Week 3: Ch 28
When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers? (Select all that apply.) A. Exercise B. Allergies C. Emotional stress D. Decreased humidity E. Upper respiratory infections
A, B, C, & E Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, stress, and gastroesophageal reflux disease (GERD).
The provider has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? A. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." B. "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." C. "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." D. "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."
A. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." The patient should be instructed to tightly close the lips around the mouthpiece and breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.
The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? A. Albuterol B. Ipratropium bromide C. Salmeterol (Serevent) D. Beclomethasone (Qvar)
A. Albuterol Albuterol is a short-acting bronchodilator that should be given initially when the patient has an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide is an anticholinergic agent that is less effective than β2-adrenergic agonists. It may be used in an emergency with a patient unable to tolerate short-acting β2-adrenergic agonists (SABAs).
A 45-yr-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which manifestation would be an early indication of an exacerbation of asthma? A. Anxiety B. Cyanosis C. Bradycardia D. Hypercapnia
A. Anxiety An early manifestation of an asthma attack is anxiety because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.
A patient with chronic obstructive pulmonary disease (COPD) becomes dyspneic at rest. The baseline ABG results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? A. Arterial pH 7.26 B. PaCO2 50 mm Hg C. Patient in tripod position D. Increased sputum expectoration
A. Arterial pH 7.26 The patient's pH shows acidosis that supports an exacerbation of COPD along with the worsening dyspnea. The PaCO2 has improved from baseline, the tripod position helps the patient's breathing, and the increase in sputum expectoration will improve the patient's ventilation.
While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse teach the patient to do? A. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. B. Increase the dose of the long-term control medication if the peak flow numbers decrease. C. Use the flowmeter each morning after taking medications to evaluate their effectiveness. D. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.
A. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. It is important to keep track of peak flow readings daily, especially when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the provider based on personal peak flow numbers. Peak flow is measured by exhaling into the flowmeter and should be assessed before and after medications to evaluate their effectiveness.
A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should nurse report to the provider? A. Stridor B. Copious oral secretions C. Hoarseness D. Sore throat
A. Stridor Stridor, or high-pitched crowing sound heard during inspiration, is a result of laryngeal edema. This finding indicates possible obstruction of the client's airway. Therefore, the nurse should report it to the provider immediately. Copious secretions, hoarseness, and sore throat following extubation are expected findings.
A nurse is administered nasal decongestant drops for a client. Which of the following actions should the nurse take? A. Tell the client to blow her nose gently before instillation B. Assist the client to a side-lying position C. Hold the dropper 2 cm (1 in) above the naris D. Instruct the client to stay in the same position for 2 min
A. Tell the client to blow her nose gently before instillation Prior to the instillation, the nurse should instruct the client to blow their nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.
A patient is admitted to the emergency department with a severe exacerbation of asthma. Which finding is of most concern to the nurse? A. Unable to speak and sweating profusely B. PaO2 of 80 mmHg and PaCO2 of 50 mmHg C. Presence of inspiratory and expiratory wheezing D. Peak expiratory flow rate at 60% of personal best
A. Unable to speak and sweating profusely During a severe exacerbation of asthma, the patient may not be able to speak because of difficulty breathing; the patient may also be perspiring profusely. Other indicators of severe asthma include the absence of wheezing because of limited airflow, arterial blood gas resulting in decreased PaO2 and increased PaCO2; and peak expiratory flow rate at or below 40% of personal best.
The nurse is caring for a patient with an acute exacerbation of asthma. After initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? A. Wheezing becomes louder. B. Cough remains nonproductive. C. Vesicular breath sounds decrease. D. Aerosol bronchodilators stimulate coughing.
A. Wheezing becomes louder. The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Vesicular breath sounds will increase with improved respiratory status. After a severe asthma exacerbation, the cough may be productive and stringy. Coughing after aerosol bronchodilators may indicate a problem with the inhaler or its use.
The nurse determines the patient with asthma has activity intolerance. What is the most likely reason for this problem? A. Work of breathing B. Fear of suffocation C. Effects of medications D. Anxiety and restlessness
A. Work of breathing When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity. Fear of suffocation, effects of medications or anxiety, and restlessness are not etiologies for activity intolerance for a patient with asthma.
The nurse is teaching a patient how to self-administer ipratropium via a metered-dose inhaler (MDI). Which instruction is most appropriate to help the patient learn the proper inhalation technique? A. "Avoid shaking the inhaler before use." B. "Breathe out slowly before positioning the inhaler." C. "Using a spacer should be avoided for this type of medication." D. "After taking a puff, hold the breath for 30 seconds before exhaling."
B. "Breathe out slowly before positioning the inhaler." It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication, thus enhancing the effectiveness of the dose. The inhaler should be shaken well. A spacer may be used. Holding the breath after the inhalation of medication helps keep the medication in the lungs, but 30 seconds will not be possible for a patient with COPD.
The nurse teaches a patient with chronic obstructive pulmonary disease (COPD) how to administer fluticasone by metered-dose inhaler (MDI). Which statement indicates a correct understanding of the instructions? A. "I should not use a spacer device with this inhaler." B. "I will rinse my mouth each time after I use this inhaler." C. "I will feel my breathing improve over the next 2 to 3 days." D. "I should use this inhaler immediately if I have trouble breathing."
B. "I will rinse my mouth each time after I use this inhaler." Fluticasone may cause oral candidiasis (thrush). The patient should rinse the mouth with water or mouthwash after use or use a spacer device to prevent oral fungal infections. Fluticasone is an inhaled corticosteroid and it may take 2 weeks of regular use for effects to be evident. This medication is not recommended for an acute asthma attack.
A nurse is providing dietary teaching for a client who has COPD. Which of the following instructions should the nurse include? A. "Eat 3 large meals each day" B. "Limit water intake with meals" C. "Reduce protein intake" D. "Use a bronchodilator 1 hour before eating"
B. "Limit water intake with meals" The nurse should instruct the client to limit low nutrient liquids during meals to prevent easily satiety and increase intake of nutrient-dense foods. The nurse should instruct the client to eat small, frequent meals to conserve energy, increase protein and calories to increase muscle mass and energy, and to use a bronchodilator 30 min before eating to reduce the risk of bronchospasm.
The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? A. "I will pay less for medication because it will last longer." B. "More of the medication will get down into my lungs to help my breathing." C. "Now I will not need to breathe in as deeply when taking the inhaler medications." D. "This device will make it so much easier and faster to take my inhaled medications."
B. "More of the medication will get down into my lungs to help my breathing." A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. It does not affect the cost or increase the speed of using the inhaler.
Which test result identifies that a patient with asthma is responding to treatment? A. An increase in CO2 levels B. A decreased exhaled nitric oxide C. A decrease in white blood cell count D. An increase in serum bicarbonate levels
B. A decreased exhaled nitric oxide Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma and adherence to treatment. An increase in CO2 levels, decreased white blood cell count, and increased serum bicarbonate levels do not indicate a positive response to treatment in a patient with asthma.
The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring which patient parameters? A. Apical pulse B. Daily weight C. Bowel sounds D. Deep tendon reflexes
B. Daily weight Corticosteroids such as prednisone can lead to weight gain. For this reason, it is important to monitor the patient's daily weight. The drug should not affect the apical pulse, bowel sounds, or deep tendon reflexes.
When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands the manifestations of the disease are related to what process? A. An overproduction of the antiprotease a1-antitrypsin B. Hyperinflation of alveoli and destruction of alveolar walls C. Hypertrophy and hyperplasia of goblet cells in the bronchi D. Collapse and hypoventilation of the terminal respiratory unit
B. Hyperinflation of alveoli and destruction of alveolar walls In COPD, structural changes include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.
The nurse is evaluating if a patient understands how to safely determine whether a metered-dose inhaler (MDI) is empty. The nurse decides the patient understands this important information when the patient describes which method to check the inhaler? A. Place it in water to see if it floats. B. Keep track of the number of inhalations used. C. Shake the canister while holding it next to the ear. D. Check the indicator line on the side of the canister.
B. Keep track of the number of inhalations used. It is no longer appropriate to see if a canister floats in water or not because this is not an accurate way to determine the remaining inhaler doses. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing it after the number of days when those inhalations have been used (100 puffs/2 puffs each day = 50 days).
When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse determines that the patient's nutritional status is impaired after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient? A. Order fruits and fruit juices to be offered between meals. B. Order a high-calorie, high-protein diet with six small meals a day. C. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet. D. Encourage the patient to double carbohydrate consumption and decrease fat intake.
B. Order a high-calorie, high-protein diet with six small meals a day. Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, thus interfering with the work of breathing. For these reasons, the patient with COPD should eat 6 small meals per day taking in a high-calorie, high-protein diet, with nonprotein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient's caloric intake.
The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone after what occurs? A. Hypertension and pulmonary edema B. Oropharyngeal candidiasis and hoarseness C. Elevation of blood glucose and calcium levels D. Adrenocortical dysfunction and hyperglycemia
B. Oropharyngeal candidiasis and hoarseness Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.
A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? A. Oxygen tent B. Venturi mask C. Nasal cannula D. Oxygen-conserving cannula
B. Venturi mask The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered.
A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? A. "Rest in a side-lying position after the tube is removed." B. "Use incentive spirometer every 4 hr after the tube is removed." C. "Avoid speaking for long periods." D. "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed"
C. "Avoid speaking for long periods." The client should avoid speaking for long periods to promote gas exchange. To promote ventilation, the client should sit upright in a semi-Fowler's position and use the incentive spirometer every 2 hr. To reduce risk of respiratory distress after the tube is removed, the nurse will monitor the client's vital signs every 5 minutes.
A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide? A. Consume a high-protein diet B. Administer the medication with food C. Avoid caffeine while taking this medication D. Increase fluids to 1 L/day
C. Avoid caffeine while taking this medication The nurse should instruct the client that caffeine should be avoided as it can increase central nervous system stimulation, to increase fluid intake to 2L/day to decrease the thickness of mucous secretions, to take this medication with water and not with food, and to avoid high-protein diet as this decreases theophylline's duration of action.
When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included about the effects of smoking on the lungs? A. Smoking causes a hoarse voice. B. Cough will become nonproductive. C. Decreased alveolar macrophage function. D. Sense of smell is decreased with smoking.
C. Decreased alveolar macrophage function. The damage to the lungs includes alveolar macrophage dysfunction that increases the incidence of infections and thus increases patient discomfort and cost to treat the infections. Other lung damage that contributes to infections includes cilia paralysis or destruction, increased mucus secretion, and bronchospasms that lead to sputum accumulation and increased cough. The patient may already be aware of respiratory mucosa damage with hoarseness and decreased sense of smell and taste, but these do not increase the incidence of pulmonary infection.
The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with chronic obstructive pulmonary disease (COPD) are successful based on which finding? A. Absence of dyspnea B. Improved mental status C. Effective and productive coughing D. PaO2 within normal range for the patient
C. Effective and productive coughing Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing. Absence of dyspnea, improved mental status, and PaO2 within normal range for the patient show improved respiratory status but do not evaluate airway clearance.
The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? A. Giving care will calm the patient B. Observing for signs of diaphoresis C. Evaluating the use of intercostal muscles D. Monitoring the patient for bilateral chest expansion
C. Evaluating the use of intercostal muscles The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress. The other options may also occur, but they are not the primary reason for inspecting the chest wall of this patient.
Assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? A. Acute respiratory failure B. Secondary respiratory infection C. Fluid volume excess from cor pulmonale D. Pulmonary edema caused by left-sided heart failure
C. Fluid volume excess from cor pulmonale Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.
In which position should the nurse place a patient experiencing an asthma exacerbation? A. Supine B. Lithotomy C. High Fowler's D. Reverse Trendelenburg
C. High Fowler's The patient experiencing an asthma attack should be placed in high Fowler's position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation.
A patient with bronchiectasis has copious thick respiratory secretions. Which intervention should the nurse add to the plan of care? A. Use the incentive spirometer for at least 10 breaths every 2 hours. B. Give prescribed antibiotics and antitussives on a scheduled basis. C. Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. D. Provide nutritional supplements that are high in protein and carbohydrates.
C. Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. Adequate hydration helps to liquefy secretions and thus make it easier to remove them. Unless there are contraindications, the nurse should teach the patient to drink at least 3 L of fluid daily. Although nutrition, breathing exercises, and antibiotics may be indicated, these interventions will not liquefy or thin secretions. Antitussives may reduce the urge to cough and clear sputum, increasing congestion. Expectorants may be used to liquefy and facilitate clearing secretions.
The nurse determines that therapy with ipratropium is effective after noting which assessment finding? A. Decreased respiratory rate B. Increased respiratory rate C. Increased peak flow readings D. Decreased sputum production
C. Increased peak flow readings Ipratropium is a bronchodilator that should result in increased peak expiratory flow rates.
During an assessment of a patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? A. Laryngospasm B. Pulmonary edema C. Narrowing of the airway D. Overdistention of the alveoli
C. Narrowing of the airway Narrowing of the airway by persistent but variable inflammation leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing. Laryngospasm, pulmonary edema, and overdistention of the alveoli do not produce wheezing.
The nurse teaches pursed-lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? A. Loosening secretions so that they may be coughed up more easily B. Promoting maximal inhalation for better oxygenation of the lungs C. Preventing bronchial collapse and air trapping in the lungs during exhalation D. Increasing the respiratory rate and giving the patient control of respiratory patterns
C. Preventing bronchial collapse and air trapping in the lungs during exhalation The purpose of pursed-lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation. It does not affect secretions, inhalation, or increase the rate of breathing.
The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? A. Temperature of 98.4° F B. Oxygen saturation 96% C. Pulse rate of 72 beats/min D. Respiratory rate of 18/ breaths/min
C. Pulse rate of 72 beats/min Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 72 beats/min indicates that the patient does not have tachycardia as an adverse effect.
The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? A. IV fluids B. Biofeedback therapy C. Systemic corticosteroids D. Pulmonary function testing
C. Systemic corticosteroids Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. IV fluids may be used but not to improve ventilation. Biofeedback therapy and pulmonary function testing may be used after recovery to assist the patient and monitor the asthma.
The nurse is caring for a patient admitted for exacerbation of chronic obstructive pulmonary disease. The patient develops severe dyspnea at rest, with an increase in respiratory rate from 26 to 44 breaths/min. Which action by the nurse would be the most appropriate? A. Have the patient perform huff coughing. B. Perform chest physiotherapy for 5 minutes. C. Teach the patient to use pursed-lip breathing. D. Instruct the patient in diaphragmatic breathing.
C. Teach the patient to use pursed-lip breathing. Pursed-lip breathing (PLB) prolongs exhalation and prevents bronchiolar collapse and air trapping. PLB is simple and easy to teach and learn. It also gives the patient more control over breathing. Evidence from controlled studies does not support the use of diaphragmatic breathing in patients with COPD. Diaphragmatic breathing results in hyperinflation because of increased fatigue and dyspnea and abdominal paradoxical breathing rather than with normal chest wall motion. Chest physiotherapy (percussion and vibration) is used primarily for patients with excessive bronchial secretions who have difficulty clearing them. Huff coughing is a technique that helps patients with COPD to use a forced expiratory technique to clear secretions.
Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching about the use of an ipratropium inhaler? A. "I should wait at least 1 to 2 minutes between each puff of the inhaler." B. "I can rinse my mouth following the two puffs to get rid of the bad taste." C. "Because this medication is not fast acting, I cannot use it in an emergency if my breathing is worse." D. "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."
D. "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily." The patient should not just keep taking extra puffs of the inhaler to make breathing easier. Excessive treatment could trigger paradoxical bronchospasm, which would worsen the patient's respiratory status. Rinsing the mouth after the puffs will eliminate a bad taste. Waiting 1 to 2 minutes between each puff will facilitate the effectiveness of the administration. Ipratropium is not used in an emergency for COPD.
A patient has been receiving oxygen per nasal cannula while hospitalized for chronic obstructive pulmonary disease (COPD). The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? A. "Long-term home oxygen therapy should be used to prevent respiratory failure." B. "Oxygen will not be needed unless you are in the terminal stages of this disease." C. "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." D. "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."
D. "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia." Long-term oxygen therapy in the home will not be considered until the oxygen saturation is less than or equal to 88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status. PaO2 less than 55 mm Hg will also allow home oxygen therapy to be considered.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following is the nurse's highest priority? A. Initiating oxygen therapy B. Providing immediate rest for the client C. Positioning the client in high-Fowler's D. Administering a nebulized beta-adrenergic
D. Administering a nebulized beta-adrenergic The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing brochiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation.
The nurse is assessing a client has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel
D. Barrel Clients who has COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase anterior-posterior diameter, making it appear barrel-shaped.
A nurse is caring who has emphysema and has a difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? A. Increased insulin production B. Decreased RBC production C. Decreased sodium excretion D. Increased calcium excretion
D. Increased calcium excretion Prolonged immobility leads to the breakdown of bone tissue, resulting in increased calcium excretion. Prolonged immobility does not affect insulin production, RBC production, and sodium excretion.
The nurse supervises a team including another registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and unlicensed assistive personnel (UAP) on a medical unit. The team is caring for many patients with respiratory problems. In what situation should the nurse intervene with teaching for a team member? A. LPN/VN obtained a pulse oximetry reading of 94% but did not report it. B. UAP report to the nurse that the patient is reporting of difficulty breathing. C. RN taught the patient about home oxygen safety in preparation for discharge. D. LPN/VN changed the type of oxygen device based on arterial blood gas results.
D. LPN/VN changed the type of oxygen device based on arterial blood gas results. It is not within the LPN scope to change oxygen devices based on analysis of lab results. It is within the scope of practice of the RN to assess, teach, and evaluate. The LPN provides care for stable patients and may adjust oxygen flow rates depending on desired oxygen saturation levels of stable patients. The UAP may obtain oxygen saturation levels, assist patients with comfort adjustment of oxygen devices, and report changes in patient's level of consciousness or difficulty breathing.
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? A. Administer low-flow oxygen continuously via nasal cannula B. Encourage oral intake of at least 3,000 mL of fluids per day C. Offer high-protein and high-carbohydrate foods frequently D. Place in a prone position
D. Place in a prone position Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent and consistent turning of the client is also beneficial and can be accomplished by the use of specialty beds.
The nurse is teaching a patient how to self-administer beclomethasone, 2 puffs inhaled every 6 hours. What should the nurse teach the patient to do to prevent oral infection while taking this medication? A. Chew a hard candy before the first puff of medication. B. Ask for a breath mint after the second puff of medication. C. Rinse the mouth with water before each puff of medication. D. Rinse the mouth with water after the second puff of medication.
D. Rinse the mouth with water after the second puff of medication. Because beclomethasone is a corticosteroid, the patient should rinse the mouth with water after the second puff of medication to reduce the risk of fungal overgrowth and oral infection.
A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? A. Reduced inflammation B. Suppresses the urge to cough C. Dries mucous membranes D. Stimulates secretions
D. Stimulates secretions Expectorants act by increasing secretions to improve a cough's productivity. Glucocorticoids reduce inflammation; Antitussives suppress the cough stimulus; Anticholinergic medications dry mucous membranes and reduce secretions
Before discharge, the nurse discusses activity levels with a 61-yr-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? A. Slightly increase activity over the current level. B. Swim for 10 min/day, gradually increasing to 30 min/day. C. Limit exercise to activities of daily living to conserve energy. D. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.
D. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min. The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220—patient's age).
