c: Due to malabsorption and decrease pancreatic function, the patient will need to take pancreatic enzymes before meals and ensure adequate nutrient intake. Option d: DIOS is a complication of cystic fibrosis, but it's treated with laxatives to thin bowl contents (Miralax), not increased water intake.

What is the priority nursing assessment in the care of a patient who has a tracheostomy? a. Electrolyte levels and daily weights b. Assessment of speech and swallowing c. Respiratory rate and oxygen saturation d. Pain assessment and assessment of mobility

C Duh.

What nursing intervention is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? a. Positioning patient on right side b. Maintaining adequate fluid intake c. Positioning patient with "good lung" down d. Performing postural drainage every 4 hours

C Malignant lung disease (lung cancer) is primarily caused by cigarette smoking. Option a: Whichever lung is dependent (facing down) will have the better ventilation. If the patient has bilateral lung disease, then the right lung should be dependent, as it's the larger lung. Options b, d: Maintaining adequate fluid intake and performing posture drainage will facilitate airway clearance, but does not enhance oxygenation (↑ ventilation). Option c: Since we don't know which lung is affected in the question, then we just need to ensure the unaffected (good) lung is dependent.

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing intervention is most appropriate based upon these findings? a. Continue with ambulation since this is a normal response to activity. b. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. c. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. d. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.

C Option a: Decreased oxygen saturation is not a normal response to activity. They need to rest and resaturate. Option b: Pulse ox is fairly accurate of O2 saturation, so an ABG would not be needed in his specific case. Option c: This patient is not tolerating exercise and will require supplemental O2 during ambulation. Option d: The pulse ox was working at the beginning of the walk, so the reading is accurate and the probe doesn't need to be moved.

Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia? a. Hyperresonance on percussion b. Vesicular breath sounds in all lobes c. Increased vocal fremitus on palpation d. Fine crackles in all lobes on auscultation

C Option a: Hyperresonance (increased resonance) on percussion indicates air accumulation in the lungs, such as pneumothorax, emphysema (hyperinflation of alveoli/decreased expiration), or asthma. Option b: Vesicular breath sounds are normal, healthy breath sounds. You wouldn't hear this with pneumonia. Option c: Vocal fremitus (vibrations during speech) on palpation is a normal finding. However, increased vibrations indicates fluid accumulation. Option d: Fine crackles would be heard on auscultation due to fluid accumulation, but it would only be in the affected lobes and not all lobes.

The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? IV fluids Biofeedback therapy Systemic corticosteroids Pulmonary function testing

C Option a: IV fluids may be used to prevent dehydration and hypotension, but they will not treat bronchoconstriction. Option b: Biofeedback therapy is a non-drug treatment in which patients learn to control bodily processes that are normally involuntary, such as muscle tension, blood pressure, or heart rate. Option c: Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. Option d: A pulmonary function test measures lung volume, capacity, rates of flow, and gas exchange and can be completed after the asthma attack is resolved to assess lung function.

During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? a. Laryngospasm b. Pulmonary edema c. Narrowing of the airway d. Overdistention of the alveoli

C Option a: Laryngospasm is a sudden constriction of the larynx, making it difficult to breathe or speak. The nurse will hear stridor (high-pitched, whistling sound caused by extremely disrupted airflow) on auscultation. Option b: Pulmonary edema (excess fluid in the lungs) would cause crackles (clicking/rattling sound caused by fluid in alveoli) on auscultation. Option c: A narrowed airway would cause wheezing (musical, high-pitched sound caused by inflammation) on auscultation. Option d: Volutrauma refers to the local overdistention of normal alveoli, usually caused by mechanical ventilation exerting too much pressure in the lungs.

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect? a. Nasal packing b. Epistaxis balloon c. Gastrostomy tube d. Peripheral skin care

C Option a: Nasal packing is used to prevent a hematoma after rhinoplasty and to facilitate clotting with epistaxis (nose bleeds). Option b: An epistaxis balloon, like nasal packing, is used to control intranasal bleeding and facilitate clot formation. Option c: Patients with head and neck cancer have difficulty swallowing and are likely malnourished before treatment begins. GI tube placement may be necessary for enteral feedings. Option d: Skin care should be maintained regardless and is not specific to head and neck cancer treatment (Prevent/treat: dry skin, ulcerations, skin infections).

Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? a. Supine b. Lithotomy c. High Fowler's d. Reverse Trendelenburg

C Option a: Supine (lying flat on back) and lithotomy (on back, legs elevated in stirrups) do not promote lung expansion. Option c: High fowler's or orthopneic positioning promote full lung expansion and enlist the aid of gravity during inspiration. Option d: Reverse trendelenburg (supine with 15-30 degree incline, head elevated above feet) is used in abdominal surgical procedures for better access.

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? a. Allow time to calm the patient. b. Observe for signs of diaphoresis. c. Evaluate the use of intercostal muscles. d. Monitor the patient for bilateral chest expansion.

C Option a: The patient is struggling to breathe and probably won't be able to calm down until symptoms are relieved. Option b: Due to anxiety and increase RR, the patient is probably diaphoretic. This is an expected finding. Option c: By evaluating the chest wall for intercostal (accessory) muscle use, the nurse can determine the extent of respiratory distress the patient is experiencing. Option d: Atelectasis (collapsed alveoli due to lack of air entering the space), and eventually pneumothorax (collapsed lung), can occur due to asthma. However, auscultation (↓ lung sounds) and tracheal deviation are better indicators of these conditions.

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? a. Water-seal chamber has 5 cm of water. b. No new drainage in collection chamber d. Chest tube with a loose-fitting dressing c. Small pneumothorax at CT insertion site

C Option a: The water seal chamber creates an air tight collection chamber for chest fluid drainage. The water seal chamber usually contains 2 cm, but more water won't contribute to an air leak (although <2 cm would contribute to an air leak). Option b: No new drainage in the collection chamber does not indicate an air leak, but it may indicate the chest tube is no longer needed. Option c: A loose-fitting dressing around the chest tube insertion site can cause an air leak and will need to be sealed; an air leak will prevent a strong suction and may cause air to enter the thoracic cavity. Option d: If there is a pneumothorax (air in pleural cavity), the chest tube should remove the air.

A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? a. Bilateral erythema of especially large tonsils b. Temperature 102.2° F, diaphoresis, and chills c. Contraction of neck muscles during inspiration d. β-hemolytic streptococcus in the throat culture

C Option a: Tonsillitis is inflammation of the tonsils, which can cause erythema (reddening) and enlargement. Options b, d: Strep infection can cause cause fever, diaphoresis, and chills. Option c: Contraction of neck muscles during inspirations is accessory muscle use and indicates respiratory distress.

When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections? a. Smoking causes a hoarse voice. b. Cough will become nonproductive. c. Decreased alveolar macrophage function. d. Sense of smell is decreased with smoking.

C Options a, d: A hoarse voice (larynx damage) and decreased sense of smell do not increase the incidence of pulmonary infection. These occur due to mucosa damage. Option c: Smoking damages the lungs by causing macrophage dysfunction, which increases the incidence of pulmonary infection. Other lung damage includes cilia paralysis/destruction, bronchospasm, and increased mucus secretion. Option d: Cough will become more productive due to increased mucous secretion.

The nurse teaches pursed lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? a. Loosening secretions so that they may be coughed up more easily b. Promoting maximal inhalation for better oxygenation of the lungs c. Preventing bronchial collapse and air trapping in the lungs during exhalation d. Increasing the respiratory rate and giving the patient control of e. respiratory patterns

C Patients with COPD tend to have non-elastic alveoli, creating dead air space in the lungs. Pursed lip breathing helps expel extra air from the lungs.

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with COPD are successful based on which finding? a. Absence of dyspnea b. Improved mental status c. Effective and productive coughing d. PaO2 within normal range for the patient

C The question asks which intervention would best assess for airway clearance, not respiratory status. Option a: Dyspnea is shortness of breath that can be caused by constricted airway, mucus production, or fluid in the lungs and is not a strong indicator of airway clearance specifically. Option b: Improved mental status may indicate the brain is receiving more O2, which would be better to assess respiratory status, but is still more of a subjective observation. Option c: Effective, productive cough indicates the airway is clear enough that sputum can be expelled. Option d: PaO2 is a good, objective assessment to indicate respiratory status, not airway clearance.

The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium (Atrovent) after noting which assessment finding? a. Decreased respiratory rate b. Increased respiratory rate c. Increased peak flow readings d. Decreased sputum production

C Ipratropium is a bronchodilator and expands the airway, which should result increased peak flow (inspiratory and expiratory). This is the maximum speed that air can be moved in/out of the lungs.

After swallowing, a 73-year-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormality? a Decreased response to hypercapnia b Decreased number of functional alveoli c Increased calcification of costal cartilage d Decreased respiratory defense mechanisms

D Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). The other answers are changes related to aging, but they do not increase the risk of aspiration.

When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? a. Vomiting b. Increased urination c. Decreased heart rate d. Rapid respiratory rate

D Diabetic acidosis (also called diabetic ketoacidosis/DKA) is a form of metabolic acidosis that develops during uncontrolled diabetes when there is decreased insulin and decreased glucose uptake. When this occurs, the body starts metabolizing fat for energy (since it cannot access glucose, since glucose cannot enter cells without insulin), releasing acidic ketones into the blood. With metabolic acidosis, the compensatory system (respiratory) will attempt to decrease acidity. Deep, rapid breaths (Kussmaul's respirations) will blow off CO2, decreasing acidity in blood.

A patient has been receiving oxygen per nasal cannula while hospitalized for COPD. The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? a. "Long-term home oxygen therapy should be used to prevent respiratory failure." b. "Oxygen will not be needed until or unless you are in the terminal stages of this disease." c. "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." d. "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."

D Long term O2 therapy is not considered until: SaO2 is <88%, PaO2 <55 mmHg, or the patient has signs of hypoxia (↓ O2 in tissues).

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? a. The patient has lung cancer. b. The incision will be medial sternal or lateral. c. Chest tubes will not be needed postoperatively. d. Less discomfort and faster return to normal activity

D Option a: A VATS can be used for more can just lung cancer. Option b: An incision for a thoracotomy (surgical opening into the thorax). is usually medial sternal or lateral, and much larger. Option c: A chest tube is needed after VATS or traditional thoracotomy. Option d: VATS uses minimally invasive incisions that cause less discomfort and faster healing than an open thoracotomy.

What is the priority nursing intervention in helping a patient expectorate thick lung secretions? a. Humidify the oxygen as able. b. Administer cough suppressant q4hr. c. Teach patient to splint the affected area. d. Increase fluid intake to 3 L/day if tolerated.

D Option a: Humidifying the air can decrease discomfort, but it won't affect the viscosity of lung secretions. Option b: Cough suppressants are contraindicated with increased mucus production in the lungs, as this will prevent the patient from expelling it through cough. Option c: If there is an incision, splinting it while coughing can ease chest pain and can therefore increase the intensity/productiveness of the cough, but it's not the most effective method to expectorate secretions. Option d: Increasing fluid intake will decrease mucus viscosity, making it easier to expel from the lungs.

Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching regarding the use of an ipratropium inhaler?" a. I can rinse my mouth following the two puffs to get rid of the bad taste." b. "I should wait at least 1 to 2 minutes between each puff of the inhaler." c. "Because this medication is not fast-acting, I cannot use it in an emergency if my breathing gets worse." d. "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily.

D Option a: Rinsing your mouth after inhaler use can remove any lingering bad taste and (for steroidal inhalers) prevent thrush. Option b: Waiting 1-2 minutes before inhalation increases the effectiveness of each dose. Option c: Ipratropium is a long acting beta agonist and prevents bronchoconstriction; it cannot treat an acute attack. Option d: Too many doses can lead to paradoxical bronchospasm.

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure 130/88, respirations 36/minute, and oxygen saturation 91% on room air. What action should the nurse take first? a. Notify the physician. b. Administer a nitroglycerin tablet sublingually. c. Conduct a thorough assessment of the chest pain. d. Sit the patient up in bed as tolerated and apply oxygen.

D Option a: The nurse should always provide intervention before contacting the physician. Option b: Nitroglycerin can be given with angina pectoris attacks, but the patient's chest pain is slight. This also will not address the RR or low O2 sat. Option c: The chest pain is slight and the patient is in respiratory distress, so a thorough assessment is not the priority. Option d: The patient is in respiratory distress, as their RR is elevated and O2 sat is dropping.

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? a. "I will seek immediate medical treatment for any upper respiratory infections." b. "I should continue to do deep-breathing and coughing exercises for at least 12 weeks." c. "I will increase my food intake to 2400 calories a day to keep my immune system well." d. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

D Option a: The patient should not seek medical attention unless the URI persists for >7 days. Option b: The patient should continue to do cough/ deep breathing exercises for 6-8 weeks, not 12 weeks. Option c: Increased caloric intake will not help with the treatment of pneumonia. Option d: A chest follow-up X-ray should be after conducted 6-8 weeks to evaluate pneumonia resolution.

The patient seeks relief from the symptoms of an upper respiratory infection (URI) that has lasted for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? a. Coughing b. Fever, chills c. Dust allergy d. Maxillary pain

D Options a, b: Coughing, fever, and chills are nonspecific signs of an infection, such as a URI. Option c: Allergies can cause both a URI or sinusitis. Option d: A sinus infection can cause maxillary pain.

A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? a. Apply an external splint to the nose. b. Insert plastic nasal implant surgically. c. Humidify the air for mouth breathing. d. Maintain surgical packing in the nose.

D Options a, b: It's not in the nurse's scope of practice to apply splints for surgical implants. Option c: Humidifying the air won't affect recovery post-op from rhinoplasty. Option d: After rhinoplasty, the goal post-op is to prevent formation of a septal hematoma (clotted blood caused by a broken blood vessel). Nasal packing applies direct pressure to oozing vessels to stop post-op bleeding. Preventing a hematoma can prevent complications such as infection.

A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admission of this patient? a. Perform a comprehensive health history with the patient to review prior respiratory problems. b. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. c. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. d. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

D Pulmonary heart disease, also known as cor pulmonale, is the enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance, such as from pulmonic stenosis or high blood pressure in the lungs from COPD. Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed.

A client has a Mantoux test performed. A response of 5mm would indicate: A. The presence of respiratory allergies B. The early stages of COPD in an at risk patient C. A need for bronchodilator treatment in asthma D. Unlikely tuberculosis infection in a low-risk patient

D The Mantoux test is a test for screen for tuberculosis by injecting the dermis with turberculin (protein found in tuberculosis). A reaction at the injection site (induration >5 mm) indicates a positive test result, and indicates the patient may have come into contact with TB. A positive test result can also occur, even with no TB exposure, if the patient is immunocompromised (such as HIV).

Before discharge, the nurse discusses activity levels with a 61-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? a. Slightly increase activity over the current level. b. Swim for 10 min/day, gradually increasing to 30 min/day. c. Limit exercise to activities of daily living to conserve energy. d. Walk for 20 min/day, keeping the pulse rate <30 bpm.

D The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than ~75% of maximum heart rate. [Maximum heart rate = 220 - patient's age]

A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma? a. Anxiety b. Cyanosis c. Bradycardia c. Hypercapnia

a An asthma attack is a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, making it difficult to breathe. Option a: An early manifestation of an asthma attack is anxiety because the patient is aware of their inability to get sufficient air. Option b: Cyanosis is a late sign and indicates hypoxia (insufficient O2 perfusion to tissues). Option c: An early sign of an asthma attack is hypoxemia (insufficient O2 in blood), leading to tachycardia to try to compensate to low O2 levels. Also, this patient has anxiety, which will also increase HR. Option d: Hypercapnia is a build up of CO2 in the blood. This patient will be hyperventilating (↑RR) to attempt to get more oxygen, so CO2 will decrease (and pH will increase/become more basic). Eventually, this can lead to respiratory alkalosis.