Respitory

The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter? 1. 10 seconds 2. 25 seconds 3. 30 seconds 4. 35 seconds

1. 10 seconds Rationale:During suctioning, the nurse should apply suction during the withdrawal of the catheter for a period of 5 to 10 seconds. Suction applied longer than this can cause hypoxia in the client.

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points would be included in the instructions? Select all that apply. 1. The client leans over a bedside table. 2. The client should sit on the edge of the bed. 3. The procedure involves obtaining a biopsy. 4. A time-out is performed before the procedure. 5. The procedure is performed during a bronchoscopy. 6. A local anesthetic is administered before the procedure.

1. The client leans over a bedside table. 2. The client should sit on the edge of the bed. 4. A time-out is performed before the procedure. 6. A local anesthetic is administered before the procedure. Rationale:A thoracentesis is a procedure in which fluid is removed from the pleural space. The procedure involves insertion of a needle percutaneously and then removal of the fluid by connecting the needle to a vacuum bottle. Before the thoracentesis, the nurse needs to check for allergies because a local anesthetic is administered. A time-out is performed in which the client identification, coagulation studies, and area of the pleural effusion are verified. A chest x-ray is performed after the procedure. A potential complication is a pneumothorax. The client sits on the bedside and leans over a bedside table, which exposes the area between the ribs. A lung biopsy is often done during a bronchoscopy. Test-Taking Strategy(ies):Focus on the subject, thoracentesis. Recall that the procedure is performed percutaneously and removes pleural fluid. Consider that the area for the needle insertion is best exposed by the client sitting at the bedside while leaning over the bedside table, and a local anesthetic is indicated.

The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator that suctioning has been effective? 1.Breath sounds are now clear. 2.Suctioning is required only once a shift. 3.Oxygen saturation has increased two points. 4.Respiratory rate has gone down by four breaths per minute.

1.Breath sounds are now clear. Rationale:Clear breath sounds are the most accurate indicator of the effectiveness of a suctioning procedure. Options 3 and 4 are incorrect because they are less precise. Option 2 is incorrect because the need for suctioning may be influenced by factors other than the effectiveness of previous suctioning. These other factors could include improvement of underlying respiratory condition, fluid status, and effectiveness of cough.

A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. Which recommendations by the nurse are therapeutic? Select all that apply. 1.Get plenty of rest. 2.Take antipyretics for fever. 3.Increase intake of liquids. 4.Get a flu vaccine immediately. 5.Eat carbohydrates only for energy.

1.Get plenty of rest. 2.Take antipyretics for fever. 3.Increase intake of liquids. Rationale:Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms. Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. Carbohydrates are not necessarily more important than other elements of a healthy diet.

The nurse is collecting data on a client with chronic sinusitis. Which are signs and symptoms of chronic sinusitis? Select all that apply. 1.Loss of smell 2.Chronic cough 3.Nasal stuffiness 4.Clear nasal discharge 5.Severe evening headache

1.Loss of smell 2.Chronic cough 3.Nasal stuffiness Rationale:Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough caused by nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep.

The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observations are consistent with the need for suctioning? Select all that apply. 1.Restlessness 2.Gurgling sounds with respiration 3.Presence of congestion in the lungs 4.Increased pulse and respiratory rates 5.Low peak inspiratory pressure on the ventilator

1.Restlessness 2.Gurgling sounds with respiration 3.Presence of congestion in the lungs 4.Increased pulse and respiratory rates Rationale:Indications for suctioning include moist, wet respirations; restlessness; congestion on auscultation of the lungs; visible mucus bubbling in the ETT; increased pulse and respiratory rates; and increased peak inspiratory pressures on the ventilator. A low peak inspiratory pressure would indicate a leak in the mechanical ventilation system.

The nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection? 1.High fever 2.Chills and night sweats 3.Complaints of diarrhea 4.Petechiae on the upper extremities

2.Chills and night sweats Rationale:The client with tuberculosis usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. Which statements indicate prevention of transmission of tuberculosis? Select all that apply. 1. "I will bleach my clothes and bedding after use." 2. "My family and I will practice good hand hygiene." 3."I will discard disposable tissues into a plastic bag." 4. "I will cover my mouth when I cough, sneeze, or laugh." 5."All the deep pile carpeting will be removed from my home."

2. "My family and I will practice good hand hygiene." 3."I will discard disposable tissues into a plastic bag." 4. "I will cover my mouth when I cough, sneeze, or laugh." Rationale:TB is spread by droplet nuclei or by the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. Bleaching of clothing and linens is unnecessary, although the client and family members should use good hand-washing technique. It is unnecessary to remove carpeting from the home. The client should protect others by covering the mouth when coughing, laughing, or sneezing. The client and family should wash hands often. Disposable tissues should be used and discarded in a plastic bag. Test-Taking Strategy(ies):Focus on the subject, transmission of tuberculosis. Knowing that tuberculosis is not carried on inanimate objects helps you eliminate the options of removing deep pile carpet and bleaching clothing and sheets first. Recalling that the disease is transmitted by the airborne route will direct you to the correct options 2, 3, and 4.

The nurse is caring for a client with emphysema receiving oxygen. The nurse would consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen? 1. 1 L/min 2. 2 L/min 3. 6 L/min 4. 10 L/min

2. 2 L/min Rationale: Between 1 L/min and 3 L/min of oxygen by nasal cannula may be required to raise the PaO2 level to 60 mm Hg to 80 mm Hg. However, oxygen is used cautiously in the client with emphysema and should not exceed 2 L/min unless specifically prescribed. Because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system.

Cycloserine is added to the medication regimen for a client with tuberculosis. Which instruction would the nurse include in the client teaching plan regarding this medication? 1. Take the medication before meals. 2. Return to the clinic weekly for serum drug levels. 3. It is not necessary to restrict alcohol intake with this medication. 4. It is not necessary to call the primary health care provider if a skin rash occurs.

2. Return to the clinic weekly for serum drug levels. Rationale:Cycloserine is an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity. A serum drug level less than 30 mg/mL reduces the incidence of neurotoxicity. The medication needs to be taken after meals to prevent gastrointestinal irritation. The client needs to be instructed to notify the primary health care provider if a skin rash or early signs of central nervous system toxicity are noted. Alcohol needs to be avoided because it increases the risk of seizure activity.

The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax? 1. Bradypnea 2. Shortness of breath 3. A low respiratory rate 4. The presence of a barrel chest

2. Shortness of breath Rationale:The client has sustained a blunt or a closed chest injury. This type of injury can result in a closed pneumothorax. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. There may also be hyperresonance on the affected side. The presence of a barrel chest is characteristic of chronic obstructive pulmonary disease or emphysema.

The nurse has finished suctioning a client. The nurse would use which parameters to best determine the effectiveness of suctioning? 1.Client skin color (pink) 2.Breath sounds are clear 3.Client statement of comfort 4.Sao2 is 98% by pulse oximetry

2.Breath sounds are clear Rationale:The nurse evaluates the effectiveness of the suctioning procedure by auscultating breath sounds. This helps determine if the respiratory tract is clear of secretions. In addition, breath sounds must be auscultated before every suctioning procedure. Client skin color, client statement of comfort, and Sao2 at 98% do not determine the effectiveness of suctioning.

The nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which would the nurse do first? 1. Contact the registered nurse. 2.Check for kinks in the chest drainage system. 3.Check the client's blood pressure and heart rate. 4.Connect a new drainage system to the client's chest tube.

2.Check for kinks in the chest drainage system. Rationale:If the nurse notes that a chest tube is not draining, the nurse would first check for a kink or possible clot in the chest drainage system. The nurse then notifies the registered nurse and observes the client for respiratory distress or mediastinal shift (if this occurs, the primary health care provider is notified). Checking the heart rate and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new drainage system to the client's chest tube is done when the fluid drainage chamber is full. There is a specific procedure to follow when a new drainage system is connected to a client's chest tube.

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action? 1. Call a code. 2.Check the client. 3.Confirm the rhythm. 4.Check the cardiac leads and wires.

2.Check the client. Rationale:If a monitor alarms sounds, the nurse should first assess the clinical status of the client to see whether the problem is an actual dysrhythmia or a malfunction of the monitoring system. Asystole should not be mistaken for an unattached electrocardiogram wire. The other options would be appropriate once the nurse has checked the client.

The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis? Select all that apply. 1. Scant mucus 2.Early onset cough 3.Marked weight loss 4.Purulent mucous production 5.Mild episodes of dyspnea

2.Early onset cough 4.Purulent mucous production 5.Mild episodes of dyspnea Rationale:Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucous production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucous production, minimal weight loss, and milder episodes of dyspnea.

The nurse is collecting data from a client who is experiencing the typical signs/symptoms of tuberculosis (TB). Which are signs and symptoms of tuberculosis? Select all that apply. 1. Weight gain 2.Night sweats 3.Sporadic coughing 4.Mucopurulent sputum 5.Afternoon low grade fever

2.Night sweats 4.Mucopurulent sputum 5.Afternoon low grade fever Rationale:The client with tuberculosis may report symptoms that have been present for weeks or even months. The symptoms may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever in the afternoon, and cough with mucoid or blood-streaked sputum. The cough is often persistent.

The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse would monitor for which item as the best indicator of an adequate respiratory status? 1. Oxygen saturation of 89% 2.Respiratory rate of 18 breaths per minute 3.Moderate amounts of tracheobronchial secretions 4.Small to moderate amounts of frank blood suctioned from the tube

2.Respiratory rate of 18 breaths per minute Rationale:An airway problem could occur following tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion caused by immobility, or concurrent respiratory conditions. The respiratory rate of 18 breaths per minute is well within the normal range of 14 to 20 breaths per minute. An oxygen saturation of 89% is less than optimal.

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly? 1. The client breathes in through the mouth. 2.The client breathes out slowly through the mouth. 3. The client avoids using the abdominal muscles to breathe out. 4.The client puffs out the cheeks when breathing out through the mouth.

2.The client breathes out slowly through the mouth. Rationale:Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, to inhale before beginning the activity, and to exhale while performing the activity. The client should never hold his or her breath.

A client is at risk of developing a pulmonary embolism. The nurse monitors for which initial sign/symptom? 1.Hot, flushed feeling4 2.Sudden chills and fever 3.Chest pain that occurs suddenly 4.Dyspnea noted when deep breaths are taken

3.Chest pain that occurs suddenly Rationale:The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include cough, tachycardia, fever, diaphoresis, anxiety, and possibly syncope.

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made? 1. Skin color becomes cyanotic. 2.Secretions are becoming bloody. 3.Coughing occurs with suctioning. 4.Heart rate decreases from 78 to 54 beats per minute.

3.Coughing occurs with suctioning. Rationale:The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, or the sudden development of bloody secretions. If they occur, the nurse stops suctioning and reports these signs to the primary health care provider immediately. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure.

The nurse is assessing a client diagnosed with sinusitis. Which are signs and symptoms of sinusitis? Select all that apply. 1.A high fever 2.Nuchal rigidity 3.Headache, especially in the morning 4.Elevated white blood cell (WBC) count 5.Feeling of heaviness over affected areas

3.Headache, especially in the morning 4.Elevated white blood cell (WBC) count 5.Feeling of heaviness over affected areas Rationale:Signs and symptoms of sinusitis include a feeling of heaviness over the affected areas. This can feel like a toothache if maxillary sinusitis or a headache, especially in the morning, for frontal sinusitis. Nasal drainage can become purulent. The white blood count is elevated. A high fever and nuchal rigidity are signs and symptoms of meningitis, which is a possible complication of sinusitis.

The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problems? Select all that apply. 1.Fever 2.Epilepsy 3.Hypotension 4.Respiratory failure 5.Use of peripheral vasoconstrictors

3.Hypotension 5.Use of peripheral vasoconstrictors Rationale:Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings from impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.

The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement? 1. "I need to sit upright when using the device." 2."I will inhale slowly, maintaining a constant flow." 3."I need to place my lips completely over the mouthpiece." 4."After maximal inspiration, I will hold my breath for 10 seconds and then exhale."

4."After maximal inspiration, I will hold my breath for 10 seconds and then exhale." Rationale:For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 5 seconds and then exhale slowly through pursed lips.

The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse would expect to note which finding? 1. High fever 2. Flushed skin 3. Complaints of weight gain 4.Complaints of night sweats

4.Complaints of night sweats Rationale:The client with TB usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease.

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially? 1. Listen to the client's heart sounds. 2. Determine whether the client has a pulse deficit. 3. Instruct the client to use an incentive spirometer. 4.Determine the client's ability to follow verbal commands.

4.Determine the client's ability to follow verbal commands. Rationale:Cheyne-Stokes respirations, rhythmic respirations with periods of apnea, occur with disorders affecting the respiratory center of the pons in the central nervous system such as a metabolic dysfunction in the cerebral hemisphere or basal ganglia. The nurse should initially obtain data about neurological functioning, starting with determining the client's ability to respond to verbal stimuli. Listening to heart sounds is important but is secondary to determining the neurological status. There is no information related to the need to check for a pulse deficit (difference between the apical and radial pulse). The use of incentive spirometry is indicated for shallow breathing and postoperatively. Test-Taking Strategy(ies):Focus on the strategic words, most appropriate and initially. Use the steps of the nursing process to eliminate use of the incentive spirometer because this is an intervention. Next, recall that Cheyne-Stokes respirations occur in clients with problems involving the central nervous system. Eliminate the options dealing with data collection of the circulation systems. Select the option that details basic data collection of the nervous system.

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response? 1. Call a code. 2.Administer a bronchodilator. 3.Contact the registered nurse. 4.Disconnect the suction source from the catheter.

4.Disconnect the suction source from the catheter. Rationale:The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse would immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse would then connect the oxygen source to the catheter. The nurse also notifies the registered nurse who then notifies the primary health care provider. The primary health care provider will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if this situation occurs during suctioning.

A client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. In addition to respiratory failure, the nurse plans to monitor the client for which complication of this disorder? 1.Paralytic ileus 2.Hypernatremia 3.Hyperglycemia 4.Increased intracranial pressure

4.Increased intracranial pressure Rationale:Carbon dioxide acts as a vasodilator to cerebral blood vessels. With a sufficient rise in carbon dioxide, the client may suffer increased intracranial pressure, which is reflected initially as papilledema and dilated conjunctival blood vessels. Options 1, 2, and 3 are not complications.

The nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a Pao2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client? 1. Fatigue 2. Aspiration 3.Airway obstruction 4.Ineffective gas exchange

4.Ineffective gas exchange Rationale:Restlessness and low Pao2 are hallmark signs of ineffective oxygen exchange. Airway obstruction and aspiration are not problems that are specifically associated with existing pneumonia. Although many clients with pneumonia experience fatigue, this is not the priority problem.

While assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder? 1.Early morning fatigue 2.Dyspnea that is relieved by lying flat 3.Pain that worsens when the breath is held 4.Knifelike pain that worsens on inspiration

4.Knifelike pain that worsens on inspiration Rationale:A typical symptom with pleurisy is a knifelike pain that worsens on inspiration. This is a result of the friction caused by the rubbing together of inflamed pleural surfaces. This pain usually disappears when the breath is held because these surfaces stop moving. The client does not experience early morning fatigue or dyspnea relieved by lying flat.

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and has an arterial blood gas test done. Which results would the nurse expect to note? 1. Po2 of 70 mm Hg and Pco2 of 45 mm Hg 2. Po2 of 68 mm Hg and Pco2 of 40 mm Hg 3. Po2 of 62 mm Hg and Pco2 of 40 mm Hg 4.Po2 of 60 mm Hg and Pco2 of 50 mm Hg

4.Po2 of 60 mm Hg and Pco2 of 50 mm Hg Rationale:During an acute exacerbation of COPD, the arterial blood gases deteriorate with a decreasing Po2 and an increasing Pco2. In the early stages of COPD, arterial blood gases demonstrate a mild to moderate hypoxemia, with the Po2 in the high 60s to high 70s and normal arterial Pco2. As the condition advances, hypoxemia increases and hypercapnia may result.

A client with chronic obstructive pulmonary disease has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if which action is taken? 1.The client selects foods that are very dry. 2.The client increases the use of milk products. 3.The client increases the use of stimulants such as caffeine. 4.The client plans to eat the largest meal of the day at a time when hungry.

4.The client plans to eat the largest meal of the day at a time when hungry. Rationale:The client is taught to plan the largest meal of the day at a time when the client is most likely to be hungry. It is also beneficial to eat four to six small meals per day if needed. The client avoids dry foods, which are hard to chew and swallow. The client also avoids milk and chocolate, which have a tendency to thicken saliva and secretions. Finally, the client should avoid the use of caffeine, which contributes to dehydration by promoting diuresis.

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information would reassure the client that contaminating family members and others is not likely? 1. The family does not need therapy, and the client will not be contagious after 1 month of medication therapy. 2. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy. 3. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy. 4.The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

4.The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Rationale:Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis.

The nurse is assisting a primary health care provider with the insertion of an endotracheal tube (ETT). The nurse would plan which as a final measure to determine correct tube placement? 1.Hyperoxygenate the client. 2,Tape the tube securely in place. 3.Listen for bilateral breath sounds. 4.Verify placement by a chest x-ray.

4.Verify placement by a chest x-ray. Rationale:The final measure to determine ETT placement is to verify it by a chest x-ray. The chest x-ray shows the exact placement of the tube in the trachea, which should be above the bifurcation of the right and left mainstream bronchi. The other options are incorrect because they are completed initially after tube placement.

A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? 1. Restricting the client's potassium intake 2.Encouraging the client to rest after meals 3.Administering the heparin with a 25-gauge needle 4Holding the digoxin for a heart rate less than 60 beats per minute

1. Restricting the client's potassium intake Rationale:Clients with acute pulmonary edema are on a sodium-restricted diet, not potassium restricted. Restricting potassium makes the client more prone to digoxin toxicity. Digoxin should be held and the health care provider notified when the client's heart rate is less than 60 beats per minute unless otherwise prescribed. Heparin should be administered with a 25- or 27-gauge needle to reduce tissue trauma. Resting after meals decreases the demands placed on the heart and should be encouraged.

The nurse is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement? 1."I will take this medication every day." 2."I will take this medication every other day." 3."I will take this medication until I feel better." 4."I will take this medication only when I have pain."

1."I will take this medication every day." Rationale:A single daily dose of 1 baby aspirin (low-dose aspirin) may be a component of the standard treatment regimen for the client after an MI. Aspirin helps prevent clotting and may prevent a thrombosis that could cause a second MI. If the client cannot tolerate aspirin, then another antiplatelet medication may be prescribed. The other three options are unacceptable because the benefit comes in taking the medication on a daily basis.

The licensed practical nurse (LPN) in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The LPN immediately notifies the registered nurse (RN) and expects which interventions to be prescribed? Select all that apply. 1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously 5.Transporting the client to the coronary care unit 6.Placing the client in a low-Fowler's side-lying position

1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously Rationale:Pulmonary edema is a life-threatening event that can result from severe heart failure. During pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? 1.Baked turkey 2.Tomato soup 3.Boiled shrimp 4.Chicken gumbo

1.Baked turkey Rationale:Regular soup (1 cup) contains 900 mg of sodium. Fresh shellfish (1 oz) contains 50 mg of sodium. Poultry (1 oz) contains 25 mg of sodium.

The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse determines that the client understands the instructions if the client states that which food item will be avoided? 1.Catsup 2.Sherbet 3.Cooked cereal 4.Leafy green vegetables

1.Catsup Rationale:Catsup is high in sodium. Leafy green vegetables, cooked cereal, and sherbet all are low in sodium. Clients with heart failure should monitor sodium intake.

A client at risk for pulmonary embolism (PE) suddenly develops respiratory distress, chest pain, and anxiety. The nurse would plan to take which actions? Select all that apply. 1.Check vital signs. 2.Administer warfarin. 3.Notify the registered nurse. 4.Begin low-flow oxygen therapy. 5.Raise the bed to a low-Fowler's position.

1.Check vital signs. 3.Notify the registered nurse. 4.Begin low-flow oxygen therapy. Rationale:Initial care for a client who might be experiencing a PE is to remain calm, stay with the client, raise the head of the bed to a high-Fowler's position, begin low-flow O2 therapy, check vital signs, notify the registered nurse and primary health care provider of the client's symptoms, start a peripheral intravenous line if one is not already established, and assist to administer heparin when it is prescribed. A low-Fowler's position would not be used initially, and heparin is administered in the initial stage of a suspected pulmonary embolism.

Which diagnostic tests indicate active tuberculosis? Select all that apply. 1.Chest x-ray 2.Tuberculin skin test 3.Gastric analysis washings 4.Sputum smear and culture 5.Interferon gamma release assays (IGRA)

1.Chest x-ray 3.Gastric analysis washings 4.Sputum smear and culture Rationale:Active tuberculosis is diagnosed by a chest x-ray, sputum smear, and sputum culture. A diagnosis of active TB is established when the tubercle bacillus has been found in the sputum or gastric washings. Interferon gamma release assays (IGRA) is a diagnostic aid that measures a component of cell-mediated immune reactivity to M. tuberculosis much like the tuberculin skin testing. These test results indicate a need for further evaluation.

The nurse is discussing signs of severe airway obstruction with a group of nursing students. Which sign would the nurse emphasize as one that indicates severe airway obstruction? 1.Cyanosis 2.A loud cough 3.Pink color to the skin 4.Respiratory rate of 12 to 16 breaths per minute

1.Cyanosis Rationale:Signs of severe airway obstruction include cyanosis, poor air exchange, increased breathing difficulty, a silent cough, or inability to speak or breathe. A loud cough, pink color to the skin, and respiratory rate of 12 to 16 breaths per minute are incorrect and may be signs of mild respiratory distress that would not require immediate intervention.

A client brings the following medications to the clinic for a yearly physical. The nurse realizes which medication has been prescribed to treat heart failure? 1.Digoxin 2.Warfarin 3.Amiodarone 4.Potassium chloride

1.Digoxin Rationale:Digoxin strengthens the heartbeat and decreases the heart rate. It is used in the treatment of heart failure. Potassium chloride increases the potassium level. Although digoxin does lower the potassium level, potassium chloride is not specifically administered for heart failure. Warfarin and amiodarone do not treat heart failure.

The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis? 1.High-grade fever 2.Chills and night sweats 3.Anorexia and weight loss 4.Nonproductive or productive cough

1.High-grade fever Rationale:The client with TB usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweating (which may occur at night), and a low-grade fever.

A client with chronic obstructive pulmonary disease (COPD) on bed rest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, which is the priority client activity for the nurse to incorporate in the plan of care? 1.Instruct the client to reposition himself. 2.Elevate the head of the bed to 15 degrees. 3.Transfer the client to the chair three times daily. 4.Perform passive flexion and extension of the ankles.

1.Instruct the client to reposition himself. Rationale:Therapy for COPD usually includes glucocorticoids that carry a high risk of complications such as muscle and bone wasting, fragile skin, impaired immune functioning, and fluid retention, so the nurse must restore some client strength before attempting to get the client out of the bed. Because the client is likely to be weak from bed rest and lack of activity during mechanical ventilation and treatment, the nurse establishes outcomes for the client including restoration of pulmonary, cardiovascular, and musculoskeletal functioning to return to baseline functioning. To begin safely, the nurse instructs the client to reposition himself in bed to exert force on muscles and bones helping to reverse the tissue loss incurred during bed rest. The nurse initially positions a client with COPD at 45 degrees or higher until the client can tolerate a lower position and still maintain adequate oxygenation. Self-repositioning can be followed with dangling at the bedside and sitting in the chair before attempting ambulation. Active flexing and extending ankles is very important to prevent a thromboembolic event related to bed rest, but this activity will not adequately restore strength.

The nurse is caring for a newly admitted client with pneumonia. The primary health care provider has prescribed a sputum specimen for culture and sensitivity. The nurse would perform the actions concerning the sputum collection in which priority order? Arrange the actions in the order that they should be performed. All options must be used. 1.Obtain and label a sterile container. 2.Administer the prescribed antibiotics. 3.Send the specimen immediately to the laboratory. 4.Have the client brush teeth and rinse mouth with water. 5.Have the client take several deep breaths before coughing. 6.Have the client expectorate sputum (not saliva) into sterile container.

1.Obtain and label a sterile container. 4.Have the client brush teeth and rinse mouth with water. 5.Have the client take several deep breaths before coughing. 6.Have the client expectorate sputum (not saliva) into sterile container. 3.Send the specimen immediately to the laboratory. 2.Administer the prescribed antibiotics. Rationale:Once the nurse notes the prescription to obtain a sputum specimen for culture and sensitivity, the nurse should obtain and label a sterile specimen container. The client is then instructed to brush teeth and rinse mouth with water to decrease contamination of the sputum. Antiseptic mouth wash should not be used. The client should then take several deep breaths before coughing. The client should then expectorate sputum (not saliva) into the sterile container. The collected specimen should be taken immediately to the laboratory. After the specimen is collected, then antibiotics can be started.

The nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB? 1.Residents of a long-term care facility 2.Persons admitted to the hospital for day surgery 3.A family who has recently emigrated from Australia 4.Children older than 6 years of age in a summer school program

1.Residents of a long-term care facility Rationale:Residents of long-term care facilities are considered high-risk candidates for TB. Children younger than 4 years of age also are considered a high-risk group. Persons admitted for day surgery are not high-risk candidates. Foreign immigrants (especially from Mexico, the Philippines, and Vietnam) are considered high risk, but those from Australia are not.

The nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse would implement which action? 1.Review the intake and output records for the last 2 days. 2.Prescribe daily weights starting on the following morning. 3.Change the time of diuretic administration from morning to evening. 4.Request a sodium restriction of 1 g/day from the health care provider.

1.Review the intake and output records for the last 2 days. Rationale:Edema is the accumulation of excess fluid in the interstitial spaces, which can be determined by intake greater than output and by a sudden increase in weight (2.2 lb = 1 kg). To determine the extent of fluid accumulation, the nurse first reviews the intake and output records for the past 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.

The nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? 1.Tall, peaked T waves 2.ST segment depressions 3.Shortened P-R intervals 4.Shortening of the QRS complex

1.Tall, peaked T waves Rationale:The symptoms of hyperkalemia relate to its effect on the myocardial muscle. These include changes noted on the ECG such as tall, peaked T waves, prolonged P-R interval, widening of the QRS complex, shortening of the Q-T interval, and disappearance of the P wave. Other cardiac symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST-segment depression is noted in hypokalemia.

The nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse uses this data to make which interpretation? 1.The behavior is likely the result of hypoxia. 2.The client probably suffers from alcoholism. 3.The client must also have a high blood alcohol level. 4.The carbon monoxide has caused the blood glucose to fall.

1.The behavior is likely the result of hypoxia. Rationale:The client with carbon monoxide poisoning may appear intoxicated. This is the end result of hypoxia on the central nervous system (CNS). With carbon monoxide poisoning, oxygen cannot easily bind onto the hemoglobin, which is carrying strongly bound carbon monoxide. Because cerebral tissue has a critical need for oxygen, sustained hypoxia may yield this typical finding. For this reason, options 2, 3, and 4 are incorrect interpretations.

The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when an alarm sounds. Which action would the nurse do first?' 1Check the client. 2Check the ventilator. 3Manually ventilate the client with a resuscitation bag. 4Call the respiratory therapist or rapid response team.

1Check the client. Rationale:For a client receiving mechanical ventilation, always check the client first and then check the ventilator. A resuscitation bag should be available at the bedside for all clients receiving mechanical ventilation. If the cause of the alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is corrected. The nurse needs to determine if the respiratory therapist or rapid response team needs to be called.

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item? 1.Apples 2.Cheese 3.Oranges 4.Skim milk

2.Cheese Rationale:Fruits, vegetables, and skim milk contain minimal amounts of fat. Cheese is high in fat.

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement? 1."This diet will help lower my blood pressure." 2."Fresh foods such as fruits and vegetables are high in sodium." 3."This diet is not a replacement for my antihypertensive medications." 4."The reason I need to lower my salt intake is to reduce fluid retention."

2."Fresh foods such as fruits and vegetables are high in sodium." Rationale:A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Fresh foods such as fruits and vegetables are low in sodium.

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statements by the client indicate a need for further teaching? Select all that apply. 1."I will avoid using table salt with meals." 2."I am going to switch to electronic cigarettes." 3."It is best to exercise once a week for an hour." 4."I will take nitroglycerin whenever chest discomfort begins." 5."I will use muscle relaxation to cope with stressful situations."

2."I am going to switch to electronic cigarettes." 3."It is best to exercise once a week for an hour." Rationale:Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthy habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that causes pain, and to take the medication at the first sign of chest discomfort. Electronic cigarettes contain nicotine, which causes vasoconstriction.

The nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question? 1."Are you having any nausea?" 2."Where is the pain located?" 3."Are you allergic to any medications?" 4."Do you have your nitroglycerin with you?"

2."Where is the pain located?" Rationale:If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, precipitating factors, location, radiation, and quality. Although options 1, 3, and 4 may be components of the assessment, these would not be the initial assessment questions in this situation.

The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)? 1.A client with blunt chest trauma 2.A client with pancreatitis and gram-negative sepsis 3.A client who has received 1 unit of packed red blood cells 4.A client with acute pulmonary edema after myocardial infarction

2.A client with pancreatitis and gram-negative sepsis Rationale:The client with pancreatitis and gram-negative sepsis is at greatest risk of developing ARDS because of the presence of two risk factors for its development. Although the client with blunt chest trauma is also at risk, those who have multiple risk factors have a three to four times greater incidence for development of ARDS. Massive blood transfusion is a risk factor for ARDS; however, this client has received only 1 unit. Pulmonary edema after myocardial infarction occurs when increased pulmonary capillary hydrostatic pressure causes flooding of the pulmonary interstitial spaces and then the alveoli. The pulmonary edema that occurs in ARDS is due to damage to pulmonary vasculature resulting in increased pulmonary capillary permeability.

The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder? 1.Central cyanosis 2.Arterial Pao2 of 48 3.Arterial Pao2 of 81 4.Respiratory rate of 10 breaths per minute

2.Arterial Pao2 of 48 Rationale:The most characteristic sign of ARDS is increasing hypoxemia with a Pao2 of less than 60 mm Hg. This occurs despite increasing levels of oxygen that are administered to the client. The client's earliest sign is an increased respiratory rate. Breathing then becomes labored, and the client may exhibit air hunger, retractions, and peripheral cyanosis.

The nurse assessing a client who has a history of hypertension would assess the client for pulsations by palpating which cardiac landmark? 1.Strict bed rest for 24 hours 2.Bathroom privileges and self-care activities 3.Unrestricted activities because the client is monitored 4.Unsupervised hallway ambulation with distances less than 200 feet

2.Bathroom privileges and self-care activities Rationale:Upon transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).

The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse would include which items on a list of suggestions to be given to the client? Select all that apply. 1.Wear elastic stockings. 2.Be careful not to injure the legs or feet. 3.Use a heating pad on the legs to aid vasodilation. 4.Walk each day to increase circulation to the legs. 5.Cut down on the amount of fats consumed in the diet.

2.Be careful not to injure the legs or feet. 4.Walk each day to increase circulation to the legs. 5.Cut down on the amount of fats consumed in the diet. Rationale:Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Elastic stockings will not increase circulation. They are worn with peripheral vascular disease but not peripheral arterial disease. Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds expecting to hear which breath sounds bilaterally? 1.Rhonchi 2.Crackles 3.Wheezes 4. Diminished breath sounds

2.Crackles Rationale:Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.

The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention would be included in the postprocedure plan of care? 1.Place the client's bed in the Fowler's position. 2.Encourage the client to increase fluid intake. 3.Instruct the client to perform range-of-motion exercises of the extremities. 4.Hold regularly scheduled medications for 24 hours following the procedure.

2.Encourage the client to increase fluid intake. Rationale:Immediately following a cardiac catheterization using the femoral approach, the client should not flex or hyperextend the affected leg. Placing the client in the Fowler's position increases the risk of hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. Flexion or hyperextension and range-of-motion exercises of the extremity are contraindicated. The regularly scheduled medications are needed to treat acute and chronic conditions.

A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse would provide which explanation for these symptoms? 1.Expected and will last for at least a year 2.Expected, and the client should very gradually increase activity as tolerated 3.An unexpected finding with TB, but it should resolve within about 1 month 4.A short-lived problem that should be gone within 1 week of medication therapy

2.Expected, and the client should very gradually increase activity as tolerated Rationale:The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this will resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased. The nurse explains that this can be harmful because it could cause which difficulty? 1.It could be drying to nasal passages. 2.It could decrease the client's oxygen-based respiratory drive. 3.It could increase the risk of pneumonia from drier air passages. 4.It could decrease the client's carbon dioxide-based respiratory drive.

2.It could decrease the client's oxygen-based respiratory drive. Rationale:Normally, respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD this natural center becomes ineffective after exposure to high carbon dioxide levels for prolonged periods. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD usually cannot increase oxygen levels independently because it could deplete the respiratory drive and lead to respiratory failure. Physician prescriptions are always followed.

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope in which location? 1.Near the lateral 12th rib 2.Just under the left clavicle 3.In the 5th intercostal space 4.Posteriorly under the left scapula

2.Just under the left clavicle Rationale:The apex of the lung is the rounded, uppermost part of the lung. To check breath sounds in a client with a left apical pneumothorax, the nurse would place the stethoscope just under the left clavicle. The other options are incorrect.

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems? 1.Anterior chest pain 2.Pericardial friction rub 3.Weakness and irritability 4.Chest pain that worsens on inspiration

2.Pericardial friction rub Rationale:A pericardial friction rub is heard when there is inflammation of the pericardial sac during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints that could accompany a wide variety of disorders.

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action? 1.Monitor oxygen saturation levels. 2.Place the client on a cardiac monitor. 3.Measure blood pressure every 4 hours. 4.Check capillary refill at least once per shift.

2.Place the client on a cardiac monitor. Rationale:The client with decreased cardiac output should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed. Other cardiovascular data should be collected at least every 2 hours initially.

A licensed practical nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. Which action should the nurse take? 1.Tell the RN that a stronger medication is needed. 2.Report the client's symptoms to the registered nurse (RN). 3.Tell the client to administer a second dose of the medication. 4.Ask the client about any over-the-counter medications taken recently.

2.Report the client's symptoms to the registered nurse (RN). Rationale:The client taking an adrenergic bronchodilator may experience paradoxical bronchospasm, which is evidenced by the client's wheezing. This can occur with excessive use of inhalers. If this occurs, further medication should be withheld, and the RN immediately notified

The nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? 1.Tall, peaked T waves 2.ST-segment depression 3.Prolonged P-R interval 4.Widening of the QRS complex

2.ST-segment depression Rationale:In the client with hypokalemia, the nurse would note ST-segment depression on a cardiac monitor. The client may also exhibit a flat T wave. Options 1, 3, and 4 are cardiac findings noted in the client with hyperkalemia.

The nurse is monitoring a client following cardioversion. Which observations would be of highest priority to the nurse? 1.Blood pressure 2.Status of airway 3.Oxygen flow rate 4.Level of consciousness

2.Status of airway Rationale:Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which would be the nurse's next action? 1.Notify the registered nurse immediately. 2.Stop the procedure and oxygenate the client. 3.Continue to suction the client at a quicker pace. 4.Ensure that the suction is limited to 15 seconds.

2.Stop the procedure and oxygenate the client. Rationale:During suctioning the nurse should monitor the client closely for complications including hypoxemia, drop in heart rate due to vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If complications develop, especially cardiac irregularities, the nurse should stop the procedure and oxygenate the client.

The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse would perform which action? 1.Suction the client vigorously. 2Place the client in high-Fowler's position. 3Begin assembling medications that are anticipated to be given. 4Call the respiratory therapy department to request a ventilator.

2Place the client in high-Fowler's position. Rationale:The client in pulmonary edema is placed in the high-Fowler's position if the blood pressure is adequate. Vigorous suctioning may deplete the client of vital oxygen at a time when the respiratory system is compromised. Assembling medications is useful but not critical to the immediate well-being of the client. The client may or may not need mechanical ventilation.

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client? 1."Herbal substances are not safe and should never be used." 2."I will teach you how to take your blood pressure so that it can be monitored closely." 3."You will need to talk to your primary health care provider (PHCP) before using an herbal substance." 4."If you take an herbal substance, you will need to have your blood pressure checked frequently."

3."You will need to talk to your primary health care provider (PHCP) before using an herbal substance." Rationale:Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects, because the combination may lead to an excessive reaction or unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the PHCP.

A client has an inoperable abdominal aortic aneurysm (AAA). Which measure would the nurse anticipate reinforcing when teaching the client? 1.Bed rest 2.Restricting fluids 3.Antihypertensives 4.Maintaining a low-fiber diet

3.Antihypertensives Rationale:The medical treatment for abdominal aortic aneurysm is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to be on bed rest. A low-fiber diet is not helpful and will cause constipation.

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse would expect to note which specific characteristic of this condition? 1.Dyspnea 2.Hacking cough 3.Dependent edema 4.Crackles on lung auscultation

3.Dependent edema Rationale:Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

A client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include a beta blocker, digoxin, and a diuretic. A tentative diagnosis of digoxin toxicity is made. Which assessment data supports this diagnosis? 1.Dyspnea, edema, and palpitations 2.Chest pain, hypotension, and paresthesia 3.Double vision, loss of appetite, and nausea 4.Constipation, dry mouth, and sleep disorder

3.Double vision, loss of appetite, and nausea Rationale:Double vision, loss of appetite, and nausea are signs of digoxin toxicity. Additional signs of digoxin toxicity include bradycardia, difficulty reading, visual alterations such as green and yellow vision or seeing spots or halos, confusion, vomiting, diarrhea, decreased libido, and impotence.

While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur? 1.Lub-dub sounds 2.Scratchy, leathery heart noise 3.Gentle, blowing or swooshing noise 4.Abrupt, high-pitched snapping noise

3.Gentle, blowing or swooshing noise Rationale:A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. It occurs from increased or abnormal blood flow through the valves of the heart. Lub-dub sounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial friction rub is described as a scratchy, leathery heart sound that occurs with pericarditis. A click is described as an abrupt, high-pitched snapping sound.

A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure? 1.Sims' position with the head of the bed flat 2.Prone with the head turned to the side supported by a pillow 3.Left side-lying with the head of the bed elevated at 45 degrees 4.Right side-lying with the head of the bed elevated at 45 degrees

3.Left side-lying with the head of the bed elevated at 45 degrees Rationale:To facilitate removal of fluid from the chest wall, two positions may be used. The client may be positioned sitting on the edge of the bed, leaning over the bedside table with his or her feet supported on a stool. The other position is lying in bed on the unaffected side with the head of the bed elevated 45 degrees (Fowler's position). The other options are incorrect because they do not facilitate drainage of fluid to an area where it can be easily removed with thoracentesis.

The nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure? 1.Asks the client to sit upright 2.Uses the diaphragm of the stethoscope 3.Places the stethoscope on the client's gown 4.Asks the client to breathe slowly and deeply through the mouth

3.Places the stethoscope on the client's gown Rationale:To listen to breath sounds, the stethoscope always is placed directly on the client's skin, and not over a gown or clothing. The nurse asks the client to sit up and breathe slowly and deeply through the mouth. Breath sounds are auscultated using the diaphragm of the stethoscope, which is warmed before use.

The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the primary health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? 1.Mental status 2.Urinary output 3.Respirations and blood pressure 4.Temperature and blood pressure

3.Respirations and blood pressure Rationale:Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client who experienced an MI. Although monitoring mental status is a component of the nurse's assessment, it is not the priority following administration of morphine sulfate. The nurse should monitor the client's respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Urinary output is unrelated to the administration of this medication. Monitoring the temperature is also not associated with the use of this medication.

The nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse would interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse? 1. The client is not experiencing nausea or vomiting. 2.The pain is described as substernal and radiating to the left arm. 3.The pain has not been relieved by rest and nitroglycerin tablets. 4.The client says the pain began while trying to open a stuck dresser drawer.

3.The pain has not been relieved by rest and nitroglycerin tablets. Rationale:The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI may also radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and is frequently accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety). The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics such as morphine sulfate for relief.

A client has a prescription for niacin. The nurse determines that the client understands the importance of this therapy if the client verbalizes the importance of which periodic monitoring? 1.The creatinine level 2.Renal function studies 3.The serum cholesterol level 4.The blood urea nitrogen level

3.The serum cholesterol level Rationale:Niacin is used as adjunctive therapy in the management of hyperlipidemia. This is used in conjunction with a low-fat, low-cholesterol diet; exercise; and smoking cessation. Serum cholesterol and triglyceride levels are monitored periodically to assess the effectiveness of therapy. The laboratory studies in options 1, 2, and 4 assess renal function.

For a client diagnosed with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal? 1.Elevating the legs when in bed 2.Sleeping in the supine position 3.Using a bedside commode for stools 4.Seasoning beef with a meat tenderizer

3.Using a bedside commode for stools Rationale:Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client's legs would increase venous return to the heart and result in an increase in cardiac workload. The supine position can increase respiratory effort and decrease oxygenation, which increases cardiac workload. Meat tenderizers are high in sodium. Sodium contributes to hypertension, which increases cardiac workload.

A client with heart failure is scheduled to be discharged to home with digoxin and furosemide as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect? 1.Decrease in pedal edema 2.High urine output during the day 3.Weight gain of 2 to 3 pounds in a few days 4.Cough accompanied by other signs of respiratory infection

3.Weight gain of 2 to 3 pounds in a few days Rationale:Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in daytime voiding is expected while on diuretic therapy. A cough as a result of respiratory infection does not necessarily indicate that heart failure is exacerbating.

The nurse is talking with a client with angina about factors that can precipitate an angina attack. Which statement by the client indicates an understanding of the precipitating events? 1."I am going to run a mile each day." 2."I am going to switch to electronic cigarettes." 3."I will walk up two flights of stairs without stopping." 4."I will pay my neighbor to shovel my snow this winter."

4."I will pay my neighbor to shovel my snow this winter." Rationale:Excessive exertion and cold frequently trigger angina attacks. Having the neighbor shovel snow will prevent the client from exertion in cold weather. Electronic cigarettes contain nicotine, which causes vasoconstriction.

A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6°F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question would the nurse ask the client first? 1."Do you exercise regularly?" 2."Would you consider losing weight?" 3."Is there a history of diabetes mellitus in your family?" 4."When was the last time you had your blood pressure checked?"

4."When was the last time you had your blood pressure checked?" Rationale:The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors for CAD not exhibited by this client include smoking and hyperlipidemia. The client is overweight, which is also a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority on the client's major modifiable risk factors.

The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position? 1.Midsternum equal with the nipple line 2.At the midaxillary line on the left side of the chest 3.At the midline of the chest just below the xiphoid process 4.At the midclavicular line at the fifth left intercostal space

4.At the midclavicular line at the fifth left intercostal space Rationale:The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart's apex.

An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse consults with the registered nurse to verify a prescription for which medication that the client was taking before admission? 1.Acarbose 2.NPH insulin 3.Regular insulin 4.Chlorpropamide

4.Chlorpropamide Rationale:Chlorpropamide is an oral hypoglycemic agent that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. It is a first-generation sulfonylurea. Insulin does not cause or aggravate fluid retention. Acarbose is a miscellaneous oral hypoglycemic agent.

In order to assess the dorsalis pedis pulse of a client diagnosed with arterial vascular disease, the nurse palpates which anatomical location? Refer to figure. 1. A 2.B 3.C 4.D

4.D Rationale:The dorsalis pedis pulse is located on the dorsum (top) of the foot. The carotid artery is located in the neck region. The radial artery is located in the wrist. The posterior tibial artery is located at the medial aspect of the ankle.

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation? 1.Expected and indicates the result of massive hemolysis 2.Unexpected and indicates a concurrent history of renal insufficiency 3.Unexpected and indicates a deficit of hydrogen ions in the bloodstream 4.Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out

4.Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out Rationale:With severe respiratory acidosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell forcing intracellular potassium out. This is an expected finding in this situation. Options 1, 2, and 3 are incorrect interpretations.

The nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse would assess for which earliest sign of acute respiratory distress syndrome? 1.Diffuse crackles 2.Bilateral wheezing 3.Intercostal retractions 4.Increased respiratory rate

4.Increased respiratory rate Rationale:The first sign of ARDS is usually increased respiratory rate. Auscultation of the lungs may reveal fine crackles. The client may be restless, agitated, and confused. The pulse rate increases, and a cough may be present. These early signs are followed by progressively worsening dyspnea with retractions, cyanosis, and diaphoresis. Diffuse crackles and rhonchi may be heard on auscultation.

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu? 1.Tea 2.Cola 3.Coffee 4.Lemonade

4.Lemonade Rationale:A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.

Which medications would the nurse expect to be prescribed to effectively reduce nasal edema and rhinorrhea (thin watery discharge from the nose)? Select all that apply 1.Isoniazid 2.Terbutaline 3.Corticotropin 4.Oxymetazoline 5.Phenazopyridine 6.Pseudoephedrine

4.Oxymetazoline 6.Pseudoephedrine Rationale:Oxymetazoline and pseudoephedrine are decongestants that reduce nasal edema and rhinorrhea. Corticotropin is an anti-inflammatory agent. Isoniazid is used in the treatment of tuberculosis. Terbutaline causes bronchodilation. Phenazopyridine is a urinary analgesic.

The nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client? 1.Prinzmetal's angina is effectively managed by beta-blocking agents. 2.Prinzmetal's angina improves with a low-sodium, high-potassium diet. 3.Prinzmetal's angina has the same risk factors as stable and unstable angina. 4.Prinzmetal's angina is generally treated with calcium channel blocking agents.

4.Prinzmetal's angina is generally treated with calcium channel blocking agents. Rationale:Prinzmetal's angina results from spasm of the coronary arteries and is generally treated with calcium channel blocking agents. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Beta blockers are contraindicated because they may actually worsen the spasm. Diet therapy is not specifically indicated, although a healthy diet consuming foods low in fat and sodium is advocated in cardiac disease.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse would incorporate which action as the best strategy to assist the client in coping with the disease? 1.Ask family members if they wish a psychiatric consult. 2.Allow the client to deal with the disease in an individual fashion. 3.Encourage the client to visit with the pastoral care department chaplain. 4.Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

4.Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. Rationale:A primary role of the nurse in working with a client with tuberculosis is to teach the client about medication therapy. The anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids) and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy that will eradicate it. This gives the client a measure of power over the situation and outcome.

A client with respiratory congestion is scheduled to receive acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer. The nurse checks the client's room to ensure that which equipment is available for use following administration of this medication? 1.Ambu bag 2.Intubation tray 3.Nasogastric tube 4.Suction equipment

4.Suction equipment Rationale:Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. The nurse administering this medication as a mucolytic should have suction equipment available in case the client cannot manage to clear the increased volume of liquefied secretions. The items in options 1, 2, and 3 are not necessary.

The nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse would incorporate which instruction in discussion with the client? 1.Increase fluids to 3000 mL per day to promote renal perfusion. 2.Consume 1 to 2 ounces of liquor each night to promote vasodilation. 3.Try to engage in vigorous activity to strengthen cardiac reserve. 4.Take in adequate daily fiber to prevent straining during a bowel movement.

4.Take in adequate daily fiber to prevent straining during a bowel movement. Rationale:Standard instructions for a client with cardiac disease include, among others, lifestyle changes such as decreasing alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen program to prevent straining and constipation, and maintaining fluids and electrolytes. Increasing fluids to 3000 mL could lead to increased blood volume and an increased workload on the heart in the client with cardiac disease.

A client is being discharged to home following recovery from an anterior myocardial infarction with recurrent angina. The client will be taking diltiazem, isosorbide dinitrate, and nitroglycerin sublingually as needed, and the nurse reinforces information to the client about the medications. Which statement by the client indicates a need for further teaching about the medications? 1."I will store these medications in a cool place away from light." 2."All three of these medications will increase blood flow to my heart." 3."All three of these medications will help decrease the intensity of my chest pain." 4."I should notify my doctor immediately if I experience headaches with any of these medications."

Rationale:Because of the vasodilating effects of nitrates, headache is a common side effect. Medical attention is not needed unless the headaches increase in severity or frequency. All three medications are nitrates, which improve myocardial circulation by dilating coronary arteries and collateral vessels, thus increasing blood flow to the heart. These medications are used to help prevent the frequency, intensity, and duration of anginal attacks. Nitrates should be stored in a cool place and in a dark container. Heat and light cause these medications to break down and lose their potency. Test-Taking Strategy(ies):Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that these medications have a vasodilating effect and that headache is a common side effect will direct you to option 4.

The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate? 1. Continue to monitor. 2.Empty the drainage. 3.Encourage the client to deep breathe. 4.Encourage the client to hold his or her breath periodically.

1. Continue to monitor. Rationale:The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. Encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his or her (client) breath.

The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse reinforce? Select all that apply 1. Activities should be resumed gradually. 2. Avoid contact with other individuals except family members for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. 6. When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment.

1. Activities should be resumed gradually. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. Rationale:The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is reassured that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities should be resumed gradually. The client and family are informed that respiratory isolation is not necessary because family members have already been exposed. The client is instructed about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication is initiated and that when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment.

The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining a proper specimen? 1. Have the client take three deep breaths. 2. Limit fluids before obtaining the specimen. 3. Ask the client to obtain the specimen after eating. 4. Ask the client to spit into the collection container.

1. Have the client take three deep breaths. Rationale:To obtain a sputum specimen, the client should brush his or her teeth to reduce mouth contamination. The client should then take three deep breaths and cough into a sputum specimen container. The client should be encouraged to cough and not spit so that sputum can be obtained. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.

The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles? 1. Mask 2.Gown 3.Gloves 4.Eye protection

1. Mask Rationale:Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. The other options are not necessary.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions would the nurse take? Select all that apply. 1. Notify the RN. 2. Notify the Rapid Response Team. 3. Finish the suctioning as quickly as possible. 4. Discontinue suctioning until the client is stabilized. 5. Contact the respiratory department to suction the client.

1. Notify the RN. 4. Discontinue suctioning until the client is stabilized. Rationale:When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the RN. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and PHCP may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified.

A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse would take which action after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour? 1. Refrigerate the specimen. 2.Obtain a second specimen immediately. 3. Discard the specimen and make the client wait an hour to get a new one. 4.Keep the client nothing-by-mouth (NPO) for 30 minutes and obtain a second specimen.

1. Refrigerate the specimen. Rationale:Refrigeration will stabilize the culture and prevent the growth of additional bacteria. Options 2, 3, and 4 are unnecessary.

A clinic nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. Which intervention would the client be encouraged to perform? 1.Avoid foods that are highly seasoned. 2.Restrict fluid intake to 1000 mL daily. 3.Drink warm herbal tea throughout the day. 4.Substitute hot chocolate in place of coffee.

1.Avoid foods that are highly seasoned. Rationale:The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. Milk and milk products are avoided because they tend to increase mucus production. Foods that are highly seasoned are irritating to the throat and should be avoided, and the client should be instructed to drink 2000 to 3000 mL of fluid daily unless contraindicated.

The licensed practical nurse (LPN) in the emergency department is caring for a client who was assaulted and sustained blunt force injuries to the chest and abdomen. Which priority client data would the LPN immediately report to the registered nurse (RN)? 1. Pedal pulses 2. +2Tracheal deviation to the left 3. Capillary refill time of 2 seconds 4. Ecchymosis noted on the chest and abdomen

2. +2Tracheal deviation to the left Rationale:A tension pneumothorax is a life-threatening emergency that results when air enters the pleural space but cannot escape. The intrapleural pressures increasingly elevate, which results in compression of the lung on the affected side and pressure on the heart and great vessels, which decreases cardiac output. The mediastinum also shifts toward the unaffected side, which further compromises oxygenation by compressing the unaffected lung. The trachea deviates towards the unaffected side. Option 2 is an abnormal assessment finding that indicates the client is suffering from a tension pneumothorax and needs to be immediately reported to the registered nurse, who will then notify the primary health care provider. Options 1 and 3 are normal assessment findings. Option 4 is an expected assessment finding for a client who suffered blunt trauma to those areas and is not the priority over option 2. Note the strategic words, priority and immediately. Also, focus on the subject, the client data that warrants immediate RN notification. Use of the ABCs - airway, breathing, and circulation will direct you to the correct option. Tracheal deviation indicates there is a problem with the airway that needs to be immediately addressed.

A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect? 1. Hypercalcemia 2. Peripheral neuritis 3. Small blood vessel spasm 4. Impaired peripheral circulation

2. Peripheral neuritis Rationale:An adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesia in the extremities. This adverse effect can be minimized with pyridoxine (vitamin B6) intake. Test-Taking Strategy(ies):Focus on the subject, the adverse effects of isoniazid. Options 3 and 4 would not cause the symptoms presented in the question but instead would be manifested by pallor and coolness. Thus options 3 and 4 can be eliminated first. From the remaining options, it is necessary to know either that peripheral neuritis is an adverse effect of the medication or that the client's symptoms do not correlate with hypercalcemia.

Which statement by the client indicates a need for further teaching regarding the reinforced home care instructions for acute sinusitis? 1."I should drink large amounts of fluids." 2."I will need surgery to drain my sinuses." 3."I should apply a wet, warm heat pack over my sinuses." 4."I will need to sleep with the head of the bed elevated."

2."I will need surgery to drain my sinuses." Rationale:The nurse provides instructions to the client regarding measures to promote sinus drainage, comfort, and resolution of the infection. The nurse instructs the client to apply heat in the form of hot wet packs over the affected sinuses to promote comfort and help resolve the infection. Large amounts of fluids are important to help liquefy secretions. Sleeping with the head of the bed elevated to a 45-degree angle will assist in promoting drainage. Surgery may be performed to improve drainage in chronic conditions if other measures are not helpful, but it is not usually a treatment measure for acute sinusitis.

A client reports the chronic use of nasal sprays. The nurse reinforces instructions to this client about which piece of information related to chronic use of nasal sprays? 1. Nosebleeds are common. 2.The protective mechanism of the nose may be damaged. 3.It is acceptable to double the dose if one dose is ineffective. 4.Fungal infections of the nose may occur because of container contamination.

2.The protective mechanism of the nose may be damaged. Rationale:The protective mechanisms of the nose may be altered with the chronic use of nasal sprays. Fungal infections occur with oral inhalers but not nasal sprays. Nosebleeds are uncommon. The client should not double-dose medications to increase their effect.

The nurse is assessing a client who has frequent episodes of asthma. Which assessment finding is most closely associated with asthma? 1. Fine rhonchi 2. Pink, frothy sputum 3. Bilateral wheezing 4.Rhonchi that clear with a cough

3. Bilateral wheezing Rationale:Wheezing is the symptom most associated with asthma, a reactive airway disease. Fine rhonchi; rhonchi that clear with a cough; and pink, frothy sputum are not associated with asthma.

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which results that are consistent with this disorder? 1. Pao2 58 mm Hg, Paco2 32 mm Hg 2. Pao2 60 mm Hg, Paco2 45 mm Hg 3. Pao2 49 mm Hg, Paco2 52 mm Hg 4. Pao2 73 mm Hg, Paco2 62 mm Hg

3. Pao2 49 mm Hg, Paco2 52 mm Hg Rationale:Respiratory failure is described as a Pao2 of 50 mm Hg or less, and a Paco2 of 50 mm Hg or greater in a client with no history of respiratory disease. In a client with a history of respiratory disorder with hypercapnia, Paco2 elevations of 5 mm Hg or more from the client's baseline are considered diagnostic.

A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action? 1. Obtain a set of vital signs. 2.Administer oxygen at 21%. 3. Place the client in high-Fowler's position. 4. Obtain equipment for starting an intravenous line.

3. Place the client in high-Fowler's position. Rationale:The first nursing action is to place the client in a position that aids in respiration, which would be sitting bolt upright or in high-Fowler's position. Other nursing actions follow in rapid sequence and include monitoring vital signs and administering bronchodilators and oxygen (but at levels of 2 to 5 L/min or 24% to 28% by Ventimask). Insertion of an intravenous line and ongoing monitoring of respiratory status are also indicated.

A client who has just suffered a flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action? 1. Reposition the client. 2. Document the findings. 3.Notify the registered nurse. 4.Medicate the client for pain.

3.Notify the registered nurse. Rationale:The nurse would notify the registered nurse who would then contact the primary health care provider. The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This will lead to severe pain and dyspnea and can affect circulatory hemodynamics.

A client with pneumonia is admitted to the hospital, and the primary health care provider writes prescriptions for the client. Which prescription would the nurse complete first? 1. Increase the intake of oral fluids. 2.Administer a prescribed antibiotic. 3.Obtain a culture and sensitivity of sputum. 4. Encourage the use of an incentive spirometer.

3.Obtain a culture and sensitivity of sputum. Rationale:A culture and sensitivity should be obtained before any antibiotic therapy is begun to avoid masking the microorganisms identified in the culture. Options 1, 2, and 4 are standard parts of therapy for pneumonia, but sputum is collected first.

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method would be used to monitor the client for crepitus? 1. Auscultating the posterior breath sounds 2. Asking the client about pain upon inspiration 3. Placing the hands over the rib area and observing expansion 4. Palpating the skin around the chest and neck for a crackling sensation

4. Palpating the skin around the chest and neck for a crackling sensation Rationale:Air caught under the skin in the subcutaneous tissues is known as crepitus or subcutaneous emphysema. It presents as a "puffed-up" appearance that is caused by the leakage of air into the subcutaneous tissues. It is monitored by palpating, and it feels like bubble wrap when palpated. Auscultation of posterior breath sounds gives data about adequate depth of respirations. Pain upon inspiration can occur with pleurisy (inflammation of the pleurae) or pericarditis. Placing the hands over the rib area is a method of determining equal chest expansion on each side.

The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation? 1. Fever 2. Fatigue 3. Weight loss 4. Shortness of breath

4. Shortness of breath Rationale:Shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms that occur later include weakness and fatigue, malaise, fever, and weight loss.

The nurse is assisting in admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse plans to admit the client to which type of room? 1. Venting through single filters and ultraviolet light 2. Natural lighting with three air exchanges per hour 3. One air exchange per hour and venting to the outside 4. Venting to the outside, six air exchanges per hour, and ultraviolet light

4. Venting to the outside, six air exchanges per hour, and ultraviolet light Rationale:The client is admitted to a private room that has at least six air exchanges per hour and negative pressure in relation to surrounding areas. The room should be vented to the outside and should have ultraviolet lights installed.

A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which manifestation of histoplasmosis? 1. Dyspnea 2. Headache 3. Weight gain 4. Hypothermia

1. Dyspnea Rationale:Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There also may be enlargement of the client's lymph nodes, liver, and spleen.

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention? 1. Call the registered nurse. 2. Prepare for reintubation. 3. Call the rapid response team. 4. Check the client for spontaneous breathing.

4. Check the client for spontaneous breathing. Rationale:If unexpected intubation occurs, the nurse would first check the client for airway patency, spontaneous breathing, and vital signs. The nurse would remain with the client, call for assistance from the registered nurse, and prepare for reintubation. There are no data in the question to indicate that a code needs to be called.

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which arterial blood gas supports this diagnosis? 1. Po2 of 68 mm Hg and Pco2 of 40 mm Hg 2. Po2 of 55 mm Hg and Pco2 of 40 mm Hg 3. Po2 of 70 mm Hg and Pco2 of 50 mm Hg 4.Po2 of 60 mm Hg and Pco2 of 50 mm Hg

4.Po2 of 60 mm Hg and Pco2 of 50 mm Hg Rationale:During an acute exacerbation, the arterial blood gases deteriorate with decreasing Po2 levels and increasing Pco2 levels. In the early stages of chronic obstructive pulmonary disease, arterial blood gases demonstrate mild to moderate hypoxemia with the Po2 in the high 60s to high 70s (mm Hg) and normal arterial Pco2. As the condition advances, hypoxemia increases and hypercapnia may result.

The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has been taking medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made? 1, "I can't shop at the mall for the next 6 months." 2. "I need to continue medication therapy for 2 months." 3."I can return to work if a sputum culture comes back negative." 4."I should not be contagious after 2 to 3 weeks of medication therapy."

4."I should not be contagious after 2 to 3 weeks of medication therapy." Rationale:The client continues medication therapy for 6 to 12 months depending on the situation. The client is generally considered to not be contagious after 2 to 3 weeks of medication. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative. Test-Taking Strategy(ies):Focus on the subject, client understanding of discharge teaching regarding treatment of tuberculosis. Knowing that the medication lasts for at least 6 months helps you eliminate option 2 first. Knowing that three sputum cultures must be negative helps you eliminate option 3 next. From the remaining options, recalling that the client is not contagious after 2 to 3 weeks of therapy helps you choose option 4.

The nurse is instructing a client about pursed-lip breathing, and the client asks the nurse about its purpose. The nurse would tell the client that the primary purpose of pursed-lip breathing is which? 1.Promote oxygen intake 2.Strengthen the diaphragm 3. Strengthen the intercostal muscles 4.Promote carbon dioxide elimination

4.Promote carbon dioxide elimination Rationale:Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing

A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, which interpretation would the nurse make? 1.The client should be inhaling and exhaling quickly. 2.The client is using the incentive spirometer correctly. 3.The client should not be holding the breath following inhalation. 4.The client should be repeating the sequence 10 to 20 times in each session.

The client should be repeating the sequence 10 to 20 times in each session. Rationale:Incentive spirometer devices use a concept of sustained maximal inspiration. Each device has a means of setting an inspiratory goal. Correct use requires a spontaneous, slow, voluntary, deep breath. When full inhalation is reached, the breath is held for at least 3 seconds. This sequence is repeated 10 to 20 times an hour. Incentive spirometer exercises are most effective when used every hour while the client is awake.

The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client? 1. Abdominal distention 2. Purulent drainage around the tracheotomy site 3. Excessive secretions from the tracheotomy site 4.Inability to pass a suction catheter through the tracheotomy

1. Abdominal distention Rationale:Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and the esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also can cause aspiration of gastric contents. Option 2 may indicate an infection. Option 3 may indicate the need for more frequent suctioning. Option 4 may indicate an obstruction of some sort or the presence of bronchoconstriction.

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions would the nurse perform for this procedure? Select all that apply. 1. Apply suction for up to 10 seconds. 2. Hyperoxygenate the client before suctioning. 3. Set the wall suction unit pressure at 160 mm Hg. 4. Apply suction while gently inserting the catheter. 5.Apply intermittent suction while rotating and withdrawing the catheter. 6.Advance the catheter until resistance is met, and then pull the catheter back 1 cm.

1. Apply suction for up to 10 seconds. 2. Hyperoxygenate the client before suctioning. 5.Apply intermittent suction while rotating and withdrawing the catheter. 6.Advance the catheter until resistance is met, and then pull the catheter back 1 cm. Rationale:Intermittent suction is applied while rotating the catheter for up to 10 seconds. The nurse should hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source before suctioning because suction depletes the client's oxygen supply (option 2). The catheter should be inserted gently until resistance is met or the client coughs, then pulled back 1 cm or ½ inch. Intermittent suction is applied while rotating and withdrawing the catheter. Option 3 is incorrect because wall suction should be set to 80 mm Hg to 120 mm Hg. Pressure set at a higher level can cause trauma to respiratory tract tissues. Strict asepsis needs to be maintained, and the nurse would wear sterile gloves to perform this procedure. Suction is never applied when inserting the catheter because it will deplete oxygen and can traumatize tissues.

A client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation? 1. Directly observed therapy 2. More medication instructions 3. Involvement of the family in teaching 4.Reinforcement by the primary health care provider

1. Directly observed therapy Rationale:Tuberculosis is a highly communicable disease that is reportable to local public health departments. Each of these agencies has regulations that may be enforced to ensure compliance with tuberculosis therapy. The client may be required to have directly observed therapy to reduce the risk to the general public. This involves having a responsible person actually observe the client taking the medication each day.

The nurse is caring for a client with laryngitis. Which interventions would the nurse implement? Select all that apply. 1. Discourage smoking. 2.Use a room humidifier. 3. Speak only in whispers. 4.Use the intercom to contact the nurse. 5.Use lozenges that contain a topical anesthetic agent.

1. Discourage smoking. 2.Use a room humidifier. 5.Use lozenges that contain a topical anesthetic agent. Rationale:Smoking irritates the throat, so the client is discouraged from smoking. A humidifier will prevent a dry nose and throat. Lozenges with a topical anesthetic agent will decrease throat discomfort. Voice rest means not talking at all, even whispering. There should be a sign on the intercom indicating voice rest and going to the client's room.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom would the nurse expect the client to experience? 1. Dyspnea 2. Headache 3. Weight gain 4. Hypothermia

1. Dyspnea Rationale:Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be an enlargement of the client's lymph nodes, liver, and spleen as well. Test-Taking Strategy(ies):Focus on the subject, histoplasmosis, and recall that it begins as a respiratory infection. Recalling that histoplasmosis is an infectious process helps you eliminate hypothermia. Because the client has AIDS, as well as another infection, weight gain is an unlikely symptom and can be eliminated next. Knowing that histoplasmosis begins as a respiratory infection helps you choose dyspnea over headache as the correct option.

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply. 1. Enables the client to speak 2. Is necessary for mechanical ventilation 3. Must have the cuff deflated when capped 4. Eliminates the need for tracheostomy care 5. Prevents air from being inhaled through the tracheostomy opening

1. Enables the client to speak 3. Must have the cuff deflated when capped Rationale:A fenestrated tracheostomy tube is used when a client is being weaned from breathing through the tracheostomy to breathing normally through the nose and mouth. A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. The cuff of the tracheostomy tube must always be deflated before the fenestrated tube is capped. When the cuff is inflated, the tracheostomy tube can be used for mechanical ventilation. When the cuff is deflated and the cap is applied, the client can breathe around the tracheostomy tube. The client continues to need cleaning of the tracheostomy site. The client is unable to breathe through the tracheal opening or at all if the cuff is inflated and the opening capped. Test-Taking Strategy(ies):Focus on the subject, a fenestrated tracheostomy tube. Recall that the term fenestrated means there is an opening in the object like a fenestrated drape in a catheterization kit. Knowledge regarding the design and purpose of a fenestrated tracheostomy tube will direct you to the correct option.

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client? 1. Lateral position 2. Low-Fowler's position 3. Semi-Fowler's position 4. Head of the bed elevation at 40 degrees

1. Lateral position Rationale: Complete lateral positioning is contraindicated for a client following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. The head of the bed should be elevated.

The nurse is helping perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which would the nurse include for this type of data collection? Select all that apply. 1. Listening to lung sounds 2. Obtaining the client's temperature 3. Checking the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6.Asking the client about a family history of any illness or disease

1. Listening to lung sounds 2. Obtaining the client's temperature 4. Obtaining information about the client's respirations Rationale:A focused data collection process is centered around a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse would perform which action? 1. Notify the registered nurse. 2. Increase the frequency of suctioning. 3. Add moisture to the oxygen delivery system. 4. Document the character and amount of drainage.

1. Notify the registered nurse Rationale:Immediately following laryngectomy, there is a small amount of bleeding from the tracheostomy that resolves within the first few hours. Bleeding 24 hours after the surgery may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potentially life-threatening situation, and the registered nurse needs to be notified. The registered nurse will then contact the primary health care provider. Although the other options may be appropriate, they do not address the urgency of the problem. Failure to notify the primary health care provider in a timely fashion places the client at risk.

The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment would the nurse plan to have at the bedside when the client returns from surgery? 1. Obturator 2. Oral airway 3. Epinephrine 4. Tracheostomy tube with the next larger size

1. Obturator Rationale:A replacement tracheostomy tube of the same size and an obturator are kept at the bedside at all times in case the tracheostomy tube is dislodged. In addition, a curved hemostat that could be used to hold the trachea open if dislodgment occurs should also be kept at the bedside. An oral airway and epinephrine would not be needed. Test-Taking Strategy(ies):Use the ABCs—airway, breathing, and circulation. A larger size tracheostomy tube can be eliminated first because it would not be appropriate for the client. Next, eliminate epinephrine because it is unrelated to the subject of the question. From the remaining options, recall that the airway has been altered because of the tracheostomy, so an oral airway would not be necessary. Remember that a smaller replacement tracheostomy tube, an obturator, and a curved hemostat would be kept at the bedside of a client with a tracheostomy.

The client is diagnosed with pleurisy. The nurse would expect to see which signs and symptoms? Select all that apply. 1. Pleural friction rub 2. Sharp, knife-like pain 3. Cyanosis of lips and nailbeds 4. Pain that occurs on both sides of the chest 5. Pain that occurs most often during inspiration

1. Pleural friction rub 2. Sharp, knife-like pain 5. Pain that occurs most often during inspiration Rationale:Pleurisy is inflammation of the pleura. The most characteristic symptom of pleurisy is abrupt and severe pain. The pain almost always occurs on one side of the chest. Pleurisy pain is sharp, knife-like, and abrupt in onset and is most evident during inspiration. This causes shallow breathing. A pleural friction rub may be heard. Test-Taking Strategy(ies):Note the subject, signs and symptoms of pleurisy. Eliminate option 3 first because it is unrelated to pleurisy. Next, eliminate option 4 because a dry cough may be expected. Noting that a biopsy has been performed will assist with eliminating option 4 because the pain almost always occurs on one side of the chest, and clients usually can point to the exact spot.

The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority? 1. Report the findings. 2. Document the finding in the client's record. 3. Call the employee health service department.4 C.all the radiology department for a chest x-ray.

1. Report the findings. Rationale:The nurse who interprets a tuberculin skin test as positive notifies the PHCP immediately. The PHCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis or old healed lesions. A sputum culture would be done to confirm the diagnosis of active tuberculosis. The client is placed on tuberculosis precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client

The nurse is assisting in preparing a list of instructions for a client who is being discharged following a tonsillectomy. Which instructions would the nurse include in the list? Select all that apply. 1.Avoid hot fluids. 2.Avoid rough foods. 3.Consume milk products. 4.Rest for the next 24 hours. 5.Consume carbonated beverages. 6.Eat ice cream to soothe the throat.

1.Avoid hot fluids. 2.Avoid rough foods. 4.Rest for the next 24 hours. Rationale:Following tonsillectomy, the client is instructed to advance the diet from cool clear liquids to full liquids. Hot fluids and carbonated beverages should be avoided because they may be irritating to the throat. Milk and milk products are avoided because they may cause the client to cough, which can hurt the surgical site. Rough foods and snacks such as raw fruits or vegetables should be avoided for 10 days to protect the scab that forms over the operative site and to prevent bleeding. The client should be instructed to rest in bed or on a couch for 24 hours after the surgical procedure and gradually resume full activity.

Which are signs and symptoms characteristic of emphysema? Select all that apply. 1.Cyanosis 2.Wheezing 3.Weight loss 4.Barrel chest 5.Shortness of breath 6.Decreased lung sounds

1.Cyanosis 3.Weight loss 4.Barrel chest 5.Shortness of breath 6.Decreased lung sounds Rationale:The client with emphysema has a barrel chest, weight loss, and decreased lung sounds. Late signs and symptoms include shortness of breath and cyanosis. Wheezing is absent but is noted in other conditions such as asthma.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? 1. Suctioning is required frequently. 2. Aspiration of gastric contents occurs when suctioning. 3. The client's skin and mucous membranes are light pink. 4. Excessive secretions are suctioned from a tracheostomy.

2. Aspiration of gastric contents occurs when suctioning. Rationale:Necrosis of the tracheal wall in a client with a tracheostomy can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 3, and 4 are not signs of this complication. Test-Taking Strategy(ies):Focus on the subject, tracheoesophageal fistula. Use knowledge of anatomy and medical terminology to assist you in answering this question. A fistula is an artificial opening. The term tracheoesophageal indicates trachea to esophagus. This will direct you to option 2.

The nurse is assisting in planning care for a client with a chest tube. The nurse would suggest including which interventions in the plan? Select all that apply. 1. Pin the tubing to the bed linens. 2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or obstructed. 5.Empty the drainage from the drainage collection chamber daily.

2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or obstructed Rationale:The chest tube system must be maintained as a closed system in order for the air to be removed by suction and for the lungs to reexpand to a normal state. The connections should be airtight (no leaks), and all connections should be taped and secure. It is important that the tubes to the suction and the chest tube be patent (without kinks or obstructions). Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgment of the tube when the client moves. The chest tube system is not opened and emptied, because a closed system must be maintained; if the system is opened, air pressure causes air to rush in, and lung collapse can occur.

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action would the nurse implement? 1. Continue suctioning to remove the blood. 2. Check the amount of suction pressure being applied. 3.Encourage the client to cough out the bloody secretions. 4. Remove the suction catheter from the nose and begin vigorous suctioning through the mouth.

2. Check the amount of suction pressure being applied. Rationale:The return of bloody secretions is an unexpected outcome related to suctioning. If this occurs, the nurse should first assess the client and then determine the amount of suction pressure being applied. The amount of suction pressure may need to be decreased. The nurse also needs to be sure that intermittent suction and catheter rotation are being done during suctioning. Continuing with the suctioning or vigorous suctioning through the mouth will cause increased trauma and thus increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. Therefore, it is unlikely that the client will be able to cough out the bloody secretions.

The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions would the nurse anticipate performing during this process? Select all that apply. 1. Reinforce instructions to breathe deeply while the tube is removed. 2. Cover the site with an occlusive dressing after the tube is removed. 3Clamp the chest tube near the insertion site just before the removal. 4. Raise the drainage system to the level of the chest tube insertion site. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

2. Cover the site with an occlusive dressing after the tube is removed. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out. Rationale:A chest tube is removed when the lung has fully reexpanded or there is limited drainage. When the chest tube is removed, the client is asked to perform a Valsalva maneuver (i.e., take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight (occlusive) dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. After the tube is removed, the client should take deep breaths to ensure adequate lung expansion. The tube is not usually clamped before it is removed, and the drainage apparatus must always be lower than the chest tube site.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which would the nurse expect to note in this client? Select all that apply. 1. Hypocapnia 2. Dyspnea during exertion 3. Presence of a productive cough 4. Difficulty breathing while talking 5. Increased oxygen saturation with exercise 6. A shortened expiratory phase of respiration

2. Dyspnea during exertion 3. Presence of a productive cough 4. Difficulty breathing while talking Rationale:Clinical manifestations of COPD include hypoxemia, hypercapnia, and dyspnea during exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, and a prolonged expiratory phase of respiration. The client may also exhibit difficulty breathing while talking, and may have to take breaths between every one or two words. Some clients with COPD, especially those with a history of smoking, often have a productive cough particularly when arising in the morning. The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Test-Taking Strategy(ies):Think about the subject, the manifestations noted in COPD. Think about the pathophysiology associated with COPD. Eliminate option 5 because oxygen desaturation rather than saturation would occur. Next, eliminate option 6 because, in the client with COPD, a prolonged expiratory phase of respiration would be noted. From the remaining options, reading carefully will assist in eliminating option 1 because hypercapnia would occur.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which would the nurse expect to note? 1. Hypocapnia 2. Hyperinflated lungs on chest x-ray 3.Increased oxygen saturation with exercise 4.A widened diaphragm noted on chest x-ray

2. Hyperinflated lungs on chest x-ray Rationale:Signs/symptoms of chronic obstructive pulmonary disease include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Test-Taking Strategy(ies):Focus on the subject, chronic obstructive pulmonary disease. Eliminate increased oxygen saturation with exercise first, because oxygen desaturation rather than saturation would occur. Next, eliminate hypocapnia, because in the client with chronic obstructive pulmonary disease, hypercapnia should be noted. From the two remaining options, reading carefully will assist in directing you to select hyperinflation on chest x-ray

The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene? 1. The student uses wall suction unit pressure of 100 mm Hg. 2. The student suctions the client's tracheotomy tube for 15 seconds. 3. The student places the client in semi-Fowler's position before suctioning. 4.The student inserts the catheter into the tracheostomy without applying suction.

2. The student suctions the client's tracheotomy tube for 15 seconds. Rationale:Applying suction longer than 10 seconds can cause oxygen deprivation. The client should be placed into semi-Fowler's position to optimize breathing. Wall suction pressure of 100 mm Hg is usually recommended to prevent tissue disruption. The student is expected to insert the catheter without suction applied to maintain oxygen delivery and to prevent damage to the mucosa.

A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client? 1. Use a pad and paper. 2. Use a picture or word board. 3.Have the family interpret needs. 4. Devise a system of hand signals.

2. Use a picture or word board. Rationale:The client with a tracheostomy in place cannot speak. The nurse devises an alternative communication system with the client. Use of a picture or word board is the simplest method of communication because it requires only pointing at the word or object. A pad and pencil is an acceptable alternative but requires more client effort and more time. The use of hand signals may not be a reliable method because it may not meet all needs and is subject to misinterpretation. The family does not need to bear the burden of communicating the client's needs, and they may not understand them either.

A client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions would be done? Select all that apply. 1.Turn completely on the side. 2.Administer humidified oxygen. 3.Instruct on the use of the incentive spirometer. 4.Monitor vital signs and pulse oximetry frequently. 5.Place in respiratory isolation to prevent infection.

2.Administer humidified oxygen. 3.Instruct on the use of the incentive spirometer. 4.Monitor vital signs and pulse oximetry frequently. Rationale:A client with a pneumonectomy can be turned slightly and supported with a pillow, but complete lateral positioning is contraindicated because of pressure on the bronchial stump or shifting of mediastinal contents. In addition, the surgeon's prescription for positioning is always checked and followed. The client needs to receive oxygen and use an incentive spirometer to prevent atelectasis in the remaining lung. Vital signs and pulse oximetry need to be monitored frequently. The client should not be placed in respiratory isolation to prevent infection; this is unnecessary.

The nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which intervention is important to ensure accurate monitoring of the client's oxygenation status? 1.Tape the sensor to the client's finger. 2.Instruct the client not to move the sensor. 3.Place the sensor on a finger below the blood pressure cuff. 4.Notify the primary health care provider immediately of an O2 saturation less than 90%.

2.Instruct the client not to move the sensor. Rationale:The pulse oximeter passes a beam of light through the tissue, and a sensor attached to the fingertip, toe, or earlobe measures the amount of light absorbed by the oxygen-saturated hemoglobin. The oximeter then gives a reading of the percentage of hemoglobin that is saturated with oxygen (Sao2). Motion at the sensor site changes light absorption. The motion mimics the pulsatile motion of blood, and because the detector cannot distinguish between movement of blood and movement of the finger, results can be inaccurate. The sensor should not be placed distal to blood pressure cuffs, pressure dressings, arterial lines, or any invasive catheters. The sensor should not be taped to the client's finger. If values fall below preset norms (usually 90%), the client should be instructed to deep breathe if this is appropriate.

The nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub that was auscultated the previous day. How would this finding be interpreted? 1. The medication therapy has been effective. 2.Pleural fluid has accumulated in the inflamed area. 3.The deep breaths that the client is taking are helping. 4.There is a decreased inflammatory reaction at the site.

2.Pleural fluid has accumulated in the inflamed area. Rationale:Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. That the medication therapy has been effective, that the deep breaths the client is taking are helping, and that there is a decreased inflammatory reaction at the site are incorrect interpretations.

Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply. 1. Repositioning client every 4 hours 2.Position on the side until fully recovered 3.Encouraging coughing and deep breathing 4.Monitoring pulse oximetry readings frequently 5.Encouraging the use of an incentive spirometer

2.Position on the side until fully recovered 3.Encouraging coughing and deep breathing 4.Monitoring pulse oximetry readings frequently 5.Encouraging the use of an incentive spirometer Rationale:Monitoring and maintaining a patent airway is a nursing responsibility. The nurse should monitor oxygen saturation closely and administer oxygen as prescribed. The use of an incentive spirometer is especially helpful to prevent atelectasis and hypoventilation. Unless contraindicated, the client should be positioned on the side or with the head turned to the side to prevent aspiration until fully recovered, alert, and with the gag reflex intact. The client is encouraged to deep breathe and cough every 2 hours to prevent atelectasis. The client should be repositioned every 2 hours, which changes the distribution of gas and blood flow in the lungs and helps move secretions.

The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client? 1.The client inhales slowly. 2.The client is breathing through the nose. 3.The client removes the mouthpiece from the mouth to exhale. 4.The client forms a tight seal around the mouthpiece with the lips.

2.The client is breathing through the nose. Rationale:Incentive spirometry is not effective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 3, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results.

The nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique? 1. The client's inhalation is twice as long as exhalation. 2.The client's exhalation is twice as long as inhalation. 3.The client loosens the abdominal muscles while breathing out. 4. The client inhales with pursed lips and exhales with the mouth open wide.

2.The client's exhalation is twice as long as inhalation. Rationale:Prolonging the time for exhaling reduces air trapping because of airway narrowing or collapse in chronic obstructive pulmonary disease. Tightening the abdominal muscles aids in expelling air. Exhaling through pursed lips increases the intraluminal pressure and prevents the airway from collapsing.

The nurse is listening to the client's breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. How would the nurse interpret these noises? 1.Crackles 2.Wheezes 3.Rhonchi 4.Pleural friction rub

2.Wheezes Rationale:Wheezes are musical noises heard on inspiration, expiration, or both. They are the result of narrowed air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together near the ear and indicate fluid in the alveoli. Rhonchi are usually heard on expiration when there is excessive production of mucus that accumulates in the air passages. A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating in quality. The sounds are localized over an area of inflammation of the pleura and may be heard in both the inspiratory and expiratory phases of the respiratory cycle.

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply. 1. Excessive bubbling in the water-seal chamber 2. Vigorous bubbling in the suction-control chamber 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation Rationale:In a thoracotomy the lung is opened and exposed, and a wedge resection is the removal of part of the lung. The chest tube is placed during the surgery to remove fluid and air so the remaining lung can reinflate. The bubbling of water in the water-seal chamber should be gentle and indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 mL/hour to 100 mL/hour is considered excessive and requires RN and surgeon notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space. Excessive and/or vigorous bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding.

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection? 1. An uninsured man who is homeless 2.A woman newly immigrated from Korea 3. A man who is an inspector for the U.S. Postal Service 4. An older woman admitted from a long-term care facility

3. A man who is an inspector for the U.S. Postal Service Rationale:People at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas such as long-term care facilities, prisons, and mental health facilities; older clients; malnourished individuals, those with an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are IV drug users. Test-Taking Strategy(ies):Note the subject, the client at least risk for developing a tuberculosis infection. Begin to answer this question by eliminating options 1 and 2 because immigrants and the medically underserved are more frequently affected by this infection. From the remaining options, note that the postal inspector may or may not come in contact with many people depending on job description. The client from the long-term care facility, however, lives in a group setting, where a large number of people share a common environment 24 hours a day.

A client arrives in the emergency department with a bloody nose. Which is the initial nursing action? 1. Place the client in a supine position. 2. Apply an ice collar around the client's neck. 3. Assist the client to a sitting position with the head tilted slightly forward. 4. Instruct the client to swallow the blood until the bleeding can be controlled.

3. Assist the client to a sitting position with the head tilted slightly forward. Rationale:The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied along with a topical vasoconstrictive medication. The primary health care provider may also prescribe packing to the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood to reduce the risk of nausea and vomiting.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding would be reported immediately to the primary health care provider (PHCP)? 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-tinged sputum

3. Bronchospasm Rationale:If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure. Test-Taking Strategy(ies):Note the strategic word, immediately. Eliminate option 2 first because it is unrelated to the procedure. Next, eliminate option 1 because a dry cough may be expected. Noting that a biopsy has been performed will assist you with eliminating option 4, because blood-streaked sputum would be expected. Note that the correct option relates to the airway.

The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications? 1. Decreasing oral fluid intake 2. Monitoring the vital signs every shift 3. Changing the client's position every 2 hours 4. Instructing the client to bear down every hour and to hold his or her breath

3. Changing the client's position every 2 hours Rationale:Frequent position changes help mobilize lung secretions and prevent pooling. This is the only intervention identified in the options that will prevent respiratory complications. The nurse should encourage fluid intake to thin secretions and thus enable the client to expectorate more easily. It is important to encourage coughing and deep breathing to mobilize lung secretions. The nurse should assess the client's vital signs every 4 hours to identify an elevated temperature, which may suggest infection. The client should be instructed to avoid the Valsalva maneuver or any activity that involves holding the breath. Test-Taking Strategy(ies):Focus on the subject, preventing respiratory complications. Changing the position of the immobilized client every 2 hours will help prevent the pooling of lung secretions. The other options do not assist the client with improving ventilatory efforts or preventing respiratory complications.

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made? 1. Skin color becomes cyanotic. 2. Secretions are becoming bloody. 3. Coughing occurs with suctioning. 4. Heart rate decreases from 78 beats/minute to 54 beats/minute.

3. Coughing occurs with suctioning. Rationale:Coughing is a normal response to suctioning for the client with an intact cough reflex, and it is not an indication that the client is not tolerating the procedure. The client should be encouraged to cough to help with removal of secretions from the lungs. The nurse should monitor for the adverse effects of suctioning, which include cyanosis (pulse oximetry falls below 90% or 5% from baseline), excessively rapid or slow heart rate (a 20 beat/minute change), or the sudden development of bloody secretions. If they occur, the nurse stops suctioning, administers oxygen as appropriate, and reports these signs to the PHCP immediately. Test-Taking Strategy(ies):Note the subject, adequately tolerating nasotracheal suctioning. Cyanosis and bradycardia are abnormal findings and are eliminated first. From the remaining options, the use of the word becoming in association with bloody secretions tells you that this has not been an ongoing occurrence, making this an incorrect option. Because the cough reflex is normally present and suction triggers coughing, option 3 is preferable.

The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse would review the results of which diagnostic test to confirm this diagnosis? 1. Chest x-ray 2. Bronchoscopy 3. Sputum culture 4. Tuberculin skin test

3. Sputum culture Rationale:A definitive diagnosis of tuberculosis is confirmed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs would the nurse expect to note in the health record when collecting data related to the respiratory system for this client? 1, Stridor and cyanotic lips 2. Diminished breath sounds and fever 3. Wheezes and use of accessory muscles 4. Pleural friction rub and inspirational chest pain

3. Wheezes and use of accessory muscles Rationale:Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Clients with respiratory distress use other chest muscles to breathe. Muscle retraction is observed at the sternum and between the ribs. Stridor is a harsh crowing sound noted with an upper airway obstruction and often signals a life-threatening emergency. Cyanosis is bluish coloration of the lips occurring as a result of poor oxygenation of the circulating blood. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. Fever (elevated temperature) occurs with a respiratory infection such as pneumonia. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces) and often causes chest discomfort with inspiration. Test-Taking Strategy(ies):Focus on the subject, signs observed with acute asthma. Think about the pathophysiology that occurs in this disorder. Recalling that bronchial constriction occurs with asthma will assist in directing you to option 3. Also, thinking about the definition of the lung sounds and the signs identified in the choices will direct you to the correct option.

The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action would the nurse implement? 1. Continue suctioning. 2.Call respiratory therapy. 3.Stop the suctioning procedure. 4.Obtain a smaller suction catheter.

3.Stop the suctioning procedure Rationale:The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation below 90% indicates hypoxia. If hypoxia occurs during suctioning, the nurse stops the suctioning procedure. Using the 100% oxygen delivery system, the client is reoxygenated until baseline parameters are achieved. The size of the catheter should not exceed half of the size of the tracheal lumen. In adults, the standard catheter size is 12 to 14 French. Adequate catheter size facilitates efficient removal of secretions without causing hypoxemia.

A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which sign or symptom observed by the nurse clearly indicates that the pneumothorax is rapidly worsening? 1.Hypertension 2.Pain with respiration 3.Tracheal deviation to the right 4.Respiratory rate of 18 breaths per minute

3.Tracheal deviation to the right Rationale:A pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), subcutaneous emphysema, tracheal deviation to the unaffected side, decreased fremitus, and worsening cyanosis. The client could have pain with respiration even with a milder pneumothorax. The increased intrathoracic pressure causes the blood pressure to fall, not rise. A respiratory rate of 18 breaths per minute is within the normal range.

A client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. The nurse determines that which data accurately indicate effectiveness of the treatments prescribed for this problem? 1. Venous oxygen saturation is 95%. 2. Respiratory rate is 20 breaths per minute. 3.Client demonstrated effective coughing techniques. 4. Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, and Pco2 of 40 mm Hg.

4. Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, and Pco2 of 40 mm Hg. Rationale:Demonstration of adequate ventilation can only be accurately evaluated when both Po2 and Pco2 levels are known. The other options do not indicate adequate gas exchange. Remember that oxygen saturation index is a measure of the percent of oxygen attached to the available hemoglobin.

The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position would the nurse instruct the client to assume? 1. Side-lying in bed 2. Sitting in a recliner chair 3. Sitting up in bed at a 90 degree angle 4. Sitting on the side of the bed leaning on an overbed table

4. Sitting on the side of the bed leaning on an overbed table Rationale:Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall. The positions in options 1, 2, and 3 will not enhance the effectiveness of breathing. Test-Taking Strategy(ies):Focus on the subject, positioning for a client with emphysema. Eliminate option 2 because side-lying will not promote appropriate lung expansion. Next, eliminate options 1 and 3 because they are comparable or alike and will restrict lung expansion.

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis? 1. pH of 7.35, Pco2 of 50 mm Hg, HCO3- of 32 mEq/L 2. pH of 7.45, Pco2 of 35 mm Hg, HCO3- of 22 mEq/L 3. pH of 7.38, Pco2 of 45 mm Hg, HCO3- of 32 mEq/L 4. pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L

4. pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L