Unit 3 - Respiratory

B Decreased lung sounds and decreased lung expansion could indicate the development of a complication such as empyema or pus in the pleural space. The nurse should check the client's oxygen saturation and notify the provider. Infection can also move into the bloodstream and result in sepsis, so quick treatment is needed. 10. An older adult is admitted to the emergency department with respiratory symptoms. Which client symptom requires the nurse to intervene immediately? a. Confusion b. Scattered wheezing c. Crackles d. Flushed cheeks ANS

A Confusion in an older adult can signify hypoxia. If the nurse waited to intervene until the older adult showed more traditional symptoms of pneumonia, the client may become critically ill. The other manifestations also require intervention but not as the priority. 11. Which is the highest priority goal to set for a client with pneumonia? a. Absence of cyanosis b. Maintenance of SaO2 of 95% c. Walking 20 feet three times daily d. Absence of confusion ANS

Care of Critically Ill Patients with Respiratory Problems Chapter 34

Care of Critically Ill Patients with Respiratory Problems Test Bank MULTIPLE CHOICE 1. The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What is the nurse's best action? a. Increase the heparin dose. b. Increase the warfarin dose. c. Continue the current therapy. d. Discontinue the heparin. ANS

C Bronchodilators may need to be held before PFTs. The client should not plan to use them at any time during the test if he or she experiences dyspnea. The other options show adequate understanding. Chapter 30

Care of Patients Requiring Oxygen Therapy or Tracheostomy Chapter 30

d, b, a, c, e, f, g The proper order for obtaining a peak expiratory flow rate is as follows

Make sure the device reads zero or is at base level. Stand up (unless you have a physical disability). Take as deep a breath as possible. Place the meter in your mouth, and close your lips around the mouthpiece. Blow out as hard and as fast as possible for 1 to 2 seconds. Write down the value obtained. Repeat the process two more times, and record the highest of the three numbers in your chart. Chapter 33

pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3-, 26 mEq/L d. Urinary output of 30 mL/hr ANS

A Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal. 18. The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action? a. Sedate the client. b. Call the health care provider. c. Assess the client for pain. d. Assess the client's oxygenation. ANS

B, C, D Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraine, and elevated platelets and cholesterol levels do not cause epistaxis. 4. The nurse is assessing a client with facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin ANS

A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis or bruising behind the ear is called "battle sign" and indicates basilar skull fracture. Chapter 32

B Tracheostomy dressings should be made from gauze pads with a manufactured slit in them that fits around the tube. If none are available, use two gauze pads folded in half placed on either side of the tube. Cutting a piece of gauze could result in entry of tiny shreds of the gauze the tracheostomy. The other interventions are appropriate. 21. A client receiving high-flow oxygen has new crackles and diminished breath sounds since the last assessment 1 hour ago. Which action by the nurse is most appropriate? a. Call respiratory therapy and request a bronchodilator treatment. b. Instruct the client to use the spirometer and to cough and deep breathe. c. Consult with the health care provider and request an order for diuretics. d. Ensure that the ordered FiO2 is what is being provided. ANS

B A client who is receiving high rates of oxygen is at risk for absorption atelectasis, in which the normal nitrogen in the air becomes diluted and the alveoli collapse. Hallmarks of this condition include new onset of crackles and diminished breath sounds. Spirometer use, coughing, and deep-breathing exercises would help to re-expand the alveoli. None of the other options are appropriate choices. 22. Which statement by a client indicates an accurate understanding of home self-care of a tracheostomy? a. "The stoma should be left uncovered during the day to dry." b. "I need to put normal saline in my airway twice daily." c. "While showering, I need to keep water out of my airway." d. "I don't need to use tracheostomy ties on a daily basis." ANS

1. A client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse? a. Decreased level of consciousness b. Tachycardia c. Increased temperature d. Slowed respiratory rate ANS

B An increased heart rate may indicate that the client is developing a pneumothorax or hypoxia. Although it is important to note immediately whether the client is experiencing a decreased level of consciousness, increased temperature, or a slowed respiratory rate, none of these is as indicative of a life-threatening complication as tachycardia. 2. The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client feels "dizzy;" nurse applies oxygen and pulse oximeter. b. Client's heart rate is 55 beats/min; nurse withholds pain medication. c. Client has reduced breath sounds; nurse calls physician immediately. d. Client's respiratory rate is 18 breaths/min; nurse decreases oxygen flow rate. ANS

D Decreased wheezing accompanied by decreased breath sounds can mean airway occlusion from mucus and from inflammation. The nurse should assess the client's oxygenation and determine whether additional interventions are needed. Coughing forcefully may cause the smaller airways to collapse and may not help the client.Encouraging the client to remain calm and to try to take deep breaths is not helpful. Although providing documentation is important, the nurse needs to do more than that. 2. A client with asthma has been having frequent asthma attacks. What is the nurse's best action? a. Teach the client to stay away from pets. b. Assist the client in using an incentive spirometer. c. Administer aspirin for its anti-inflammatory properties. d. Administer montelukast (Singulair). ANS

D A client who has been having increased attacks can have some chronic inflammation occurring. This inflammation is probably stimulated by mediators such as histamine and leukotriene and can be blocked by drugs like diphenhydramine (Benadryl) and montelukast (Singulair). 3. A client diagnosed with asthma has not responded well to medication. The client is concerned and asks the nurse, "What is wrong with me, and why am I not getting better?" What is the nurse's best response? a. "You just weren't used to the medication yet." b. "The medication dose has to be increased." c. "It is possible that genetic testing may help." d. "You should try homeopathic medicine." ANS

B, C, D, F Older adults, especially those with chronic lung problems, are at higher risk for pulmonary embolism. Prolonged bedrest is also a risk factor, as are abdominal surgery and smoking. Because platelets are involved in the clotting process, elevated platelets may contribute to increased clotting. Diabetes and waiting for surgery are not known risk factors. 3. A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)?(Select all that apply.) a. Oxygen administered at 100%, PaO2 60 b. Increased dyspnea c. Anxiety d. Chest pain e. Pitting pedal edema f. Clubbing of fingertips ANS

A, B, C A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety. Chest pain is not specific to ARDS; although chest pain can occur with ARDS, it occurs with many other conditions as well. Pitting edema would not be an assessment factor that confirms ARDS. Clubbing occurs in chronic, not acute, respiratory conditions. 4. The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a. Assess the tubing for kinks. b. Assess whether the tubing has become disconnected. c. Determine the need for suctioning. d. Call the health care provider. e. Call the Rapid Response Team. f. Auscultate the client's lungs. ANS

A The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would effectively change the FiO2. The nurse should ensure that the holes remain unobstructed. Other options are appropriate but are not the first choice, because this simple step may be what solves the problem. 7. A client requires oxygen received via a face mask but wants to remain as mobile as possible once discharged home. Which intervention by the home health nurse best provides the client with maximal mobility? a. Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs. b. Encourage the client to remove the mask occasionally to assess tolerance. c. Add extra connecting pieces of tubing to the client's existing oxygen setup. d. Change the face mask to a nasal cannula occasionally, such as at mealtimes. ANS

C To increase mobility, up to 50 feet of connecting tubing can be used with connecting pieces. A client with a chronic respiratory condition needing home oxygen may not be able to decrease oxygen needs through pulmonary rehabilitation, but that would not increase mobility with an oxygen device. The nurse should not independently encourage the client to remove the mask for periods of time or change to a cannula. 8. A client has been brought in by the rescue squad to the emergency department. The client is having an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is severely short of breath. On arrival, the client is on 15 L/min of oxygen via rebreather mask. Which action by the nurse takes priority? a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula. b. Perform a thorough respiratory assessment and attach pulse oximetry. c. Call the laboratory to obtain arterial blood gases as soon as possible. d. Obtain a stat chest x-ray, then slowly wean the client's oxygen down. ANS

A The client can speak with a fenestrated tube, which has a hole in it and allows air to flow over the vocal cords. The tube still needs to be cleaned and suctioned. The tube may become dislodged, and the client is able to swallow. 17. The nurse observes a nursing student suctioning a client. Which intervention by the student nurse requires the supervising nurse to intervene? a. Checking oxygen saturation post suctioning b. Hyperoxygenating the client after removal of the catheter c. Applying intermittent suction during catheter removal d. Applying suction when the catheter is inserted ANS

D Applying suction as the catheter is introduced allows the tubing to adhere to the airway and destroys cells. The other options are appropriate actions on the part of a nurse or student who is suctioning a client. 18. The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped? a. Heart rate increases from 86 to 102 beats/min. b. Respiratory rate increases from 16 to 20 breaths/min. c. Blood pressure increases from 110/70 to 120/80 mm Hg. d. Heart rate decreases from 78 to 40 beats/min. ANS

A This is the only statement that is accurate. Small doses of radiation given over long periods are an effective routine treatment. Lung cancer does not have a good prognosis, and it often metastasizes. Surgery often is only palliative. 31. Which nursing intervention is an example of primary prevention for lung cancer? a. Teaching clients with lung cancer how to cough and deep breathe b. Teaching clients with lung cancer to avoid infection c. Teaching clients about prophylactic antibiotics d. Teaching people about smoking and secondhand smoke ANS

D Primary prevention for lung cancer focuses on reducing tobacco smoking. The other examples are examples of secondary prevention. 32. A client's chest tube is accidentally dislodged. What action by the nurse is best? a. No action is necessary because the area will reseal itself. b. Cover the insertion site with a sterile gauze and tape three sides. c. Obtain a suture kit and prepare for the physician to suture the site. d. Cover the area with an occlusive dressing. ANS

A, C, F Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team. If the tubing became disconnected, the low-pressure alarm would sound. 5. The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions for this client? (Select all that apply.) a. Change the settings in accordance with provider orders. b. Modify the settings for weaning the client. c. Assess the reasons for alarms. d. Compare the ventilator settings with ordered settings. e. Assess the water level in the humidifier. f. Change the ventilator tubing according to hospital policy. ANS

C, D, E The nurse should assess the client when an alarm sounds and should intervene accordingly. The nurse should also check the settings to make sure they are correct and should evaluate the water level to make sure the humidifier does not go dry. The nurse would not be responsible for changing ventilator settings, weaning the client, or changing the ventilator tubing. 6. The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.) a. Use antiembolism stockings. b. Massage calf muscles per client request. c. Maintain supine position with the legs flat. d. Turn every 2 hours if client is in bed. e. Refrain from active range-of-motion exercises. ANS

Care of Patients with Infectious Respiratory Problems Chapter 33

Care of Patients with Infectious Respiratory Problems Test Bank MULTIPLE CHOICE 1. A client has acute rhinitis. What is the most important intervention for the nurse to perform? a. Assess for symptoms of infection. b. Ascertain whether the client has allergies. c. Question the client on the use of nasal sprays. d. Do blood and urine screenings for drug use. ANS

A Stridor is the sound heard. This sound indicates severe airway constriction. The nurse must administer a bronchodilator to get air into the lungs. Administering oxygen will not help until the client's airways are open. 41. The nurse assesses an older adult after an upper respiratory infection and notes the following lung sound on auscultation. What is the nurse's best action? (Click the media button to hear the audio clip.) a. Assess the client for the development of asthma. b. Ask the client if he or she finished all the medication. c. Administer oxygen immediately. d. Assess arterial blood gas. ANS

A Scattered wheezes is the sound heard. New-onset asthma can occur in older clients after they recover from an upper respiratory infection or severe cold. The nurse should assess the client for other symptoms such as sputum production and response to activity. Finishing medication would not necessarily cause the client to have wheezing. The nurse should assess oxygen saturation before administering oxygen or assessing arterial blood gas. MULTIPLE RESPONSE 1. A client has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Oxygen saturation greater than 95% d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Pain at insertion site g. Disconnection at Y site ANS

C Normal pulse oximetry readings are 95% to 100%. However, people with dark skin can have readings that are 3% to 5% lower owing to the darker coloration of the nail bed. The nurse should assess other signs of respiratory adequacy because this may be a normal finding for this client. 7. The nurse is caring for an older adult client with a pulmonary infection. Which nursing action is a priority with this client? a. Encouraging the client to increase fluid intake b. Assessing the client's level of consciousness c. Raising the head of the bed to at least 45 degrees d. Providing the client with humidified oxygen ANS

B Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and breathe deeply frequently; to raise the head of the bed; and to humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present. 8. The nurse is assessing a client's breath sounds. Which assessment finding has been correctly linked to the nurse's primary intervention? a. Hollow sounds heard over trachea; increase oxygen flow rate. b. Crackles heard in bases; have the client cough forcefully. c. Wheezes heard in central areas; administer inhaled bronchodilator. d. Vesicular sounds heard over the periphery; have the client breathe deeply. ANS

D Immune modulators are monoclonal antibodies that prevent allergens from binding to receptor sites on mast cells and basophils. The risk of anaphylaxis is high; the nurse should assess and stay with the client. 10. A client is demonstrating diaphragmatic breathing for the nurse. Which action by the client shows adequate understanding of this breathing technique? a. Lying on his or her side with knees bent b. Having his or her hands on the abdomen c. Having his or her hands over the head d. Lying in the prone position ANS

B To perform diaphragmatic breathing correctly, the client should put the hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone. 11. A client is undergoing lung reduction surgery. What is the nurse's highest priority preoperatively? a. Administer medications. b. Discuss the possibility of ventilator dependency. c. Teach how to cough and deep breathe. d. Teach about preoperative testing. ANS

C Immune compromised clients are contagious for several weeks. The client should remain at home until he is not contagious. 8. A client is worried about contracting influenza. What is the nurse's best response to the client? a. "Flu is no longer a prevalent problem." b. "Did you receive a flu vaccine this year?" c. "Current flu strains are generally mild." d. "If you develop symptoms, antibiotics will cure you." ANS

B Vaccines for influenza are widely available and are recommended to prevent flu. Flu continues to be a major problem, affecting up to 20% of the U.S. population and causing 36,000 deaths annually. 9. The nurse assesses a client with pneumonia and notes decreased lung sounds on the left side and decreased lung expansion. What is the nurse's best action? a. Have the client cough and deep breathe. b. Check oxygen saturation and notify the health care provider. c. Perform an arterial blood gas analysis. d. Increase oxygen flow to 10 L/min. ANS

Care of Patients with Noninfectious Lower Respiratory Problems Chapter 32

Care of Patients with Noninfectious Lower Respiratory Problems Test Bank MULTIPLE CHOICE 1. A client with asthma reports "not being able to take deep breaths." The nurse auscultates decreased breath sounds in the bases, and no wheezes. What is the nurse's best action? a. Encourage the client to stay calm and take deep breaths. b. Document the findings and continue to monitor. c. Have the client cough forcefully. d. Assess the client's oxygen saturation. ANS

B Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. 33. Which is the highest priority problem for a client with late-stage lung cancer? a. Malnutrition b. Constipation c. Weakness and fatigue d. Pain ANS

D Although all of these problems are important issues, effective pain management is the most important issue for this client and family. The nurse must serve as a client advocate and must ensure that all appropriate measures for management of intractable, severe pain are implemented. 34. The nurse assesses a client's chest tube and finds continuous bubbling in the water seal chamber. When the nurse clamps the chest tube close to the client's dressing, the bubbling stops. How does the nurse interpret this finding? a. An air leak is present at the chest tube insertion site or in the thoracic cavity. b. An air leak is present in the drainage system. c. More water needs to be added to the water seal. d. The system is functioning appropriately and no intervention is needed. ANS

C Clients with cystic fibrosis (CF) often are malnourished owing to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better. 24. The nurse is assessing a client with lung disease. Which symptom does the nurse intervene for first? a. The client's anterior-posterior chest diameter is 2

2. b. Clubbing of the finger tips is noted. c. The client has bilateral dependent leg edema. d. The client is pale. ANS

A The nurse should first assess the throat for signs of peritonsillar abscess. If present, the nurse should call the health care provider immediately because aspiration of the abscess may be needed to maintain the airway. 6. The nurse has determined that a client has an acute sore throat. What is the nurse's best action? a. Assess whether the client can speak. b. Call an ear-nose-throat specialist. c. Administer an antibiotic. d. Give the client ice chips. ANS

A A dry cough and difficulty swallowing may indicate that the client is developing laryngitis. The nurse should assess whether the client can speak or shows any changes in his or her voice. The other interventions are not appropriate. 7. A client who is immune compromised develops muscle aches and fever. The client is admitted to the hospital for several days and is diagnosed with influenza. At discharge, the client asks when he can go back to work. What is the nurse's best response? a. "You should be able to return to work in 5 days." b. "You can return to work as soon as you feel ready." c. "You cannot return to work for several weeks." d. "You will need to have cultures performed before returning to work." ANS

B Class III dyspnea occurs during usual activities, such as showering, but the client does not require assistance from others. The client may need to rest during activities. A client with class I dyspnea would likely need no assistance. A client with class IV dyspnea may require assistance for some but not all tasks. A client with class V dyspnea cannot participate in any self-care. 15. A postoperative client has an oxygen saturation of 96% but is pale and dyspneic and says, "I can't get enough air!" The client's lung sounds are clear. Which action by the nurse is most appropriate? a. Call the physician and request a hemoglobin and hematocrit level. b. Notify respiratory therapy and request a breathing treatment. c. Encourage the client to cough and deep breathe 10 times each hour. d. Take the client's temperature and give antipyretics if needed. ANS

A A normal pulse oximetry reading is 95% to 100%. Pulse oximetry measures the percent of hemoglobin saturated with oxygen. However, if the client's hemoglobin level is low, the pulse oximetry reading may not correlate with his or her condition. A postoperative client is at risk for bleeding, so the nurse should request a hemoglobin and hematocrit level. Respiratory treatment is not indicated. Coughing and deep breathing are appropriate but are not the priority. Monitoring for and treating fevers is also appropriate but is not the priority. 16. A client had a flexible bronchoscopy 2 hours ago and has become mildly cyanotic despite the application of oxygen. When giving change-of-shift report, which question by the oncoming nurse elicits the most useful information? a. "How long was the client sedated for the procedure?" b. "Were the oximetry readings during the test normal?" c. "Are you sure the client was NPO before the bronchoscopy?" d. "What kind of topical anesthetic was used on the client?" ANS

C The client should wear a mask when out of the home environment and in crowds to prevent spread of the infection. The other statements are not accurate. 18. The nurse is worried that a client who is not entirely reliable is being discharged home on therapy for multidrug-resistant tuberculosis. What strategy is the best to use for this client? a. Directly observed therapy b. IV drug administration c. Remaining in the hospital d. Isolation ANS

A If a client is "not reliable," the risk is that the client will not take medications as required, causing spread of an organism that may become more drug resistant. The other answers are not correct. 19. A client is admitted with suspected avian influenza. The family asks the nurse what kind of care the client will get. Which statement by the nurse is correct? a. "He will be given standard antibiotic agents and will be placed in contact isolation." b. "He will be placed on airborne and contact isolation." c. "Oseltamivir (Tamiflu) will reduce complications of this infection." d. "All family members should be tested for evidence of the same disease." ANS

C The D and C cylinders are small enough to be carried. The H cylinder cannot be carried. The E tank can be transported. The tanks should not be rolled and should be carried only in a stand or a rack. 13. The nurse assesses a client with a new tracheotomy, and the tracheostomy tube is pulsating in synchrony with the client's heartbeat. Which is the nurse's priority action? a. Notify the health care provider immediately. b. Stabilize the tube by reapplying the ties. c. Change the inner cannula of the tube. d. Increase the inflation pressure of the cuff. ANS

A If a tracheostomy tube is pulsating with the client's heart rate, this could indicate proximity to the innominate artery and may cause erosion of the artery if left in this position. The provider should be notified immediately. Reapplying the ties, changing the inner cannula, and increasing the inflation pressure of the cuff are all interventions that will not solve the immediate problem of proximity of the tube to the innominate artery. 14. A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse takes priority? a. Auscultate breath sounds bilaterally. b. Ventilate with a resuscitation bag and mask. c. Call a code or the Rapid Response Team. d. Insert a new obturator into the neck. ANS

A The nurse should have the client point to words on a board to communicate needs. The endotracheal tube is positioned and placement is maintained with tape or some other type of appliance. Asking the client to move his or her mouth and lips could result in possible extubation. Communication is limited and could be misunderstood with blinking. Teaching the client sign language, even simple, would be an involved and unrealistic goal. 27. A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take? a. Stays with the client and replaces the oxygen mask b. Asks the client's spouse to hold the oxygen mask in place c. Restrains the client per facility policy d. Contacts the health care provider and requests sedation ANS

A Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse stay with the client, ensure that the oxygen is maintained, and attempt to calm the client. Because of the client's restlessness, the nurse cannot delegate care to the spouse. Requesting a sedative might adversely affect the client's respiratory status further. Restraining the client could increase restlessness and increase oxygen demand. 28. A client with severe respiratory insufficiency becomes short of breath during activities of daily living. Which nursing intervention is best? a. Call the Rapid Response Team. b. Decrease involvement in care until the episode is past. c. Cluster morning activities to provide long rest periods. d. Space out interventions to provide for periods of rest. ANS

B Explain that edema and bruising may last for weeks, and that the final surgical result will be evident in 6 to 12 months. The client should take his or her temperature and report fever in case of infection. The client should take acetaminophen because risk of bleeding is less than with aspirin. Fluids and stool softeners will decrease the risk of straining. 10. What is the highest priority for the nurse to teach the client who is being discharged after a fixed centric occlusion for a mandibular fracture? a. How to use wire cutters b. Eating six soft or liquid meals each day c. How to irrigate the mouth every 2 hours d. Sleeping in semi-Fowler's position postoperatively ANS

A The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. Although the client will need to sleep in a semi-Fowler's position to assist in avoiding aspiration if vomiting does occur, this will not be as high a priority as knowing how to cut the wires. 11. Which client is at greatest risk for development of obstructive sleep apnea? a. Woman who is 8 months pregnant b. Middle-aged man with gastroesophageal reflux disease c. Middle-aged woman who is 50 pounds overweight d. Older man with type 2 diabetes and a history of sinus infections ANS

D A patent airway is the priority. The nurse first should make sure that the airway is patent, then should determine whether the client is in pain, and whether bone displacement or blood loss has occurred. 2. After facial trauma, a client has a nasal fracture and is reporting constant nasal drainage, a headache, and difficulty with vision. What is the nurse's first action? a. Collect the nasal drainage on a piece of filter paper. b. Send the client for a facial x-ray. c. Perform a vision test. d. Palpate all facial areas for crepitus. ANS

A The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebral spinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the client's risk for infection. 3. What is the nurse's most important action after a client's gag reflex has returned post rhinoplasty? a. Teach the client to change position every 2 hours. b. Tell the client to put heating pads on the face. c. Instruct the client to lay flat. d. Have the client drink at least 2500 mL/day. ANS

D The client who is being treated for pulmonary embolism usually continues on heparin and warfarin until the INR reaches a therapeutic level between 2 and 3. Heparin can then be discontinued because warfarin is therapeutic. 2. The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse's priority action? a. Elevate the head of the bed and apply oxygen. b. Listen to the client's lung sounds. c. Pull the call bell out of the wall socket. d. Assess the client's pulse oximetry. ANS

A The client's immediate need is to have oxygen applied. The nurse should then assess the client's pulse oximetry. 3. It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action? a. Monitor the client's oxygenation. b. Teach the client about potential side effects. c. Monitor the IV insertion site. d. Monitor for bleeding. ANS

A Pain is the priority for the client. Bloody drainage may be normal, depending on the client's condition. Intermittent bubbling in the water seal indicates air escaping as the lung fully expands, and does not need to be addressed immediately. Tidaling often occurs with inspiration and expiration. 37. The nurse assesses a client who is on fluticasone (Flovent) and notes oral lesions. What is the nurse's best action? a. Teach the client to rinse the mouth after Flovent use. b. Have the client use a mouthwash daily. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect. ANS

A The drug reduces local immunity and increases the risk for local infection, especiallyCandida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using Flovent. 38. A client has recently been placed on prednisone (Deltasone). What is the highest priority instruction the nurse will provide? a. "Expect to experience weight gain." b. "Watch your diet while on this medication." c. "Take the drug with food or milk." d. "Report any abdominal pain or dark-colored vomit." ANS

B, D, E, G Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax; sudden shortness of breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 mL/hr because this could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention. 2. What information about nutrition does the nurse teach a client with chronic obstructive pulmonary disease (COPD)? (Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Practice diaphragmatic breathing against resistance four times daily." e. "Eat high-fiber foods to promote gastric emptying." f. "Eat dry foods rather than wet foods, which are heavier." g. "Increase carbohydrate intake for energy." ANS

A, B, C Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Dry foods can cause coughing. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. Diaphragmatic breathing will not necessarily help nutrition. 3. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) to determine activity tolerance. Which questions elicit the most important information?(Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?" ANS

A, B, C, D, G The nurse should observe for clear drainage because of the risk for cerebrospinal fluid (CSF) leakage. The nurse should note whether the client is swallowing frequently because this could indicate postnasal bleeding. The nurse should also ask the client to open his or her mouth and should observe the back of the throat for bleeding. Pain medication should also be administered. It is too soon to change the packing, which should be changed by the surgeon the first time. A nasal steroid would increase the risk for infection. 2. The client with which conditions requires immediate nursing intervention? (Select all that apply.) a. Shortness of breath b. Sternal retractions c. Pulse oximetry reading of 95% d. Occasional expiratory wheeze e. Respiratory rate of 8 breaths/min f. Arterial blood gas showing a pH of 7.35 g. Stridor ANS

A, B, E, G The client with sternal retraction is experiencing serious respiratory difficulty, as is the client with stridor. The client who reports shortness of breath needs immediate assessment, as does the client with a respiratory rate of 8. A pulse oximetry of 95% is within normal limits, as is a pH of 7.35. The client with expiratory wheezes needs to be assessed, but not immediately. 3. A client develops epistaxis. Which conditions in the client's history could have contributed to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets g. High cholesterol ANS

D The tuberculin test (Mantoux test) result is the most commonly used reliable test of TB infection. The photo shows a positive reaction. A positive reaction does not mean that active disease is present but indicates exposure to TB or the presence of inactive (dormant) disease. Conclusive evidence of TB is not provided through an examination of the chest or a chest x-ray. Only a sputum specimen will provide definitive evidence of the disease process. MULTIPLE RESPONSE 1. What teaching is appropriate for a client with acute rhinitis and sinusitis? (Select all that apply.) a. Using hot packs over the sinuses b. Fluid restriction c. Saline irrigations d. Staying in a dry climate e. Taking echinacea f. Antifungal medications ANS

A, C, E Treatment of sinusitis includes the use of broad-spectrum antibiotics (e.g., amoxicillin), analgesics for pain and fever, decongestants, steam humidification, hot and wet packs over the sinus area, and nasal saline irrigations. As complementary therapy, echinacea is recommended for the symptom of rhinitis. Antifungal medications, fluid restrictions, and staying in a dry climate are not recommended. 2. A client enters the clinic with an acute sore throat and a temperature of 101.5° F (38.5° C). What diagnostic testing does the nurse educate the client about? (Select all that apply.) a. Complete blood count (CBC) b. Throat culture c. Monospot test d. Arterial blood gas e. Biopsy f. HIV testing ANS

A, B, E TB symptoms include nausea and weight loss, as well as night sweats. Inability to sleep and ankle edema are not typical symptoms. Increased urination also is not a typical symptom. 5. A client started on therapy for tuberculosis infection is reporting nausea. What does the nurse teach this client? (Select all that apply.) a. Eat a diet rich in protein, iron, and vitamins. b. Do not drink fluids with medications. c. Take medications at bedtime. d. Space medications 12 hours apart. e. Take medications with milk. f. Take an antiemetic daily. ANS

A, C, F Taking the daily dose of medications at bedtime may help to decrease nausea. A well-balanced diet with foods rich in iron, protein, and vitamins C and B also helps to decrease nausea. Antiemetics are often prescribed. Drinking fluids with medications should not influence the nausea; neither should taking medications with milk. Spacing medications 12 hours apart is not recommended therapy. 6. The nurse is caring for a client who is suspected of having severe acute respiratory syndrome (SARS). What actions by the nurse are most appropriate? (Select all that apply.) a. Wash hands when entering the client's room and use Standard Precautions. b. Wear a gown and goggles when entering the client's room. c. Teach the client to wear a mask at all times when someone is in the room. d. Use a disposable particulate mask respirator when the client is coughing. e. Keep the door to the client's room open to allow close monitoring. f. Place the client in a negative airflow room, if available in the facility. ANS

D The family member can suction using clean technique because fewer organisms are present in the home than in the hospital. Never suction the mouth first because airway pathogenic organisms could be introduced into the airway. The family member should not be required to recannulate the tube except in an emergency. MULTIPLE RESPONSE 1. Which interventions help to prevent aspiration during eating for a client with a tracheostomy? (Select all that apply.) a. Provide close supervision for the client during eating and drinking. b. Add liquids to foods to make them thinner and easier to swallow. c. Inflate the tracheostomy cuff tube to maximum pressure before starting. d. Let the client indicate readiness for another bite when being fed. e. Have the client tuck the chin down and forward while swallowing. f. Instruct the client to dry swallow to clear food particles from the throat. g. Place the client in a semi-Fowler's position for an hour after eating. ANS

A, D, E, F The client with a tracheostomy will require close supervision, even if the client is feeding himself or herself. Do not rush the client. Allow him or her to indicate when ready for another bite. Teaching interventions should include instructing the client to tuck the chin down and forward while swallowing to encourage food to move down smoothly. Dry swallowing helps remove food residue. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further without a physician's order; if possible, the cuff should be deflated during eating. Placing the client in a semi-Fowler's position after the meal will not prevent aspiration. Chapter 31

C, F, G, H Decreased peak flow could indicate worsening of symptoms of airflow occlusion. Likewise, expiratory wheezing and stridor can indicate inflammation and fluid accumulation leading to airway occlusion. A change in the amount and color of sputum can indicate infection. The other symptoms normally occur with chronic disease. 6. The nurse is teaching a client with asthma how to avoid attacks. What information does the nurse give the client? (Select all that apply.) a. "You should not dust your furniture." b. "Stay inside as much as possible." c. "Stay away from people who are sick." d. "Do not go out in the fall." e. "Stay out of the snow." f. "Do not take aspirin." ANS

A, F Dusting the furniture may increase dust in the air and cause an asthma attack. Aspirin may stimulate asthma. Staying inside probably will not help. Staying away from snow probably will not have an effect on the client's attacks; neither will going outside during the fall. 7. The nurse is assessing a client with asthma. Scattered wheezes are noted, and the client's oxygen saturation is 88%. What other assessments are essential for the nurse to perform? (Select all that apply.) a. Assess for accessory muscle use. b. Assess anterior-posterior diameter. c. Assess inspiration/expiration ratios. d. Assess the suprasternal notch. e. Perform a stress test. f. Assess a chest x-ray. g. Assess mucous membranes. ANS

B The nurse can delegate stable clients to the LPN. The client who is 6 hours post surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching. Teaching cannot be delegated. 8. A client has a closed fracture of the nose. Which intervention is best when encouraging self-care for this client? a. Advise the client not to eat or drink for 24 hours after sustaining the fracture. b. Teach the client how to apply cold compresses to the area to reduce swelling. c. Urge the client to sleep without a pillow to hasten resolution of the swelling. d. Reassure the client that his or her appearance will normalize after the swelling is gone. ANS

B After a closed fracture of the nose, the nurse will encourage rest and the use of cool compresses on the nose, eyes, or face to help reduce swelling and bruising. Avoiding eating or drinking and sleeping without a pillow will not hasten resolution of the swelling. Reassuring the client regarding his or her appearance is not included in self-care. 9. Which statement indicates that the client needs more teaching regarding rhinoplasty? a. "I will take my temperature twice each day and will report any fever to my doctor." b. "I will wait a few weeks to have my photograph taken, when the swelling is gone." c. "I will take acetaminophen instead of aspirin for pain to avoid excessive bleeding." d. "I will drink at least 3 quarts of liquids a day and will use a stool softener." ANS

A People older than 50 years and those with chronic disease should be vaccinated against the flu each year early in the fall because they are at higher risk of developing complications if they do get ill. Flu shots appear to be effective for only one flu season, so the client should get one annually. The live vaccine is recommended only for healthy people up to age 49. This vaccination should not have interactions with heart medications. 24. Which person is at greatest risk for developing a community-acquired pneumonia? a. Middle-aged teacher who typically eats a diet of Asian foods b. Older adult who smokes and has a substance abuse problem c. Older adult with exercise-induced wheezing d. Young adult aerobics instructor who is a vegetarian ANS

B Although age is a factor in the development of community-acquired pneumonia, other lifestyle and exposure factors increase the risk to a greater extent than age. Two conditions that heavily predispose to the development of pneumonia are cigarette smoking and alcoholism. Dietary choices typically do not predispose to the development of pneumonia. Cigarette smoking interferes with the ciliary function of removal of invasive materials. Alcoholism usually results in unbalanced nutrition, as well as decreased immune function. A middle-aged adult, an older adult with wheezing induced by exercise, and a young adult vegetarian would not be at risk for community-acquired pneumonia because they have no predisposing conditions. 25. Which is the nurse's best response to an older adult client who is hesitant to take the pneumococcal vaccination and influenza vaccine in the same year? a. "You need both injections. A risk factor for getting pneumonia is infection with influenza." b. "Take both injections. They will protect you against respiratory problems for this year." c. "The flu shot may protect you against influenza but not against bacteria that cause pneumonia." d. "You should get the pneumococcal vaccination so you won't infect other people." ANS

B The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated balloon means that the cuff is also deflated and a seal is no longer present around the tube to prevent air from escaping. Thus, some of the air being moved into the client's airway by the ventilator is escaping through the client's trachea before it reaches the lower airways and alveoli. The nurse should inflate the cuff. Calling the Rapid Response Team is not necessary, and increasing tidal volume will not improve oxygenation if the cuff is leaking. 16. The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving mechanical ventilation. Which intervention is a priority for this client? a. Administering antibiotics every 6 hours b. Positioning the client with the "good lung dependent" c. Making sure that the pilot balloon line on the endotracheal tube is deflated d. Ensuring that the client is able to speak clearly ANS

B Clients who are being mechanically ventilated are experiencing a problem in that their normal ventilation is not adequate. The recommended position for clients who have one lung more affected by a problem than the other lung is to place the "good lung down," keeping the healthier lung dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung, thus helping a ventilation/perfusion mismatch. Antibiotics are not prescribed for this disorder. The pilot balloon line should be inflated to ensure that the cuff is inflated, keeping the endotracheal tube in place and directing ventilated air into the lungs. The client with an endotracheal tube that is nonfenestrated, with the cuff inflated, will not be able to speak. Communication is addressed in other ways. 17. The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention? a. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg b. Pulse oximetry value of 96% c. Arterial blood gas (ABG)

C The young adult with an impaired arterial oxygen level should be seen first. A level of 90% to 100% is a normal level for this age-group. The older adult with a pulse oxygen of 96% is within normal limits, as is an adult with a pulse oxygen of 94%. An arterial oxygen level of 94% would also be seen as normal. 11. A client with a history of chronic obstructive pulmonary disease (COPD) presents to the clinic with increased cough and low-grade temperature. Which question by the nurse elicits the most useful information? a. "How long have you been sick?" b. "Has your sputum changed color?" c. "Is anyone else in your house sick?" d. "Do you take any medications?" ANS

B Clients with COPD usually have a productive cough. If the color has changed, that is a noteworthy finding. If the client's sputum is yellow or green, this may indicate a pulmonary infection. The other questions are also appropriate to ask but will not help in gathering information specific to a pulmonary problem. 12. A client tells the nurse that he usually expectorates about 2 ounces of thin, clear, colorless sputum each day, mostly in the morning after getting out of bed. What is the nurse's initial action after gaining this information? a. Ask the client to provide a morning sputum sample for laboratory analysis. b. Obtain a specimen of the sputum in a sterile container for culture. c. Monitor for an increase in sputum production or a change in color. d. Notify the health care provider and prepare the client for possible bronchoscopy. ANS

C This medication will help prevent an acute asthma attack because it is long acting. The client will take this medication every day for best effect. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications. 8. Which statement indicates that a client understands teaching about the correct use of a corticosteroid medication? a. "This drug can reverse my symptoms during an asthma attack." b. "This drug is effective in decreasing the frequency of my asthma attacks." c. "This drug can be used most effectively as a rescue agent." d. "This drug can be used safely on a long-term basis for multiple applications daily." ANS

B Corticosteroids decrease inflammatory and immune responses in many ways, including preventing the synthesis of mediators. Both inhaled corticosteroids and those taken orally are preventive; they are not effective in reversing symptoms during an asthma attack and should not be used as rescue drugs. Systemic corticosteroids, because of severe side effects, are avoided for mild to moderate intermittent asthma and are used on a short-term basis for moderate asthma. 9. A client is using omalizumab (Xolair) for the first time. What is the priority nursing action? a. Make sure the client takes the medication with water. b. Administer ibuprofen (Motrin) because Xolair often causes headaches. c. Teach the client how to use a syringe. d. Remain with the client and assess for anaphylaxis. ANS

B The client who is experiencing avian influenza should be on both airborne and contact isolation. Standard antibiotic agents would be ineffective with this disease process, as would most of the standard antiviral medications commonly used for influenza. Human-to-human contact through family members is likely only in very close living arrangements, so only specific members of the client's family should consider diagnostic testing. 20. Which client does the nurse caution to avoid taking over-the-counter decongestants for manifestations of a cold or flu? a. Young man with a latex allergy b. Middle-aged woman with hypertension c. Teenage woman who is taking oral contraceptives d. Older man who has had type 1 diabetes mellitus for 20 years ANS

B Most decongestants work by increasing blood vessel constriction. This action increases peripheral vascular resistance and blood pressure. The client who already has hypertension may develop dangerously high blood pressure when taking a decongestant. The client who has a latex allergy, is taking oral contraceptives, or has type 1 diabetes would not be likely to be affected by the decongestant in such a life-threatening manner as the client who is hypertensive. 21. An older client reports having a cold and a "full bladder." What does the nurse obtain for or from the client? a. Order for a Foley catheter b. Order for a one-time catheterization c. Urine specimen d. History focusing on current medications ANS

C Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no interventions. 9. A client has a long-standing history of chronic obstructive pulmonary disease (COPD). Which laboratory finding does the nurse correlate with this condition? a. White blood cell count, 7500/mm3 b. Hemoglobin, 22 g/dL c. Neutrophils, 6000/ mm3 d. Monocytes, 600/mm3 ANS

B Normal hemoglobin for a female is 12 to 16 g/dL. Clients with COPD have chronic hypoxia, which stimulates the production of erythropoietin and thus raises the red blood cell count and hemoglobin and hematocrit levels. All other values are normal. 10. The nurse is caring for several clients on a respiratory unit. Which client does the nurse see first? a. Older adult with an SaO2 of 96% on room air b. Adult client with an SaO2 of 94% on 2 L/min c. Young adult with an arterial oxygen level of 85% d. Young adult with an arterial oxygen level of 94% ANS

B The nurse must ensure that a second tracheostomy tube with obturator is available at the bedside in case of accidental decannulation, because tube dislodgment in the first 72 hours is an emergency. Obtaining report and understanding pain medication orders are important for any postoperative client, but for the tracheostomy client, having the extra material on hand is critical. Obtaining supplies for tracheostomy care is not as high a priority as the other three. 25. A family member has been taught to provide oral care to a client with a tracheostomy. Which statement by the family member indicates an accurate understanding of the correct way to provide mouth care? a. "I can use glycerin swabs." b. "I'll use water and a toothette." c. "I can use hydrogen peroxide." d. "It is okay to use mouthwash." ANS

B The best choice for mouth care is water and a toothette because these are the least irritating. Glycerin swabs, hydrogen peroxide, and mouthwash all are too irritating to the mucous membranes of the mouth. 26. The nurse is teaching a family member how to suction the client's tracheostomy at home. Which information does the nurse include in the teaching plan? a. Always suction using sterile technique. b. Suction the mouth first and then the airway. c. Be prepared to recannulate the tube frequently. d. Suctioning with clean technique is acceptable. ANS

A The client who is status post partial laryngectomy should be taught alternative methods of swallowing, and a chart should be placed in the client's room to reinforce teaching. A dynamic swallow study is performed to guide rehabilitation for swallowing. Repeating the steps each shift is not as effective as showing the client a chart. Having the client demonstrate swallowing may not verify that he or she correctly understands supraglottic swallowing. A chart in the room will be most effective in helping both client and staff with this method. 6. A client has open vocal cord paralysis. Which technique does the nurse teach the client to do to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing. ANS

B The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration. 7. Which client does the nurse safely delegate to the LPN/LVN who has been assigned to the unit for the first time? a. Young adult who is 6 hours post radical neck dissection b. Older adult client with esophageal cancer who is awaiting gastric tube placement c. Client who is status post laryngectomy and is awaiting discharge teaching d. Client who is awaiting preoperative teaching for laryngeal cancer ANS

C Sputum production is a normal function of the respiratory tract. Most healthy people produce about 90 mL of sputum/day. This sputum should be thin, clear, and odorless, and should have minimal or no color. The nurse's only action should be to monitor the client for an increase in sputum production or a change in color. It will not be necessary at this time to obtain a specimen for analysis or to prepare for a bronchoscopy. 13. The nurse observes that a client's anteroposterior (AP) chest diameter is the same as his lateral chest diameter. What is the nurse's most important question for the client in response to this finding? a. No questions are needed regarding this normal finding. b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?" ANS

B The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. 14. A client with long-standing pulmonary problems is classified as having class III dyspnea. Based on this classification, what type of assistance does the nurse anticipate providing for ADLs? a. Dyspnea is minimal and the client requires no additional assistance. b. The client may require rest periods during performance of ADLs. c. The client requires assistance for some but not all tasks. d. Owing to severe dyspnea, this client cannot participate in any self-care. ANS

D The thread is attached to the client's cheek that holds the packing in place. The nurse needs to make sure that this does not move because it can occlude the client's airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective. 18. A client who has sleep apnea is reporting constant daytime sleepiness. The client has multiple other chronic diseases. What is the nurse's best action? a. Refer the client for surgery. b. Perform a health history. c. Request an order for a sleeping pill. d. Move the client to a private room. ANS

B The nurse should first assess the client and determine whether he or she has other chronic diseases. If the client's other disorders are not contradictory, the client may be eligible for therapy with modafinil (Attenace) to increase wakefulness during the day. Certain cardiac disorders may prohibit the use of this drug owing to its simulative effects. A sleeping pill would not be an appropriate intervention for a client with sleep apnea. A private room will not help to increase the client's sleep in sleep apnea. MULTIPLE RESPONSE 1. The nurse is assessing a client who is 6 hours post surgery for a nasal fracture. The client has facial pain (5 out of 10) and nasal packing in place. What actions by the nurse are most appropriate at this time? (Select all that apply.) a. Observe for clear drainage. b. Observe for bleeding. c. Observe the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing. g. Administer pain medication. h. Place the client in Trendelenburg position. ANS

C The client with bilateral dependent edema may be developing right-sided heart failure in response to respiratory disease. This symptom should be investigated right away and reported to the health care provider. Further assessment is needed. The client with chronic lung disease may develop increased anterior-posterior diameter and clubbing as responses to chronic hypoxia. These symptoms do not require immediate intervention. The client is often pale or has a dusky appearance; this also would not warrant immediate intervention. 25. A client with lung cancer is lying flat in bed and reports shortness of breath. What action does the nurse take first? a. Notify the health care provider. b. Elevate the head of the bed. c. Assess oxygen saturation. d. Have the client take deep breaths. ANS

B The nurse's first action should be to elevate the head of the bed. Next, assessing oxygen saturation will help the nurse determine the client's status. If the oxygen is low, the nurse would increase oxygen flow and have the client take deep breaths. The provider could be notified after the nurse performs the interventions. 26. The nurse observes hematuria in a client receiving IV cyclophosphamide (Cytoxan). After notifying the health care provider, what intervention is the nurse's priority? a. Obtain a urine specimen. b. Assess laboratory studies. c. Increase hydration. d. Stop the medication. ANS

C The client should put a shield over the tracheostomy to keep water from entering the airway. The airway should remain covered during the day with cotton or foam. Saline should be put in the airway 10 to 15 times daily. Tracheostomy ties should be used daily. 23. A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for 24 hours. Which action by the nurse is most appropriate? a. Collect all materials needed for suturing the stoma shut. b. Place a dry dressing over the stoma and tape it securely. c. Assess the client for air leaking around the tube. d. Select a smaller tracheostomy tube to be inserted. ANS

B The tube will be able to be removed after the client has tolerated capping of it for 24 hours. Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be sutured. It will heal on its own with a small scar. Airflow should be adequate around the capped tube. The physician will not likely insert the next smallest size tube but instead will remove the existing tube. 24. The nurse is preparing to receive a postoperative client who just had a tracheostomy. Which action by the nurse takes priority? a. Obtain report from the postanesthesia care unit. b. Place a second tracheostomy tube and obturator at the bedside. c. Review orders for postoperative pain medications. d. Order supplies for tracheostomy care for 24 hours. ANS

D A decrease in heart rate indicates that the client is not tolerating the procedure, and the vasovagal reflex may be stimulated. An increase in heart rate may be stimulated by suctioning and is expected, as is a slight increase in blood pressure. A slight increase in respiratory rate after the procedure might be caused by the feeling of oxygen being suctioned from the client's airway, along with secretions. 19. A client is being discharged home with a tracheostomy. Which action does the nurse teach the client to decrease the risk for aspiration while eating? a. Swallow quickly. b. Thicken all liquids. c. Rinse all food with water. d. Chew food completely. ANS

B Thickening liquids may assist the client in swallowing and may help prevent aspiration. Swallowing quickly will not decrease the risk of aspiration and may actually put the client at greater risk. It is not recommended that the client drink water to wash down food. Chewing food completely will help prevent choking but will not decrease aspiration risk. 20. The nursing student is performing tracheostomy care on a client. Which action by the student leads the supervising nurse to intervene? a. Using folded gauze dressings on both sides of the stoma b. Cutting a slit in a gauze 4 4 pad to fit around the stoma c. Applying new tracheostomy ties before removing old ones d. Tying the twill tape in a square knot on the side of the neck ANS

A, B, C CBC, throat culture, and monospot testing can help to determine the causes of sore throat and fever. A biopsy is not needed. Human immune deficiency virus (HIV) testing would not be indicated unless the symptoms were a recurrent problem. Arterial blood gases would not be performed unless the client had dyspnea and a low oxygen saturation reading. 3. What is the best way for the nurse to decrease the risk of ventilator-associated pneumonia (VAP) in a ventilator-dependent client? (Select all that apply.) a. Provide prophylactic antibiotics. b. Provide frequent oral care. c. Keep the head of the bed elevated. d. Maintain good hand hygiene. e. Perform chest percussion frequently. ANS

B, C, D Providing frequent oral care, keeping the head of the bed elevated, and maintaining good hand hygiene are currently stated as the best ways to help prevent VAP. Prophylactic antibiotics are not recommended; neither is taking the client off the ventilator. Likewise, frequent chest percussion is not stated as an intervention to decrease VAP. 4. A client who previously had a bacillus Calmette-Guérin (BCG) vaccine has a positive tuberculosis (TB) test. What symptoms assist in determining that the client has active disease? (Select all that apply.) a. Nausea b. Weight loss c. Insomnia d. Ankle edema e. Night sweats f. Increased urination ANS

D The sound heard is stridor. Stridor on inspiration is caused by laryngospasm or edema and heralds impending airway occlusion. The client's airway is in jeopardy and immediate intervention is necessary. Using the spirometer or coughing and deep breathing will not help the client in this situation. The nurse needs to call the Rapid Response Team. MULTIPLE RESPONSE 1. Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) a. Wheezes throughout lung fields b. Hemoptysis c. Sharp chest pain d. Flattened neck veins e. Hypotension f. Pitting edema ANS

B, C, E Hemoptysis, sharp chest pain, and hypotension all may be caused by pulmonary embolism and the pulmonary hypertension that results. Rather than wheezes, crackles usually occur along with a dry cough. 2. Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply) a. Middle-aged client awaiting surgery b. Older adult with a 20-pack-year history of smoking c. Client who has been on bedrest for 3 weeks d. Obese client who has elevated platelets e. Middle-aged client with diabetes mellitus type 1 f. Older adult who has just had abdominal surgery ANS

B, C, E Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously. 4. A client has a chest tube. What assessment findings require immediate intervention from the nurse? (Select all that apply.) a. Intermittent bubbling in the water seal chamber in the client with a pneumothorax b. "Silent chest" in the client with a pneumothorax c. Tidaling in the water seal chamber in a client with a pneumothorax d. Bloody drainage in the tubing of a client with a hemothorax e. Tracheal deviation in a client after chest trauma f. No drainage in the chest tube of a client with a pneumothorax g. Constant bubbling in the water seal chamber in a client post chest surgery ANS

B, E, G The client with a silent chest could have a mucous plug, the client with tracheal deviation could have a collapsed lung or tension pneumothorax, and the client with constant bubbling in the water seal could have an air leak. All of these assessments require intervention. The others are normal for the condition stated. 5. Which symptoms in chronic lung disease require nursing intervention? (Select all that apply.) a. Clubbed fingers b. Increased residual volume c. Decreased peak flow d. Increased anterior-posterior diameter e. Elevated platelets f. Expiratory wheezing g. Stridor h. Change in sputum color and amount ANS

D Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the adequacy of ventilation has the highest priority. The nurse would not sedate the client until the cause of the restlessness has been addressed. The nurse would call the provider if the cause could not be determined and addressed, or if the client's status deteriorated. 19. The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the nurse's first action? a. Determine whether an air leak is present in the client's endotracheal tube cuff. b. Have the respiratory therapist check the pressure settings. c. Assess the client's oxygenation. d. Manually ventilate the client with a resuscitation bag. ANS

C A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The nurse's priority is to check the client's oxygenation status. If oxygenation is inadequate, the nurse would assess for a cause while manually ventilating the client and calling for assistance. 20. A client is admitted to the emergency department several hours after a motor vehicle crash. The car's driver-side airbag was activated during the accident. Which assessment requires the nurse's immediate intervention? a. Disorientation b. Hemoptysis c. Pulse oximetry reading of 94% d. Chest pain with movement ANS

B The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs. The pulse oximetry reading is within normal limits and chest pain is expected with movement after chest trauma. Disorientation needs to be investigated, but does not take priority over a breathing problem. 21. The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurse's priority intervention? a. Notify the health care provider and document the symptoms. b. Intubate the client and prepare for mechanical ventilation. c. Administer oxygen and prepare for chest tube insertion. d. Administer an intermittent positive-pressure breathing treatment. ANS

C Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side with the air leak (pneumothorax). More air enters the pleural space with each breath, increasing intrathoracic pressure on the affected side, moving the trachea to the unaffected side, and leading to decreased cardiac output. This condition (tension pneumothorax) is life threatening without intervention. The client will need oxygen administration right away and a chest tube inserted. 22. The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. What finding requires immediate attention? a. Pain at the chest tube insertion site b. Fluctuation in the water seal chamber with breathing c. Puffiness of the skin around the chest tube insertion site and a crackling feeling d. Dullness to percussion on the affected side ANS

C Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. Toast is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic. 14. A client with lung cancer refuses pain medications because he or she is "afraid of addiction." What is the nurse's best response? a. "I can ask the physician to change your medication to a drug that is less potent." b. "I can use other measures such as music therapy to distract you." c. "It is unlikely you will become addicted from taking medicine for pain." d. "I can just give you aspirin or acetaminophen (Tylenol) if you like." ANS

C Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medications. 15. What is the best instruction for a client who has step II (mild persistent) asthma? a. "Avoid participating in aerobic exercise." b. "You will need daily inhaled low-dose steroids." c. "You need to evaluate your diet for asthma triggers." d. "Make sure you use a rescue inhaler three times per day." ANS

D Decreased vital capacity is a common finding with this disorder because the white blood cells clump and obliterate airways. The nurse should note the finding and should assist the client in activities that help him or her maintain quality of life. 29. The nurse is teaching a client with bronchiolitis obliterans organizing pneumonia (BOOP) about corticosteroid therapy. What statement is accurate for the nurse to teach the client? a. "You will be on this drug the rest of your life." b. "You will be prone to many long-term side effects of this drug." c. "A short course of therapy will help with acute episodes." d. "This medication cannot be taken with antibiotic therapy." ANS

C Corticosteroids are used for acute episodes and are very effective in decreasing manifestations. The client may never have another relapse after therapy. The client is not on the drug for "life," and therefore is not prone to long-term side effects. Agents can be given with antibiotics. 30. A client recently diagnosed with lung cancer is being taught by the nurse. What information does the nurse teach the client? a. "You will receive 6 weeks of daily radiation therapy." b. "Lung cancer has a very good prognosis." c. "Further testing is not needed because lung cancer rarely metastasizes." d. "It is very likely that surgery will be curative." ANS

B Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more oxygen. Although you would want to notify the provider of the change in the client's condition, the best action is first to assess pulse oximetry and then to increase the oxygen. You would not just document the assessment finding without intervening. Raising the head of the bed would not help the client oxygenate better. 11. The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which assessment finding does the nurse intervene to correct? a. The bag is two thirds inflated during inhalation. b. The client's pulse oximetry reading is 93%. c. The oxygen flow rate is 2 L/min. d. The arterial oxygen level is 90%. ANS

C Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag. A bag that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is adequate, as is an arterial oxygenation of 90%. 12. A client is to be discharged home on oxygen therapy. What information does the nurse teach the client? a. "Carry the H cylinder tank on short trips." b. "Only use the E tank when stationary." c. "The D or C cylinder can be carried." d. "Roll the tank gently when transporting." ANS

B Maintenance of an SaO2 of at least 95% is a clear goal that indicates that the client has adequate oxygenation. Absence of cyanosis and the presence of confusion are assessment factors that contribute to evaluation of oxygen; however, they are not absolute measures. Likewise, walking three times a day does not directly address oxygenation. 12. The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is the most effective? a. Administering an antitussive medication b. Administering an antiemetic medication c. Increasing fluids to 2 L/day if tolerated d. Having the client cough and deep breathe hourly ANS

C Increasing fluids has been proven to decrease the thickness of secretions, thus allowing them to be expectorated quickly. The other interventions would not be as effective. 13. A client who works in a day care facility is admitted to the emergency department. The client is diagnosed with pneumonia, and a sputum culture is taken. Infection withStreptococcus pneumoniae is confirmed. What is the nurse's primary action? a. Have emergency intubation equipment nearby. b. Teach the client about the treatment. c. Isolate the client. d. Perform chest physiotherapy. ANS

D Hemorrhagic cystitis is a frequent side effect of cyclophosphamide therapy. The physician should be notified to prescribe co-administration of a bladder-protecting agent. The nurse then should stop the medication. Other actions would be to further assess the client and provide hydration to flush the medication. 27. A client with pulmonary fibrosis is being discharged home. What is the highest priority teaching need? a. Dietary modifications b. Determining activity tolerance c. Avoiding infection d. Medication therapy ANS

C It is extremely important to teach the client with pulmonary fibrosis to avoid infection because the disease will quickly become worse as a result of decreased lung function. The client may take longer to recover from an infection, and the ability to recover may be severely limited owing to the progression of the disease. Teaching the client about modifications in diet, how to determine response to activity, and treatment medications would be secondary. 28. The nurse is caring for a client with bronchiolitis obliterans organizing pneumonia (BOOP) and assesses decreased vital capacity during pulmonary function testing. What is the nurse's best action? a. Administer intermittent positive-pressure breathing treatments. b. Administer a short-acting beta-adrenergic medication. c. Prepare to administer IV antibiotics. d. Document the finding in the client's chart. ANS

B Leukotriene and eotaxin cause later, prolonged inflammatory responses in asthma, which can be blocked by drugs like montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). No evidence suggests that aspirin helps this inflammatory response. Histamine starts an immediate inflammatory response, which can be blocked by drugs like diphenhydramine (Benadryl). Bitolterol (Tornalate) is a short-acting beta agonist that will enhance bronchodilation during an asthma attack, but it will not assist in controlling late inflammation. 22. A client with chronic obstructive pulmonary disease (COPD) reports social isolation. What does the nurse encourage the client to do? a. Join a support group for people with COPD. b. Ask the client's physician for an antianxiety agent. c. Verbalize his or her thoughts and feelings. d. Participate in community activities. ANS

C Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation. 23. The nurse is teaching a client with cystic fibrosis. What activity does the nurse teach as the priority? a. Taking daily antibiotics b. Having genetic screening c. Maintaining good nutrition d. Exercising daily ANS

B Urinary output is very low; this could indicate that the client has decreased cardiac output. The nurse will need to intervene and notify the health care provider. A respiratory rate that is slightly elevated is expected in this condition. Likewise, a heart rate that is a little higher is expected in this situation. A dry cough is also commonly found with pulmonary embolus. 6. A client states, "At night, I usually need to sleep propped up on two pillows in the chair, but now it seems I need three pillows." What is the nurse's best response? a. "You should try to rest more during the day." b. "You should try to lie flat for short periods of time." c. "You need to stay in the hospital for further evaluation." d. "You can take medication at night so you can sleep." ANS

C Orthopnea is the sensation of dyspnea or breathlessness in the supine position. Clients feel that they cannot catch their breath in the supine position and must rest or sleep in a semi-sitting position by placing pillows behind their backs or by using a reclining chair. The degree of breathlessness can be measured roughly by the number of pillows needed to make the client less dyspneic (e.g., one-pillow orthopnea, two-pillow orthopnea). With a client who has chronic respiratory problems, a minor increase in dyspnea may indicate a severe respiratory problem. Respiratory failure is a high risk. This client needs to stay in the hospital to be evaluated more completely. The client should not be instructed to try to lie flat, or to take a sleeping pill. 7. A client is admitted owing to difficulty breathing. The nurse assesses the client's color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse's next action? a. Give an intermittent positive-pressure breathing treatment. b. Administer a rescue inhaler. c. Call for a chest x-ray. d. Assess an arterial blood gas. ANS

A Excessive use of steroid inhalers reduces local immune function and increases the client's risk for oral-pharyngeal infection, including candidiasis, which manifests as white patches on the oral mucosa. The client should not brush the lesions, and salt water will not help the sores. Recent illnesses would have no effect on these lesions. 20. What statement indicates that a client needs further teaching regarding therapy with salmeterol (Serevent)? a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in my asthma." c. "I will use the drug when I have an asthma attack." d. "I will be careful not to let the drug escape out of my nose and mouth." ANS

C Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. The client does not have to keep this inhaler with him or her always because it is not used as a rescue medication. Salmeterol (Serevent) has a slow onset of action; therefore it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client's part allows the drug to escape through the nose and mouth. 21. The nurse is teaching a client about different medications for asthma. Which medication does the nurse teach the client to administer to control the prolonged inflammatory response? a. Diphenhydramine (Benadryl) b. Montelukast (Singulair) c. Aspirin d. Bitolterol (Tornalate) ANS

Care of Patients Requiring Oxygen Therapy or Tracheostomy Test Bank MULTIPLE CHOICE 1. The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the nurse's immediate action? a. Cuff pressure readings consistently between 14 and 20 mm Hg. b. Need to change Velcro tube holders three times in 1 day. c. Crackling sensation around the neck when skin is palpated. d. Small amount of bleeding around the incision for the first few days. ANS

C Subcutaneous emphysema occurs when an opening or tear occurs in the trachea and air escapes into fresh tissue planes of the neck. Air can also progress through the chest and other tissues into the face. Inspect and palpate for air under the skin around the new tracheostomy. If the skin is puffy and you can feel a crackling sensation, notify the physician immediately. Cuff pressures should be maintained between 14 and 20 mm Hg or between 20 and 28 cm H2O. Tracheostomy ties need to be changed at least once a day or whenever soiled. It is not uncommon for a client with a new tracheostomy to have heavy secretions that would necessitate changing them. It is not unusual to have a small amount of bleeding around the incision for the first few days after surgical placement. 2. A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse? a. Constant, nonproductive coughing b. Blood-tinged sputum c. Rhonchi in upper lobes d. Dry mucous membranes ANS

A The nurse should tell the client to keep a daily symptom diary. This will help identify triggers and responses to therapy in asthma. Chest circumference is not expected to change in clients with asthma. The client should not be instructed to discontinue medications. Comparing exercise tolerance before and after activity will not give the client the most complete information about his or her asthma. 18. Which statement indicates that a client needs additional teaching about using an inhaler? a. "I will not exhale into the inhaler." b. "I will store the inhaler in a drawer in my bedroom." c. "I will soak my inhaler in water to clean it." d. "I will inhale and hold my breath." ANS

C Submerging an inhaler in water to wash it is not necessary and may cause the medication in the inhaler to clump together if it is a dry powder inhaler. The other statements are all correct—the client should not exhale into the inhaler, can store the inhaler in his or her bedroom, and will need to inhale and hold breath slightly when using the inhaler. 19. The home care nurse observes white patches on the oral mucosa of a client with severe, chronic airflow limitation. What is the nurse's best action? a. Ask the client whether he or she uses a steroid inhaler. b. Inquire about any recent viral illnesses. c. Have the client rinse the mouth with salt water. d. Have the client brush the patches with a soft-bristled brush. ANS

B The most important information for clients with step II (mild persistent) asthma is that they need daily preventive anti-inflammatory medication. Low-dose inhaled steroids are necessary. The client should exercise as tolerated; however, using a rescue inhaler frequently is not recommended and, if this is needed, it should be reported to the health care provider because a change in therapy is likely needed. 16. The nurse assesses a client with asthma and finds wheezing throughout the lung fields and decreased pulse oxygen saturation. In addition, the nurse notes suprasternal retraction on inhalation. What is the nurse's best action? a. Perform peak expiratory flow readings. b. Assess for a midline trachea. c. Administer oxygen and a rescue inhaler. d. Call a code. ANS

C Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding. 17. The nurse is teaching a client with asthma about self-management. Which statement by the nurse is best? a. "Keep a daily symptom and intervention diary." b. "Measure your anterior/posterior diameter weekly." c. "Note your symptoms when you don't take your medications." d. "Exercise before and after taking inhalers and compare tolerance." ANS

B Treatment for vocal cord polyps includes not speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, and to stay hydrated and use stool softeners. 14. A client states that he is going to relax on the beach between radiation treatments for laryngeal cancer to help his "mental status." What is the nurse's best response? a. "You deserve to do something for yourself." b. "Make sure someone is with you because you shouldn't be alone right now." c. "Your skin can become severely burned, and you should not be out in the sun." d. "You should make sure you use sunscreen that is at least SPF 15." ANS

C The client should stay out of the sun during treatment because the skin can become severely burned. Sunscreen may or may not help, but an SPF of 15 is low and does not provide adequate prevention. 15. The nurse is observing a client performing stoma care for a laryngectomy for the first time. Which action does the nurse reinforce? a. Washing the stoma with soap and water b. Covering the stoma with a gauze pad c. Irrigating the stoma with half-strength peroxide d. Making sure any scab around the stoma is removed ANS

C The client who works in a day care facility and is infected with Streptococcus pneumoniae may have a drug-resistant pneumonia. It is extremely important that this organism does not spread to other clients; the client should be isolated. 14. What is the priority nursing intervention when caring for a client with severe acute respiratory syndrome (SARS)? a. Maintaining Standard Precautions b. Administering antibiotics c. Assessing oxygenation d. Making sure the client stays hydrated ANS

C The client with SARS can rapidly develop hypoxia. Assessing oxygenation is a priority because intubation and mechanical ventilation may be needed. Maintaining precautions is essential for preventing the spread of this illness, but oxygenation and client safety are the highest priorities. Antibiotics are administered if bacterial pneumonia occurs with this disease. Hydration is important to make sure secretions stay liquefied; this is also secondary to oxygenation. 15. The newly employed nurse received a bacillus Calmette-Guérin (BCG) vaccine before moving to the United States. The nurse needs to receive a tuberculin (TB) test as part of the pre-employment physical. What does the nurse do? a. The nurse should not receive the tuberculin test. b. The nurse will need a two-step TB test. c. The nurse will need a chest x-ray instead. d. A physician should examine the nurse before the TB test is given. ANS

B Aspirin and other NSAIDs can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks. 6. The nurse is evaluating a client's response to medication therapy for asthma. The client has a peak flowmeter reading in the yellow zone. What does the nurse do next? a. Nothing; this is an acceptable range. b. Teach the client to take deeper breaths. c. Assist the client to use a rescue inhaler. d. Assess the client's lungs. ANS

C The client with a peak flow reading in the yellow zone needs to use a rescue inhaler, then have a reading taken again within a few minutes. The nurse has no reason to assess the client's lungs at this point in time, nor would the nurse take the time to teach at this moment. 7. Which statement indicates that the client understands teaching about the use of long-acting beta2 agonist medications? a. "I will not have to take this medication every day." b. "I will take this medication when I have an asthma attack." c. "I will take this medication daily to prevent an acute attack." d. "I will eventually be able to stop using this medication." ANS

C The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea. 12. Which clinical manifestation in a client with paralysis of one vocal cord alerts the nurse to the possibility of aspiration? a. Oxygen saturation is decreased. b. Voice is weak and tremulous. c. The client coughs immediately after swallowing. d. An audible wheeze is present on exhalation. ANS

C The client with open vocal cord paralysis is at risk for aspiration because the airway may not close during swallowing. Coughing may indicate that the client's airway is irritated from aspirated contents. Decreased oxygen saturation can occur for a number of reasons. A weak voice may indicate weak muscles, and wheezing may indicate swelling or inflammation in the airways. 13. Which statement made by the client who is prescribed "voice rest" therapy for vocal cord polyps indicates the need for more teaching? a. "I will stay out of rooms and places where people are smoking." b. "When I speak at all, I will whisper rather than use a normal tone of voice." c. "For the next several weeks, I will not lift more than 10 pounds." d. "I will drink at least 3 quarts of water each day and will use stool softeners." ANS

C This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen saturation dropping, the client is at high risk for respiratory failure and needs to be intubated. Deep-breathing exercises are not enough at this point. Rib binders are not used anymore because they limit chest wall expansion and were used only for simple rib fractures. 25. The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurse's best action? a. Turn the client to the right side. b. Elevate the head of the bed. c. Assess placement of the endotracheal (ET) tube. d. Suction the client. ANS

C The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath sounds described. The nurse should assess placement of the ET tube by assessing where the markings are, making sure it is taped, and confirming equal breath sounds bilaterally. If it is believed that the tube has slipped into the right mainstem bronchus, the health care provider should order a chest x-ray and reposition the tube. 26. What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation? a. Ask the client to point to words on a board. b. Ask the client to blink for "yes" and "no." c. Have the client mouth words slowly. d. Teach the client some simple sign language. ANS

D All of these directions are appropriate to give the client; however, telling the client to report abdominal pain and dark-colored vomit is most important because these could signal gastric ulceration. 39. A client infected with Burkholderia cepacia is admitted to the unit. What is the nurse's priority action when caring for this client? a. Instruct the client to wash his or her hands after contact with other people. b. Place the client on strict isolation. c. Keep the client isolated from other clients with cystic fibrosis. d. Administer IV vancomycin daily. ANS

C The infection is spread through casual contact between cystic fibrosis clients, thus the need for isolation of these clients from each other. Strict isolation measures will not be necessary. Although the client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other cystic fibrosis clients. 40. The nurse assesses the following lung sounds in a client. What is the nurse's best action? (Click the media button to hear the audio clip.) a. Administer a rescue inhaler. b. Administer oxygen. c. Assess vital signs. d. Elevate the client's head. ANS

D An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing. The nurse is not able to make changes in the ventilator settings, so an order is needed to increase inspiratory pressure to oxygenate the client. Suctioning or performing chest physical therapy (PT) will not help the client's lung compliance; however, if mucus is impeding the airway, these interventions would be necessary and would be noticed when the airway is assessed. Administering a bronchodilator may help the client; however, an inhaler could not be used by a client on a ventilator. 10. The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)? a. Older adult with COPD b. Middle-aged client receiving a blood transfusion c. Older adult who has aspirated his tube feeding d. Young adult with a broken leg from a motorcycle accident ANS

C The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for the possibility of ARDS. A client with COPD and a middle-aged client with no other risk factors are not at as high a risk for ARDS. The client who has a broken leg from an accident is not at high risk. 11. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action? a. Change the client's position. b. Suction the client. c. Assess lung sounds. d. Turn off the pressure alarm. ANS

B The client with pneumonia may have dullness to percussion on the affected side. The other options are all inconsistent with pneumonia. 28. The nurse auscultates the following lung sound in the client with pneumonia. What is the best intervention? (Click the media button to hear the audio clip.) a. Have the client cough and deep breathe. b. Prepare to administer a bronchodilator. c. Have the client use an incentive spirometer. d. Administer IV fluids. ANS

C The sound heard is crackles. Crackles often indicate atelectasis, which can be reversed by using an incentive spirometer. If no spirometer is available, coughing and deep breathing is the next best option. This client does not have wheezing, so bronchodilators are not indicated. IV fluids would not help atelectasis. 29. A client has a tuberculin skin test as a pre-employment physical requirement. Which statement by the nurse is best made to the client who has the test result seen in the photograph below? a. "Your PPD is negative. No further follow-up is necessary." b. "You will need to have a second PPD." c. "You will need to have titers drawn." d. "You will need further testing." ANS

D A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near-normal. 19. A client had a bronchoscopy 2 hours ago and is requesting water to drink. Which action by the nurse is most appropriate? a. Call the physician and request an order for food and water. b. Give the client ice chips instead of a drink of water. c. Assess the client's gag reflex before giving anything. d. Let the client have a small sip to see whether he or she can swallow. ANS

C The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex. 20. A client is scheduled for pulmonary function tests (PFTs) in the morning. The nurse calls the client to teach about the procedure. Which statement by the client indicates a need for further teaching? a. "I should not smoke for at least 6 hours before the test." b. "PFTs can determine whether my lung problem has gotten worse." c. "I should use my inhaler anytime during the test if I need it." d. "If I get really short of breath, I'll tell the technician." ANS

B, D, F The nurse should follow Airborne Precautions when caring for clients suspected of SARS. Wear a gown and goggles when in the room and caring for the client. Use a disposable particulate mask respirator if the client is coughing, or if particles are being aerosolized. Handwashing and Standard Precautions are not enough. The client does not have to wear a mask while others are in the room because they should be protecting themselves by using Airborne Precautions. 7. The nurse is caring for a client who has inhalation anthrax. What nursing actions are of the highest priority? (Select all that apply.) a. Placing the client in an isolation room b. Teaching the client how to use a mask c. Teaching the client about long-term antibiotic therapy d. Using handwashing and other Standard Precautions e. Reporting suspected cases to the proper authorities ANS

C, D, E The client should not stop the drug merely because he or she has no manifestations. The client will need to be on the drug for longer than 1 month. The nurse should teach the client about long-term antibiotic therapy to help with compliance. Inhalation anthrax is not spread by person-to-person contact, so isolation would not be necessary. The client would not need a mask. Health care providers need only use handwashing and Standard Precautions. Always report inhalation anthrax to authorities because it is considered an intentional act of terrorism. Chapter 34

Care of Patients with Noninfectious Upper Respiratory Problems Chapter 31

Care of Patients with Noninfectious Upper Respiratory Problems Test Bank MULTIPLE CHOICE 1. A high school athlete has suffered a nasal fracture. What is the priority action of the nurse caring for the client? a. Assess for pain. b. Pack the nares to prevent blood loss. c. Assess for bone displacement. d. Assess for airway patency. ANS

B The client may have an alteration in body image because of the tracheostomy stoma. Encourage the client to wear loose-fitting shirts and collars to help hide the appearance of the stoma. Clients should not be encouraged to tell people about their illness, because they should not be made to "justify" their appearance. You should not bandage the tracheostomy, because airflow would be impaired. Ignoring comments will not help the client's self-image. 5. A client is becoming frustrated because of an inability to communicate with a tracheostomy. Which intervention by the nurse most effectively enhances communication? a. Explain to the client that speech will be clear and distinct with a fenestrated tube. b. Reassure the client that in time he or she will get used to the speech difficulties. c. Place a sign above the client's bed indicating that the client cannot speak. d. Provide the client with a communication board and call light within easy reach. ANS

D A communication board and the call light will reassure the client that needs will be communicated and met. It is doubtful that the client with a tracheostomy will ever speak clearly and distinctly, no matter what type of tube he or she uses. Reassuring the client that he or she will get used to the speech difficulties does nothing to alleviate the discomfort and fear associated with impaired communication. Placing a sign above the client's bed indicating that he cannot speak will not enhance his ability to communicate, although it may help staff remember that the client has impaired communication. 6. A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with labored respirations. Which action does the nurse perform first? a. Remove bedding from around the adaptor opening. b. Listen to lung sounds and obtain a respiratory rate. c. Call respiratory therapy to check oxygen saturation. d. Notify the provider or Rapid Response Team immediately. ANS

A Bubbling in the water seal chamber indicates air drainage from the client and usually is seen when the client's intrathoracic pressure is greater than atmospheric pressure, such as during exhalation, coughing, or sneezing. When the air in the pleural space has been sufficiently removed, bubbling stops. Continuous bubbling indicates an air leak. If the air leak is in the thoracic cavity, air and air pressure increase in the thoracic cavity, forcing more air into the water seal chamber. This air movement is prevented when the chest tube is clamped close to the insertion site. 35. A client was diagnosed with lung cancer and appears distressed. The client states, "I am so afraid." What is the best action for the nurse to take? a. Provide comfort by holding the client's hand. b. Offer to give the client a back rub for relaxation. c. Offer the client a PRN antianxiety medication. d. Ask the client what is causing the most fear right now. ANS

D A diagnosis of lung cancer often causes fear for many reasons, usually poor prognosis, fear of pain, and fear of dyspnea. The nurse should assess what is worrying the client most at the moment so appropriate interventions can be planned. Touch is often a powerful tool, but the nurse should assess whether this is acceptable to the client. The nurse should assess the client further and provide assistance with coping before offering to medicate him. 36. The nurse is assessing a client who has a chest tube. Which assessment finding requires intervention by the nurse? a. Pain at the insertion site b. Bloody drainage in the collection chamber c. Intermittent bubbling in the water seal chamber d. Tidaling in the water seal chamber ANS

B Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO2levels, such as those seen in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and can cause respiratory arrest. However, hypoxemia is a greater threat to an acutely ill client than is the potential for oxygen-induced hypoventilation, and clients should be given the amount of oxygen they require. The nurse should perform a thorough respiratory assessment and should monitor the client for signs of this problem, rather than automatically reducing oxygen delivery. Blood gases and a chest x-ray will also be obtained, but they do not take priority over assessing and monitoring the client. 9. The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO2 is the client receiving? a. 24% b. 28% c. 36% d. 40% ANS

D A nasal cannula can provide oxygen at 0.5 to 6 L/min, corresponding to an FiO2 range of 25% to 40%. At 5 L/min, the client is receiving 40% oxygen. 10. A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do first? a. Notify the health care provider. b. Assess the client's pulse oximetry. c. Document the observation. d. Raise the head of the bed. ANS

C Puffiness of the skin around the chest tube and a crackling feeling indicate subcutaneous emphysema, or air leaking into the tissue around the insertion site. This must be addressed immediately. A hemothorax involves bleeding into the thoracic cavity and decreased lung inflation on the affected side, resulting in duller and less resonant percussion notes. Pain at the insertion site, fluctuation in the water seal, and dullness to percussion are all expected. 23. The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP). What intervention is most appropriate for this client? a. Administering antianxiety medications PRN b. Administering a medication to help the client sleep c. Telling the client to relax and let the ventilator do the work d. Making sure the client is breathing spontaneously ANS

D A requirement for using CPAP is that the client will be able to breathe spontaneously. Antianxiety and sleep medications should not be administered to the client during weaning. Telling the client to relax may be helpful in some cases but does not take priority over ensuring the client's ability to breathe spontaneously. 24. The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse? a. Encourage the client to take deep, controlled breaths. b. Document findings and continue to monitor the client. c. Notify the health care provider and prepare for intubation. d. Stabilize the chest wall with rib binders. ANS

D Benzocaine spray can be used as a topical anesthetic before bronchoscopy to numb the throat. However, its use is associated with methemoglobinemia. Methemoglobin does not carry oxygen, and a clue to this problem is increasing cyanosis refractory to oxygen. Chocolate brown blood is another characteristic of this problem. The other options are all appropriate but are not the priority. 17. A client is scheduled to undergo a thoracentesis. What is the nurse's priority intervention? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Verify that informed consent has been given by the client. ANS

D A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis. 18. The nurse is caring for a client after a thoracentesis. Which assessment finding by the nurse warrants immediate action? a. Client rates pain as 5/10 at the site of the procedure. b. Small amount of drainage is noted from the site. c. Pulse oximetry is 93% on 2 liters of oxygen. d. Trachea is deviated toward opposite side of the neck. ANS

A Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when administering fibrinolytic therapy, and would monitor the IV site as well. Teaching the client is also a need, however. Oxygenation is the highest priority. 4. A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse's first action? a. Irrigate the Foley. b. Administer an antibiotic. c. Clamp the Foley. d. Notify the health care provider. ANS

D Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots outside the pulmonary embolism, and the client is at great risk for hemorrhage and shock. The nurse should realize the potential for a severe problem and should call the health care provider immediately for orders. The other actions would not be appropriate first actions in this situation. 5. The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately? a. Respiratory rate of 28 breaths/min b. Urinary output of 10 mL/hr c. Heart rate of 100 beats/min d. Dry cough ANS

C A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate. 3. The nurse is caring for four clients who had arterial blood gases (ABGs). Which laboratory value warrants immediate intervention by the nurse? a. HCO3- of 25 mEq/L b. SpO2 of 96% c. pH of 7.38 d. PaCO2 of 48 mm Hg ANS

D Although the nurse should note the results of all laboratory work, only a PaCO2 of 48 mm Hg is likely to culminate in serious symptoms for the client. HCO3-, SpO2, and pH levels as assessed would not be life threatening, nor would they be indicative of serious complications that would override the importance of the PaCO2 level. 4. The nurse is calculating a client's smoking history in pack-years. The client has recently been diagnosed with lung cancer. Which is the nurse's priority intervention during the interview? a. Encourage the client to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis. ANS

D In addition to standard preoperative testing, the client who will undergo lung reduction surgery is tested to determine the location of greatest lung hyperinflation and poorest lung blood flow. These tests include pulmonary plethysmography, gas dilution, and perfusion scans. The other interventions are lower priorities. 12. The nurse assesses a client receiving chemotherapy for lung cancer and notes red swollen mucous membranes and open sores in the mouth. The client reports mouth pain and difficulty swallowing. Which action does the nurse perform first? a. Document the size of the sores. b. Perform mouth hygiene. c. Have the client rinse his or her mouth. d. Call the health care provider and hold chemotherapy. ANS

D Although the nurse should perform all interventions for mucositis, the priority is to call the health care provider and hold the chemotherapy. Mucositis may be a dose-limiting condition in chemotherapy. The nurse should call the provider, then should assist the client with mouth hygiene, rinsing the mouth, and obtaining pain relief. Documenting the size and location of ulcers is also important. 13. A client is undergoing radiation therapy as treatment for lung cancer and has developed esophagitis. Which is the best diet selection for this client? a. Spaghetti with meat sauce, ice cream b. Scrambled eggs, bacon, toast c. Omelet, whole wheat bread d. Pasta salad, custard, orange juice ANS

A The client is taught to wash the stoma gently and to prevent anything from getting into the opening. The client should never scrape around the opening because this could cause broken skin, irritation, and infection. Peroxide is not used for irrigation; irrigation of the stoma is not done. 16. A client has undergone a nasoseptoplasty 2 hours ago. It is a priority for the nurse to assess for which factor? a. Nasal drainage b. Bleeding c. Pain d. Airway patency ANS

D Assessing and maintaining a patent airway is always the top priority. The other assessments are important but do not take priority over airway. 17. A client develops posterior nasal bleeding and has packing inserted. What is the nurse's priority action? a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the client's cheek. ANS

B Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation bag and facemask while another nurse calls for help. Although auscultation of breath sounds is important, the client's airway must be opened and ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the physician's intervention. 15. While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. Which action by the nurse is most appropriate? a. Increase the inflation pressure in the tracheostomy cuff. b. Add blue dye to a beverage to assess for aspiration. c. Make the client NPO and notify the health care provider. d. Perform a more thorough assessment of the client. ANS

D Before calling the provider, the nurse needs more data, such as lung sounds, presence of cough, pulse oximetry reading, and possibly mental status. The nurse could temporarily make the client NPO while conducting this assessment, but calling the provider must wait until he or she has more complete data. The nurse should not decide to increase the inflation pressure in the tracheostomy cuff on his or her own. Adding dye to food, drink, or tube feeding formulas was commonly done in the past but should be avoided because the dye is toxic to lung tissues if aspirated. 16. The nurse is teaching a client about his fenestrated tracheostomy tube. Which statement by the client indicates an accurate understanding of the tube? a. "I'm glad I will still be able to talk with this tube in place." b. "It is great that this tube does not have to be cleaned regularly." c. "This tube will not get dislodged because it never needs suctioning." d. "Because I can't swallow, I will need another tube for eating." ANS

D Once the gag reflex has returned, the client should drink at least 2 1/2 liters per day. The client should not change position frequently; the best position is semi-Fowler's. Ice rather than heat should be applied. Lying flat is not recommended. 4. A client reports waking up feeling very tired, even after 8 hours of good sleep. What is the nurse's best action? a. Ask for an order for sleep medication. b. Tell the client not to drink beverages with caffeine. c. Tell the client not to lie flat at night. d. Ask the client whether he or she has ever been evaluated for sleep apnea. ANS

D Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment. 5. A client had a partial laryngectomy and has received instructions on the supraglottic method of swallowing. Which action by the nurse is most appropriate? a. Place a chart in the client's room detailing the steps in the process. b. Order a dynamic swallow study. c. Repeat the instruction each day. d. Have the client demonstrate swallowing. ANS

A Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough, substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is not an emergent problem. Dry mucous membranes should be lubricated, and the client's hydration status can be checked. 3. A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the nurse is most appropriate? a. Drain condensation back into the humidifier, maintaining a closed system. b. Keep the water sterile by draining it from the water trap back into the humidifier. c. Turn down the humidity when condensation begins to collect in the tubing. d. Remove condensation in the tubing by disconnecting and emptying it appropriately. ANS

D Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and nebulizers have a water trap that hangs from the tubing so the condensation can be drained without disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or the nebulizer. Do not turn down the humidity because the physician has ordered it and the client needs it. Minimize how long the tubing is disconnected because the client does not receive oxygen during this period. 4. A client is being discharged with a tracheostomy and voices concern about his appearance. What discharge teaching will assist the client with maintaining a positive body image? a. "Tell people how sick you were when they ask about the tracheostomy." b. "Your clothing can help hide the tracheostomy so it is not as noticeable." c. "You can put a bandage around your tracheostomy so no one will see it." d. "You have to ignore comments that people make about your appearance." ANS

A Bacterial infection often occurs with acute rhinitis. The nurse should assess for symptoms because treatment may be warranted. It is not essential to assess for allergies or the use of nasal spray, or to determine whether drug use is occurring. All of these interventions are focused on determining a cause for repeated acute rhinitis and are primarily the responsibility of the health care provider. The nurse should focus on client assessment and should determine whether a secondary infection is present. 2. A client has pharyngitis. Which symptom helps the nurse determine whether the infection is bacterial versus viral? a. Redness in the back of the throat b. Enlarged lymph glands in the neck c. Nasal discharge d. Skin rash ANS

D Generally a rash can appear with bacterial pharyngitis, but not with viral. The other symptoms are characteristic of both. 3. It is suspected that a client has bacterial pharyngitis. What is the best intervention? a. Administer a broad-spectrum antibiotic. b. Have the client produce a sputum specimen. c. Obtain samples for culture and sensitivity. d. Assess a rapid antigen test (RAT). ANS

D A common cause of bacterial pharyngitis is group A streptococcal virus, which can lead to serious complications. Both RATs and culture and sensitivity can diagnose this bacterium; however, with an RAT, the health care provider can obtain results in about 15 minutes, and definitive treatment can begin much sooner. A broad-spectrum antibiotic would not be administered before it was determined whether the infection was bacterial. A sputum specimen is needed for lung infection but not for throat infection. 4. The nurse is caring for a client with recurrent bacterial pharyngitis. Which is the nurse's highest priority intervention? a. Assess for symptoms of human immune deficiency virus (HIV). b. Ask about exposure to allergens. c. Perform nasal cultures. d. Teach the client about antibiotic therapy. ANS

D Management of bacterial pharyngitis involves the use of antibiotics and the same supportive care provided for viral pharyngitis. Stress the importance of completing the entire antibiotic prescription, even when symptoms improve or subside. Failure to take all prescribed antibiotics is often the cause of recurrent infections. Although it is important for overall health that the client know his or her HIV status, it is not the highest priority intervention in the treatment plan. Allergens do not cause bacterial infections. Nasal cultures would not be a high priority unless the client had "failed" treatment with more than one antibiotic and was compliant with treatment. 5. A client who has had acute tonsillitis develops drooling and reports severe throat pain. What is the nurse's priority intervention? a. Assess the throat for deviation of the uvula. b. Prepare the client for surgery. c. Teach the client about antibiotic therapy. d. Prepare the client for percutaneous needle aspiration. ANS

C Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs a day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. 5. When assessing a client's respiratory status, which information is of highest priority for the nurse to obtain? a. Average daily fluid intake b. Neck circumference c. Height and weight d. Occupation and hobbies ANS

D Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment. 6. The nursing assistant reports to the nurse that an African-American client's pulse oximetry reading is 93%. The client has no complaints. Which action by the nurse is most appropriate? a. Replace the sensor probe of the oximeter. b. Place the probe on another finger. c. Assess other signs of respiratory adequacy. d. Prepare to obtain arterial blood gases. ANS

C Although influenza can lead to pneumonia, and preventing influenza with a flu shot reduces the risk for a secondary pneumonia, bacterial pneumonia can be acquired without influenza as a precipitating event and can be life threatening. Getting both injections will not protect the client from respiratory problems, nor will it prevent the client from being infectious to other people. 26. Which is a priority teaching intervention for the client who is using a nicotine patch? a. "Abruptly discontinuing this patch can cause high blood pressure." b. "Abruptly discontinuing this patch can cause nausea and vomiting." c. "Smoking while using this patch increases the risk for pneumonia." d. "Smoking while using this patch increases the risk for a heart attack." ANS

D Nicotine constricts blood vessels, increases mean arterial pressure, and increases afterload. Smoking while using a nicotine patch increases afterload to such an extent that the myocardium must work harder (with the coronary arteries constricted) and may cause a myocardial infarction. Abruptly discontinuing the patch will not necessarily cause hypertension or nausea and vomiting. Smoking while using the patch will not increase the risk for pneumonia. 27. A client is admitted with left lower lung pneumonia. Which assessment finding does the nurse correlate with this condition? a. Expiratory wheeze on the right side b. Dullness to percussion on the lower left side c. Crepitus of the skin around the left lung d. Crackles heard on expiration bilaterally ANS

C Some genetic variations may cause the activity of beta-adrenergic receptors to change, meaning that the client would not respond as expected to beta agonists. Genetic testing may help to determine why the drug therapy is not working and may help the clinician to identify new therapy that will work. 4. The nurse is caring for four clients with asthma. Which client does the nurse assess first? a. Client with a barrel chest and clubbed fingernails b. Client with an SaO2 level of 92% at rest c. Client whose expiratory phase is longer than the inspiratory phase d. Client whose heart rate is 120 beats/min ANS

D Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation. 5. The nurse is caring for an older adult who reports experiencing frequent asthma attacks and severe arthritic pain. What action by the nurse is most appropriate? a. Review pulmonary function test results. b. Assess use of medication for arthritis. c. Assess frequency of bronchodilator use. d. Review arterial blood gas results. ANS

C The bacillus Calmette-Guérin (BCG) vaccine contains attenuated tubercle bacilli and is used in many countries to produce increased resistance to TB. The nurse will have a positive skin test. The client should be evaluated for TB with a chest x-ray. A physician examination is not necessary. 16. The nurse is caring for several clients on a respiratory floor. The nurse should place the client with which condition in isolation? a. Fever and weight loss b. Negative QuantiFERON TB gold test c. Negative acid-fast bacillus (AFB) stain d. Positive nucleic acid amplification test (NAAT) ANS

D The NAAT is a new rapid test for the diagnosis of tuberculosis (TB). Results are available in less than 2 hours. A positive test is conclusive for TB, and the client should be placed in isolation per facility policy. A client with a negative QuantiFERON gold test would not have tuberculosis. Likewise, a client with a negative AFB would not have tuberculosis. The client with fever and weight loss could have tuberculosis, but diagnostic tests would be needed because these are nonspecific manifestations. 17. A client has multidrug-resistant tuberculosis (TB). What is the most important fact for the nurse to teach the client? a. "You will need to take medications longer than clients with other strains." b. "You will need to remain in the hospital until cultures are negative." c. "You will need to wear a mask when you go out in public." d. "You will need to have drug cultures done weekly." ANS

C One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound. Changing the client's position would not change the pressure needed to administer a breath. 12. The nurse is caring for a client who has been intubated and placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). Aside from assessing oxygenation, what is the nurse's priority action? a. Assess hemoglobin. b. Administer ferrous sulfate. c. Assess muscle strength. d. Consult with the registered dietitian. ANS

D The client who is intubated needs nutrition delivered via enteral tube feeding. If nutrition is ignored, the client's respiratory status can deteriorate, because respiratory muscle function can deteriorate. 13. The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action? a. Check cuff inflation on the endotracheal tube. b. Listen carefully to the client. c. Call the health care provider. d. Auscultate the lungs. ANS

A If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume. 14. Which assessment finding of a client requires the nurse's immediate action? a. Being intubated for 4 days b. Uneven breath sounds c. Wheezing on auscultation d. Having the endotracheal (ET) tube taped to the lower jaw ANS

D The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action. 15. The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated. What is the nurse's priority action? a. Nothing; this is required during ventilation. b. Inflate the cuff using minimal leak technique. c. Call the Rapid Response Team. d. Increase the tidal volume. ANS

D When clients with respiratory problems are assessed, an arterial blood gas is needed for the most accurate assessment of oxygenation. No indications are known for a breathing treatment or an inhaler, nor does the nurse have enough information to know whether a chest x-ray is warranted. 8. A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the nurse best intervene? a. Increase the oxygen. b. Administer an antianxiety medication. c. Administer a bronchodilator. d. Assist with relaxation techniques. ANS

D The nurse should assess the client's oxygenation; however, this client's arterial blood gas documents that the client's hypoxia has resolved. At this time it is not necessary to increase the oxygen or administer a bronchodilator; both of these interventions would be appropriate if the client were hypoxic. The client with respiratory problems should not take an antianxiety medication as a first-line intervention, because this may decrease the respiratory rate and/or alertness. The best intervention at this time is to assist with relaxation techniques. 9. The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse's best intervention? a. Suction the client. b. Perform chest physiotherapy. c. Administer an inhaler. d. Assess the airway. ANS

B Clients with shortness of breath and decreased oxygen saturation must be monitored closely. Minimal involvement in activities is required if the client is severely short of breath. The nurse should continue to assess the client and can increase involvement in activities if shortness of breath subsides. The Rapid Response Team is not required. Clustering or spacing of activities does nothing to decrease the client's involvement, which is the cause of shortness of breath. 29. The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention? a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg d. pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg ANS

D This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on ABG analysis. 30. The nurse auscultates the following lung sound in a client with a respiratory disorder. What is the nurse's best action? (Click the media button to hear the audio clip.) a. Have the client use an incentive spirometer. b. Have the client cough and deep breathe. c. Suction the client after auscultating the lower lobes of the lungs. d. Call for the Rapid Response Team. ANS

D The nurse needs to assess more before intervening. Clients often take antihistamines for a "cold." Antihistamines are often composed of anticholinergic drugs. In older adult clients, these medications can cause or worsen urinary retention. 22. A client has a peritonsillar abscess. Which priority instruction does the nurse provide to this client? a. "If you notice an enlarged node on the side of your neck where the abscess is, call your health care provider." b. "Stay home from work or school until your temperature has been normal for 24 hours." c. "You may gargle with warm water that has a teaspoon of salt in it as often as you like." d. "Take the antibiotic for the entire time it is prescribed, not just until you feel better." ANS

D Untreated or ineffectively treated peritonsillar abscesses can extend throughout the pharyngeal area, causing swelling that may jeopardize the client's airway. Therefore, the client should take his antibiotic for the entire time prescribed to maximize the therapeutic effect. Gargling with warm water and refraining from normal activities may provide symptomatic relief for the client but would not be considered priority instructions. Also, swelling, pain, and inflammation could be noted by the client on the same side of the neck as the abscess. 23. An older adult client with heart failure asks if she should get a flu shot. Which is the nurse's best response? a. "Yes, because of your heart failure you are at greater risk for complications." b. "Yes, if it has been longer than 5 years since your last flu vaccination." c. "No, your heart failure makes you too weak to get the live virus vaccine." d. "No, the vaccine will interact with your heart medications." ANS

A, C, D, G Accessory muscle use may help the client breathe during an attack. Muscle retraction may be seen at the sternum and at the suprasternal notch. Mucous membranes can also tell the nurse about oxygenation. Inspiration versus expiration can tell the nurse how the client is breathing. The anterior-posterior diameter gives indication of a chronic condition; assessing this during an attack will not help the client. Likewise, performing a stress test and a chest x-ray during an attack would not be beneficial. OTHER 1. The nurse is teaching a client to cough productively. Put the actions in proper sequence. a. Have the client flex the head and hold a pillow to the stomach. b. Assist the client to a sitting position with feet on the floor. c. Instruct the client to bend forward and to cough two or three times. d. Have the client return to an upright position and take a deep breath. e. Encourage the client to take several deep breaths. ANS

b, a, e, c, d When the client can tolerate it, the best position for effective coughing and secretion removal is sitting with the shoulders turned inward and the head bent slightly down while hugging a pillow. The client should take several deep breaths followed by holding the breath slightly before coughing two or three times in a row. Then the client should cough at the end of exhalation; this should be followed by taking several deep breaths. 2. Place the steps for obtaining a peak expiratory flow rate in the order in which they should occur. a. Take as deep a breath as possible. b. Stand up (unless you have a physical disability). c. Place the meter in your mouth, and close your lips around the mouthpiece. d. Make sure the device reads zero or is at base level. e. Blow out as hard and as fast as possible for 1 to 2 seconds. f. Write down the value obtained. g. Repeat the process two additional times, and record the highest number in your chart. ANS