4th Level Exam 2

Guaifenesin 300 mg four times daily has been ordered as an expectorant. The dosage strength of the liquid is 200mg/5ml. How many mL should the nurse administer each dose? A 5.0 ml B 7.5 ml C 9.5 ml D 10 ml

7.5

To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with a. arterial blood gas (ABG) analysis. b. hemodynamic monitoring. c. chest x-rays. d. pulse oximetry.

A Rationale: ABG analysis is useful because it provides information about both oxygenation and ventilation and assists with determining possible etiologies and appropriate treatment. The other tests may also provide useful information about patient status but will not indicate whether the patient has hypoxemia, hypercapnia, or both."v

Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia, rate 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields.

A Rationale: Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP.

When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94.

A Rationale: Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

A client is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. The nurse would expect to PaCO2 to be which of the following values? A 15 mm Hg B 30 mm Hg C 40 mm Hg D 80 mm Hg

A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected.

When developing a discharge plan to manage the care of a client with COPD, the nurse should anticipate that the client will do which of the following? A Develop infections easily B Maintain current status C Require less supplemental oxygen D Show permanent improvemen

A client with COPD is at high risk for development of respiratory infections. COPD is a slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

When developing a discharge plan to manage the care of a client with COPD, the nurse should anticipate that the client will do which of the following? A Develop infections easily B Maintain current status C Require less supplemental oxygen D Show permanent improvement

A client with COPD is at high risk for development of respiratory infections. COPD is a slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

Which of the following positions would best aid breathing for a client with acute pulmonary edema? A Lying flat in bed Left side-lying In high Fowler's position D In semi-Fowler's position

A high Fowler's position promotes ventilation and facilitates breathing by reducing venous return. Lying flat and side-lying positions worsen the breathing and increase workload of the heart. Semi-Fowler's position won't reduce the workload of the heart as well as the Fowler's position will.

Which of the following is a priority goal for the client with COPD? Maintaining functional ability B Minimizing chest pain C Increasing carbon dioxide levels in the blood D Treating infectious agents

A priority goal for the client with COPD is to manage the s/s of the disease process so as to maintain the client's functional ability. Chest pain is not a typical sign of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.

Nurse caring for client who is scheduled for thoracentesis. Which supplies should nurse ensure in the clients room (select all) a. oxygen equipment b. incentive spirometer c. pulse oximeter d. sterile dressing e. suture removal kit

A, C, D Oxygen if become SOB, pulse ox to monitor, and sterile dressing to apply to puncture site

Nurse is admitting a child who has cystic fibrosis. which of the following medications should the nurse anticipate including in the plan of care? (select all) a. tobramycin b. solu-medrol c. fat-soluble vitamins d. albuterol e. dornase alpha

A, C, D, E

Select all interventions during asthma attack. a. monitor VS b. Lay patient flat c. monitor O2 d. ABGs e. breath sounds f. leave patient

A, C, D, E, (*sit patient up, stay with patient)

Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following reasons best explains why? A Reducing fluid volume reduces oxygen demand B Reducing fluid volume improves clients' mobility C Restricting fluid volume reduces sputum production D Reducing fluid volume improves respiratory function

A. Reducing fluid volume reduces the workload of the heart, which reduces oxygen demand and, in turn, reduces the respiratory rate. It may also reduce edema and improve mobility a little, but exercise tolerance will still be harder to clear airways. Reducing fluid volume won't improve respiratory function, but may improve oxygenation.

a school-age child with CF asks the nurse what sports she can be involved in as she becomes older. Which of the following activities would be most appropriate for the nurse to suggest? a) swimming b) track c) baseball d) javelin throwing

A.swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Because track events, baseball and javelin throwing usually are performed outdoors, the child would be breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes and pulmonary system. The strenuous activity and increased energy expenditure associated with track events, in conjunction with the dust and possible heat, would play a role in placing the child at risk for an URTI and compromising her respiratory function.

Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema? A Risk for infection related to stasis of alveolar secretions B Impaired skin integrity related to pressure Activity intolerance related to pump failure D Constipation related to immobility

Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for infection related to stasis of secretions or impaired skin integrity related to pressure. However, these are not the priority nursing diagnoses for the client with HF and pulmonary edema, nor is constipation related to immobility.

Aminophylline (theophylline) is prescribed for a client with acute bronchitis. A nurse administers the medication, knowing that the primary action of this medication is to: A Promote expectoration B Suppress the cough Relax smooth muscles of the bronchial airway D Prevent infection

Aminophylline is a bronchodilator that directly relaxes the smooth muscles of the bronchial airway.

Which of the following cardiac conditions does a fourth heart sound (S4) indicate? A Dilated aorta B Normally functioning heart Decreased myocardial contractility Failure of the ventricle to eject all of the blood during systole

An S4 occurs as a result of increased resistance to ventricular filling after atrial contraction. The increased resistance is related to decreased compliance of the ventricle. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. Decreased myocardial contractility is heard as a third heart sound. An S4 isn't heard in a normally functioning heart.

The nurse is preparing a 5 year-old fora scheduled tonsillectomy andadenoidectomy. The parents are anxious andconcerned about the child's reaction toimpending surgery. Which nursingintervention would be best to prepare thechild? A) Introduce the child to all staff the day before surgery B) Explain the surgery 1 week prior to the procedure C) Arrange a tour of the operating and recovery rooms D) Encourage the child to bring a favorite toy tothe hospital

Answer B Explain the surgery 1 week prior to theprocedureA 5 year-old can understand the surgery, andshould be prepared well before the procedure.Most of these procedures are "same day"surgeries and do not require an overnight stay.

Which of the following is NOT partof the triad of cystic fibrosis? A: pancreatic enzyme deficiency B: fever C: high concentration of sweat electrolytes D: COPD

Answer B. The triad of cystic fibrosis is COPD, pancreaticenzyme deficiency, and a high concentration ofsweat electrolytes

A 6-year-old boy is returned to hisroom following a tonsillectomy. He remainssleepy from the anesthesia but is easilyawakened. The nurse should place the childin which of the following positions? a.Sims'. b. Side-lying. c. Supine. d. Prone.

Answer B. Side-lying — CORRECT: most effective to facilitatedrainage of secretions from the mouth and pharynx;reduces possibility of airway obstruction.Supine — increased risk for aspiration, would not facilitate drainage of oral secretions Prone — risk for airway obstruction and aspiration,unable to observe the child for signs of bleeding such as increased swallowing Sims' — on side with top knee flexed and thigh drawn up to chest and lower knee less sharply flexed: used for vaginal or rectal examination

A priority nursing diagnosis for a childbeing admitted from a surgery following atonsillectomy is: a.Altered nutrition b.Impaired communication c.Risk for aspiration d.Altered urinary elimination

Answer C The first priority should be on airway, breathingand circulation.

After teaching the parents of apreschooler who has undergone T and A(Tonsillectomy and Adenoidectomy) aboutappropriate foods to give the child afterdischarge, which of the following, if statedby the parents as appropriate foods, indicatessuccessful teaching? a)meatloaf and uncooked carrots b) pork and noodle casserole c) cream of chicken soup and orange sherbet d) hot dog and potato chips

Answer C for the first few days after a T and A (Tonsillectomy and Adenoidectomy) , liquids andsoft foods are best tolerated by the child while thethroat is sore. Avoid hard and scratchy foods untilthroat is healed.

Which of the following can indicate left-sided heart failure in an infant? A: feverB: low appetiteC: increased respiratory rateD: crying

Answer C.Shortness of breath and perspiration duringfeeding can also indicate left-sided heart failure.

A 2 year-old child has just beendiagnosed with cystic fibrosis. The child'sfather asks the nurse "What is our majorconcern now, and what will we have to dealwith in the future?" Which of the followingis the best response? A)"There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns thatcan be dealt with." C) "Thin, tenacious secretions from the lungs are aconstant struggle in cystic fibrosis." D) "You will work with a team of experts and also haveaccess to a support group that the family can attend."

Answer C:"Thin, tenacious secretions from the lungs are aconstant struggle in cystic fibrosis." All of theoptions will be concerns with cystic fibrosis,however the respiratory threats are the majorconcern in these clients. Other information ofinterest is that cystic fibrosis is an autosomalrecessive disease. There is a 25% chance thateach of these parent''s pregnancies will result ina child with systic fibrosis.

The nurse is caring for an 8-year oldfollowing a routine tonsillectomy. Whichfinding should be reported immediately? a.Reluctance to swallow b.Drooling of blood-tinged saliva c.An axillary temperature of 99F d.Respiratory stridor

Answer DRespiratory stridor is a symptom of partail airwayobstruction.choice A,B and C are expected with atonsillectomy.

Which of the following ABG abnormalities should the nurse anticipate in a client with advanced COPD? A Increased PaCO2 B Increased PaO2 C Increased pH D Increased oxygen saturation

As COPD progresses, the client typically develops increased PaCO2 levels and decreased PaO2 levels. This results in decreased pH and decreased oxygen saturation. These changes are the result of air trapping and hypoventilation.

The nurse would anticipate which of the following ABG results in a client experiencing a prolonged, severe asthma attack? A Decreased PaCO2, increased PaO2, and decreased pH. B Increased PaCO2, decreased PaO2, and decreased pH. C Increased PaCO2, increased PaO2, and increased pH. D Decreased PaCO2, decreased PaO2, and increased pH

As the severe asthma attack worsens, the client becomes fatigued and alveolar hypotension develops. This leads to carbon dioxide retention and hypoxemia. The client develops respiratory acidosis. Therefore, the PaCO2 level increase, the PaO2 level decreases, and the pH decreases, indicating acidosis.

A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a a. shallow breathing pattern. b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg. d. respiratory rate of 32/min.

B Rationale: The PaO2 indicates severe hypoxemia and that the nurse should take immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain.

A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of bilevel positive pressure ventilation (BiPAP)

B Rationale: The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

Care for child with asthma, which interventions included in plan of care? (select all) a. perform CPT b. place child in upright position c. monitor ox sat d. administer bronchodilators e. administer dornase alpha

B, C, D for asthma (A, E for cystic fibrosis)

a nurse is planning care for a client who is receiving mech vent. which mode increases the effort of the client's respiratory muscles? (select all) a. assist control b. synchronized intermittent mandatory ventilation c. continous positive airway pressure d. pressure support ventilation e. independent lung ventilation

B,C,D all require client to generate force to take spontaneous breath.

Your patient was diagnosed with lf. sided HF. On an EKG, left-sided failure results in a. tall peaked P waves b. Wide, notched P waves C. Changes in ST segment D. A prolonged Q wave

B. Wide notched P waves (tall peaked P waves indicate right sided heart failure)

A nurse is planning care for child with CG. Which interventions should she include in plan of care? a. provide a low calorie, low protein diet b. administer pancreatic enzymes with meals and snacks c. promote an increase in fluids after 1800 d. restrict physical activity

B. administer enzymes with each snack and meal (within 30 minutes) *need high calorie and protein, increase fluids throughout the day, and need physical activity

A 7-year-old client is brought to the E.R. He's tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and a nonproductive cough. He recently had a cold. From his history, the client may have which of the following? Acute asthma B Bronchial pneumonia C Chronic obstructive pulmonary disease (COPD) D Emphysema

Based on the client's history and symptoms, acute asthma is the most likely diagnosis. He's unlikely to have bronchial pneumonia without a productive cough and fever and he's too young to have developed COPD or emphysema.

A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes a day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions? A Adult respiratory distress syndrome (ARDS) B Asthma C Chronic obstructive bronchitis D Emphysema

Because of his extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis. Clients with ARDS have acute symptoms of and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have a chronic cough or peripheral edema.

Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy? Heart failure B Diabetes MI D Pericardial effusion

Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. MI results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with pericarditis.

A client has an order to have radial ABG drawn. Before drawing the sample, a nurse occludes the: A Brachial and radial arteries, and then releases them and observes the circulation of the hand. B Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery. C Radial artery and observes for color changes in the affected hand. D Ulnar artery and observes for color changes in the affected hand.

Before drawing an ABG, the nurse assesses the collateral circulation to the hand with Allen's test. This involves compressing the radial and ulnar arteries and asking the client to close and open the fist. This should cause the hand to become pale. The nurse then releases pressure on one artery and observes whether circulation is restored quickly. The nurse repeats the process, releasing the other artery. The blood sample may be taken safely if collateral circulation is adequate.

A client with acute asthma showing inspiratory and expiratory wheezes and a decreased expiratory volume should be treated with which of the following classes of medication right away? A Beta-adrenergic blockers B Bronchodilators C Inhaled steroids D Oral steroids

Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Beta-adrenergic blockers aren't used to treat asthma and can cause bronchoconstriction. Inhaled or oral steroids may be given to reduce the inflammation but aren't used for emergency relief.

Following the initial care of a client with asthma and impending anaphylaxis from hypersensitivity to a drug, the nurse should take which of the following steps next? A Administer beta-adrenergic blockers B Administer bronchodilators C Obtain serum electrolyte levels D Have the client lie flat in the bed

Bronchodilators would help open the client's airway and improve his oxygenation status. Beta-adrenergic blockers aren't indicated in the management of asthma because they may cause bronchospasm. Obtaining laboratory values wouldn't be done on an emergency basis, and having the client lie flat in bed could worsen his ability to breathe.

Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? A Antihypertensive B Beta-adrenergic blockers C Calcium channel blockers D Nitrates

By decreasing the heart rate and contractility, beta-adrenergic blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy. Antihypertensives aren't usually indicated because they would decrease cardiac output in clients who are often already hypotensive. Calcium channel blockers are sometimes used for the same reasons as beta-adrenergic blockers; however, they aren't as effective as beta-adrenergic blockers and cause increase hypotension. Nitrates aren't' used because of their dilating effects, which would further compromise the myocardium.

Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? A Antihypertensives B Beta-adrenergic blockers C Calcium channel blockers D Nitrates

By decreasing the heart rate and contractility, beta-blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy. Antihypertensives aren't usually indicated because they would decrease cardiac output in clients who are already hypotensive. Calcium channel blockers are sometimes used for the same reasons as beta-blockers; however, they aren't as effective as beta-blockers and cause increased hypotension. Nitrates aren't used because of their dilating effects, which would further compromise the myocardium.

Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? A Antihypertensives Beta-adrenergic blockers C Calcium channel blockers D Nitrates

By decreasing the heart rate and contractility, beta-blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy. Antihypertensives aren't usually indicated because they would decrease cardiac output in clients who are already hypotensive. Calcium channel blockers are sometimes used for the same reasons as beta-blockers; however, they aren't as effective as beta-blockers and cause increased hypotension. Nitrates aren't used because of their dilating effects, which would further compromise the myocardium.

Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) is most appropriate for the RN to delegate to an experienced LPN/LVN working in the intensive care unit? a. Placing the patient in the prone position b. Assessment of patient breath sounds c. Administration of enteral tube feedings d. Obtaining the pulmonary artery pressures

C Rationale: Administration of tube feedings is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient

When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate? a. "The infection spread through the circulation from the urinary tract to the lungs." b. "The urinary tract infection produced toxins that damaged the lungs." c. "The infection caused generalized inflammation that damaged the lungs." d. "The fever associated with the infection led to scar tissue formation in the lungs."

C Rationale: The pathophysiologic changes that occur in ARDS are thought to be caused by inflammatory and immune reactions that lead to changes at the alveolar-capillary membrane. ARDS is not directly caused by infection, toxins, or fever.

When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The skin on the patient's back is intact and without redness. b. Sputum and blood cultures show no growth after 24 hours. c. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. d. Endotracheal suctioning results in minimal mucous return.

C Rationale: The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

Captopril may be administered to a client with HF because it acts as a: Vasopressor B Volume expander Vasodilator D Potassium-sparing diuretic

C - ACE inhibitors have become the vasodilators of choice in the client with mild to severe HF. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure.

Pulses alternans in most often associated with a. mitral stenosis b. constrictive pericarditis c. left ventricle failure d. aortic stenosis

C. Pulsus alternans occurs in left ventricle heart failure. The pulses alternate between weak and strong. Also seen in CHF.

If a beta2 receptor in the heart is stimulated, the effect may be a. reflex bradycardia b. arterial vasoconstriction c. bronchodilation d. increased SVR

C. bronchodilation - also vasodilation and smooth muscle relaxation

Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet? A Apples Tomato juice C Whole wheat bread D Beef tenderloin

Canned foods and juices, such as tomato juice, are typically high in sodium and should be avoided in a sodium-restricted diet.

The best method of oxygen administration for client with COPD uses: A Cannula B Simple Face mask C Non rebreather mask D Venturi mask

Cannula

In which of the following types of cardiomyopathy does cardiac output remain normal? A Dilated B Hypertrophic C Obliterative D Restrictive

Cardiac output isn't affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. All of the rest decrease cardiac output.

In which of the following types of cardiomyopathy does cardiac output remain normal? Dilated Hypertrophic C Obliterative D Restrictive

Cardiac output isn't affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. All of the rest decrease cardiac output.

The term "blue bloater" refers to which of the following conditions? A Adult respiratory distress syndrome (ARDS) B Asthma Chronic obstructive bronchitis D

Clients with chronic obstructive bronchitis appear bloated; they have large barrel chests and peripheral edema, cyanotic nail beds and, at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amounts of oxygen. Clients with asthma don't exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic (a state of ill health, malnutrition, and wasting).

A nurse is caring for a client hospitalized with acute exacerbation of COPD. Which of the following would the nurse expect to note on assessment of this client? A Increased oxygen saturation with exercise B Hypocapnia C A hyperinflated chest on x-ray film D A widened diaphragm noted on chest x-ray film

Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-ray films reveal a hyperinflated chest and a flattened diaphragm is the disease is advanced.

A client with acute asthma is prescribed short-term corticosteroid therapy. What is the rationale for the use of steroids in clients with asthma? A Corticosteroids promote bronchodilation B Corticosteroids act as an expectorant C Corticosteroids have an anti-inflammatory effect D Corticosteroids prevent development of respiratory infections

Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.

Which of the following symptoms is most commonly associated with left-sided heart failure? A Crackles B Arrhythmias C Hepatic engorgement D Hypotension

Crackles in the lungs are a classic sign of left-sided heart failure. These sounds are caused by fluid backing up into the pulmonary system. Arrhythmias can be associated with both right and left-sided heart failure. Left-sided heart failure causes hypertension secondary to an increased workload on the system.

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of acute respiratory distress. When monitoring the patient, which assessment by the nurse will be of most concern? a. The patient is sitting in the tripod position. b. The patient has bibasilar lung crackles. c. The patient's pulse oximetry indicates an O2 saturation of 91%. d. The patient's respiratory rate has decreased from 30 to 10/min.

D Rationale: A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest; therefore, the nurse will need to take immediate action. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

A patient is diagnosed with a large pulmonary embolism. When explaining to the patient what has happened to cause respiratory failure, which information will the nurse include? a. "Oxygen transfer into your blood is slow because of thick membranes between the small air sacs and the lung circulation." b. "Thick secretions in your small airways are blocking air from moving into the small air sacs in your lungs." c. "Large areas of your lungs are getting good blood flow but are not receiving enough air to fill the small air sacs." d. "Blood flow though some areas of your lungs is decreased even though you are taking adequate breaths."

D Rationale: A pulmonary embolus limits blood flow but does not affect ventilation, leading to a ventilation-perfusion mismatch. The response beginning, "Oxygen transfer into your blood is slow because of thick membranes" describes a diffusion problem. The remaining two responses describe ventilation-perfusion mismatch with adequate blood flow but poor ventilation. Cognitive Level: Application Text Reference: p. 1802 Nursing Process: Implementation NCLEX: Physiological Integrity

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. "PEEP will prevent fibrosis of the lung from occurring." b. "PEEP will push more air into the lungs during inhalation." c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs." d. "PEEP prevents the lung air sacs from collapsing during exhalation."

D Rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's arterial oxyhemoglobin saturation (SpO2) from 94% to 88%. The nurse will a. assist the patient to cough and deep-breathe. b. help the patient to sit in a more upright position. c. suction the patient's oropharynx. d. increase the oxygen flow rate.

D Rationale: Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

6. When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Monitor the patient every 10 to 15 minutes. b. Notify the patient's health care provider immediately. c. Attempt to calm and reassure the patient. d. Assess vital signs and pulse oximetry.

D Rationale: The nurse needs to collect additional clinical data to share with the health care provider and to start interventions quickly if appropriate (e.g., increased oxygen flow if hypoxic). The change in the patient's neurologic status may indicate deterioration in respiratory function, and the health care provider should be notified immediately but only after some additional information is obtained. Monitoring the patient and attempting to calm the patient are appropriate actions, but they will not prevent further deterioration of the patient's clinical status and may delay care.

A patient in acute respiratory failure as a complication of COPD has a PaCO2 of 65 mm Hg, rhonchi audible in the right lung, and marked fatigue with a weak cough. The nurse will plan to a. allow the patient to rest to help conserve energy. b. arrange for a humidifier to be placed in the patient's room. c. position the patient on the right side with the head of the bed elevated. d. assist the patient with augmented coughing to remove respiratory secretions.

D Rationale: The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve PaCO2 and will also help to correct fatigue. If the patient is allowed to rest, the PaCO2 will increase. Humidification may help loosen secretions, but the weak cough effort will prevent the secretions from being cleared. The patient should be positioned with the good lung down to improve gas exchange.

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. The patient has a cough that is productive of blood-tinged sputum. b. The patient has scattered crackles throughout the posterior lung bases. c. The patient's temperature is 101.5° F after 2 days of IV antibiotic therapy. d. The patient's SpO2 has dropped to 90%, although the O2 flow rate has been increased.

D Rationale: The patient's dropping SpO2 despite having an increase in FIO2 indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

When teaching the parents of an older infant with CF (cystic fibrosis) about the type of diet the child should consume, which of the following would be most appropriate? a) low protein diet b) high fat diet c) low carbohydrate diet d) high calorie diet

D. CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction, a moderate fat, high calorie diet is indicated.

Which of the following cardiac conditions does a fourth heart sound (S4) indicate? A Dilated aorta B Normally functioning heart C Decreased myocardial contractility D Failure of the ventricle to eject all the blood during systole

D.An S4 occurs as a result of increased resistance to ventricular filling after atrial contraction. This increased resistance is related to decrease compliance of the ventricle. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. Decreased myocardial contractility is heard as a third heart sound. An s4 isn't heard in a normally functioning heart.

Auscultation of a client's lungs reveals crackles in the left posterior base. The nursing intervention is to: Repeat auscultation after asking the client to deep breathe and cough. B Instruct the client to limit fluid intake to less than 2000 ml/day. C Inspect the client's ankles and sacrum for the presence of edema D Place the client on bedrest in a semi-Fowlers position

Deep breath and cough. Although crackles often indicate fluid in the alveoli, they may also be related to hypoventilation and will clear after a deep breath or a cough. It is, therefore, premature to impose fluid (2) or activity (4) restrictions (which Margaret would totally do if Dani weren't there to smack her). Inspection for edema (3) would be appropriate after re-auscultation.

A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician's office. The nurse would plan on having which of the following medications readily available for use? A Diltiazem (Cardizem) Digoxin (Lanoxin) C Propranolol (Inderal) Metoprolol (Lopressor)

Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem (calcium channel blocker) and propranolol and metoprolol (beta blockers) have a negative inotropic effect and would worsen the failing heart.

Victor was transported to ED because of changes in mentation, development of ascites, orthopnea, paroxysmal nocturnal dyspnea, and excessive fatigue. On physical exam, you note S3 and S4 gallops, basilar crackles, and the EKG shows sinus tach. These symptoms are usually indicative of which of the following types of cardiomyopathy? a. restrictive b. dilated c. alcohol induced d. hypertrophic

Dilated. It is causing systolic dysfunction. EKG can also show Afib and ventricle dysrhythmias. May have systolic murmur. Will also likely have peripheral edema, ascites, hepatomegaly, and pale, cool extremities.

With which of the following disorders is jugular vein distention most prominent? A Abdominal aortic aneurysm B Heart failure C Myocardial infarction D Pneumothorax

Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump. Jugular vein distention isn't a symptom of abdominal aortic aneurysm or pneumothorax. An MI, if severe enough, can progress to heart failure; however, in and of itself, an MI doesn't cause jugular vein distention.

The nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infection. Which of the following findings would be expected? A Normal breath sounds B Prolonged inspiration C Normal chest movement D Coarse crackles and rhonchi

Exacerbations of COPD are frequently caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged antero-posterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended.

Exercise has which of the following effects on clients with asthma, chronic bronchitis, and emphysema? A It enhances cardiovascular fitness B It improves respiratory muscle strength C It reduces the number of acute attacks D It worsens respiratory function and is discouraged

Exercise can improve cardiovascular fitness and help the client tolerate periods of hypoxia better, perhaps reducing the risk of heart attack. Most exercise has little effect on respiratory muscle strength, and these clients can't tolerate the type of exercise necessary to do this. Exercise won't reduce the number of acute attacks. In some instances, exercise may be contraindicated, and the client should check with his physician before starting any exercise program.

When teaching a client with COPD to conserve energy, the nurse should teach the client to lift objects: A While inhaling through an open mouth B While exhaling through pursed lips C After exhaling but before inhaling D While taking a deep breath and holding it.

Exhaling thru pursed lips - requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduced perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhalation but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac dysrhythmias.

Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. B Activity intolerance related to increased cardiac output. Decreased cardiac output related to structural and functional changes. Impaired gas exchange related to decreased sympathetic nervous system activity.

HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.

Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy? A Heart failure B Diabetes C MI D Pericardial effusion

Heart failure. Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. MI results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with pericarditis.

A client with COPD has developed secondary polycythemia. Which nursing diagnosis would be included in the plan of care because of the polycythemia? A Fluid volume deficit related to blood loss B Impaired tissue perfusion related to thrombosis C Activity intolerance related to dyspnea D Risk for infection related to suppressed immune response

Impaired tissue perfusion - Chronic hypoxia associated with COPD may stimulate excessive RBC production (polycythemia). This results in increased blood viscosity and the risk of thrombosis. The other nursing diagnoses are not applicable in this situation.

A 34-year-old woman with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, what action should the nurse take to initiate care of the client? A Initiate oxygen therapy and reassess the client in 10 minutes B Draw blood for an ABG analysis and send the client for a chest x-ray C Encourage the client to relax and breathe slowly through the mouth D Administer bronchodilators

In an acute asthma attack, diminished or absent breath sounds can be an ominous sign of indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, intravenous corticosteroids, and possibly intravenous theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing an ABG and obtaining a chest x-ray. It would be futile to encourage the client to relax and breathe slowly without providing necessary pharmacologic interventi

Septal involvement occurs in which type of cardiomyopathy? A Congestive B Dilated C Hypertrophic D Restrictive

In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum—not the ventricle chambers—is apparent. This abnormality isn't seen in other types of cardiomyopathy.

Which of the following symptoms might a client with right-sided heart failure exhibit? A Adequate urine output B Polyuria C Oliguria D Polydipsi

Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria. Adequate urine output, polyuria, and polydipsia aren't associated with right-sided heart failure.

Which of the following is a compensatory response to decreased cardiac output? Decreased BP B Alteration in LOC C Decreased BP and diuresis Increased BP and fluid retention

Increased BP/fluid retention - The body compensates for a decrease in cardiac output with a rise in BP, due to the stimulation of the sympathetic NS and an increase in blood volume as the kidneys retain sodium and water. Blood pressure doesn't initially drop in response to the compensatory mechanism of the body. Alteration in LOC will occur only if the decreased cardiac output persists.

Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified? A Serosanguineous drainage from the puncture site B Increased temperature and blood pressure C Increased pulse and pallor D Hypotension and hypothermia

Increased pulse and pallor are symptoms associated with shock. A compromised venous return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually no more than 1 L of fluid is removed at one time to prevent this from occurring.

Which of the following outcomes would be appropriate for a client with COPD who has been discharged to home? The client: A Promises to do pursed lip breathing at home. B States actions to reduce pain. C States that he will use oxygen via a nasal cannula at 5 L/minute. D Agrees to call the physician if dyspnea on exertion increases

Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD, and therefore the physician should be notified. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

Which of the following outcomes would be appropriate for a client with COPD who has been discharged to home? The client: A Promises to do pursed lip breathing at home. B States actions to reduce pain. C States that he will use oxygen via a nasal cannula at 5 L/minute. D Agrees to call the physician if dyspnea on exertion increases.

Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD, and therefore the physician should be notified. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

Which of the following individuals would the nurse consider to have the highest priority for receiving an influenza vaccination? A A 60-year-old man with a hiatal hernia B A 36-year-old woman with 3 children A 50-year-old woman caring for a spouse with cancer D A 60-year-old woman with osteoarthritis

Individuals who are household members or home care providers for high-risk individuals are high-priority targeted groups for immunization against influenza to prevent transmission to those who have a decreased capacity to deal with the disease. The wife who is caring for a husband with cancer has the highest priority of the clients described.

Emergency treatment of a client in status asthmaticus includes which of the following medications? Inhaled beta-adrenergic agents B Inhaled corticosteroids C I.V. beta-adrenergic agents D Oral corticosteroids

Inhaled beta-adrenergic agents help promote bronchodilation, which improves oxygenation. I.V. beta-adrenergic agents can be used but have to be monitored because of their greater systemic effects. They're typically used when the inhaled beta-adrenergic agents don't work. Corticosteroids are slow-acting, so their use won't reduce hypoxia in the acute phase.

Which of the following treatment goals is best for the client with status asthmaticus? A Avoiding intubation B Determining the cause of the attack C Improving exercise tolerance D Reducing secretions

Inhaled beta-adrenergic agents, I.V. corticosteroids, and supplemental oxygen are used to reduce bronchospasm, improve oxygenation, and avoid intubation. Determining the trigger for the client's attack and improving exercise tolerance are later goals. Typically, secretions aren't a problem in status asthmaticus.

The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. A The inhaler is held upright B Head is tilted down while inhaling the medication C Client waits 5 minutes between puffs D Mouth is rinsed with water following administration E Client lies supine for 15 minutes following administration

Inhaler held upright, mouth is rinsed with water following administration

Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility? Beta-adrenergic blockers B Calcium channel blockers C Diuretics Inotropic agents

Inotropic agents are administered to increase the force of the heart's contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decrease the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.

Which of the following assessment findings would help confirm a diagnosis of asthma in a client suspected of having the disorder? A Circumoral cyanosis B Increased forced expiratory volume C Inspiratory and expiratory wheezing D Normal breath sounds

Inspiratory and expiratory wheezes are typical findings in asthma. Circumoral cyanosis may be present in extreme cases of respiratory distress. The nurse would expect the client to have a decreased forced expiratory volume because asthma is an obstructive pulmonary disease. Breath sounds will be "tight" sounding or markedly decreased; they won't be normal.

It's highly recommended that clients with asthma, chronic bronchitis, and emphysema have Pneumovax and flu vaccinations for which of the following reasons? A All clients are recommended to have these vaccines B These vaccines produce bronchodilation and improve oxygenation C These vaccines help reduce the tachypnea these clients experience D Respiratory infections can cause severe hypoxia and possibly death in these clients.

It's highly recommended that clients with respiratory disorders be given vaccines to protect against respiratory infection. Infections can cause these clients to need intubation and mechanical ventilation, and it may be difficult to wean these clients from the ventilator. The vaccines have no effect on bronchodilation or respiratory care.

Which hereditary disease is most closely linked to aneurysm? A Cystic fibrosis B Lupus erythematosus Marfan's syndrome D Myocardial infarction

Marfan's syndrome results in the degeneration of the elastic fibers of the aortic media.(Aortic regurgitation valve disorder) Therefore, clients with the syndrome are more likely to develop an aortic aneurysm. Although cystic fibrosis is hereditary, it hasn't been linked to aneurysms. Lupus erythematosus isn't hereditary. Myocardial infarction is neither hereditary nor a disease.

A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A Positive sweat test B Bulky greasy stools C Moist, productive cough D Meconium ileus

Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

Myosin was admitted to ED with dx of hypertrophic cardiomyopathy. Which of the following hemodynamic effects would usually be seen in pt with HCM? a. increased CO, increased EF b. normal CO, increased EF C. increased co, decreased EF d. decreased co, increased EF

Normal co, increased ef. myocardium thickens, but is asymmetrical

A nurse is conducting a health history with a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure? Recent URI B Nutritional anemia Peptic ulcer disease D A-Fib

Peptic ulcer disease - Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.

Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? A Incorporate physical exercise as tolerated into the treatment plan. B Monitor peak flow numbers after meals and at bedtime. C Eliminate stressors in the work and home environment D Use sedatives to ensure uninterrupted sleep at night.

Physical exercise is beneficial and should be incorporated as tolerated into the client's schedule. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Peak flow does not need to be monitored after each meal. Stressors in the client's life should be modified but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep.

An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings? A It is likely that the client is developing a secondary bacterial pneumonia. B The assessment findings are consistent with influenza and are to be expected. C The client is getting dehydrated and needs to increase her fluid intake to decrease secretions. D The client has not been taking her decongestants and bronchodilators as prescribed.

Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection are not consistent with a diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu.

The physician has scheduled a client for a left pneumonectomy. The position that will most likely be ordered postoperatively for his is the: A Nonoperative side or back Operative side or back Back only D Back or either side

Positioning the client on the operative side facilitates the accumulation of serosanguineous fluid. The fluid forms a solid mass, which prevents the remaining lung from being drawn into the space.

During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A Increase fluids that are high in protein B Restrict fluids C Force fluids and reassess blood pressure D Limit fluids to non-caffeine beverages

Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

a nurse is orienting to a newly licensed nurse who is caring for client receiving mechanical ventilation, placed on pressure support mode (PSV). What statement by new nurse demonstrates understanding? a. it keeps alveoli open and prevents atelectasis b. permits spontaneous ventilation to decrease work of breathing c. used with clients who have difficulty weaning from vent d. delivers a preset ventilatory rate and tidal volume to client

Pressure Support Ventilation Positive pressure that is applied to the airway ONLY DURING INSPIRATION. The patient initiates and performs that actual breaths, but the machine makes them easier with positive pressure. Think of really smart CPAP. Decreases the work of breathing. Patient has to have their own stable respiratory drive.

Which of the following actions is the appropriate initial response to a client coughing up pink, frothy sputum? A Call for help B Call the physician C Start an I.V. line D Suction the client

Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Because the client is at high risk for decompensation, the nurse should call for help but not leave the room. The other three interventions would immediately follow.

Which of the following actions is the appropriate initial response to a client coughing up pink, frothy sputum? Call for help B Call the physician C Start an I.V. line Suction the client

Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Because the client is at high risk for decompensation, the nurse should call for help but not leave the room. The other three interventions would immediately follow.

A nurse instructs a client to use the pursed lip method of breathing. The client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed lip breathing is: A Promote oxygen intake B Strengthen the diaphragm C Strengthen the intercostal muscles D Promote carbon dioxide elimination

Pursed lip breathing facilitates maximum expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation

Which of the following is the primary reason to teach pursed-lip breathing to clients with emphysema? A To promote oxygen intake B To strengthen the diaphragm C To strengthen the intercostal muscles D To promote carbon dioxide elimination

Pursed lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonged exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.

Which of the following complications is indicated by a third heart sound (S3)? A Ventricular dilation B Systemic hypertension C Aortic valve malfunction D Increased atrial contractions

Rapid filling of the ventricles causes vasodilation that is auscultated as S3. Increased atrial contraction or systemic hypertension can result is a fourth heart sound. Aortic valve malfunction is heard as a murmur.

If a client continues to hypoventilate, the nurse will continually assess for a complication of: A Respiratory acidosis B Respiratory alkalosis C Metabolic acidosis D Metabolic alkalosis

Respiratory acidosis represents an increase in the acid component, carbon dioxide, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood.

Teaching for a client with chronic obstructive pulmonary disease (COPD) should include which of the following topics? A How to have his wife learn to listen to his lungs with a stethoscope from Wal-Mart B How to increase his oxygen therapy C How to treat respiratory infections without going to the physician D How to recognize the signs of an impending respiratory infection

Respiratory infection in clients with a respiratory disorder can be fatal. It's important that the client understands how to recognize the signs and symptoms of an impending respiratory infection. It isn't appropriate for the wife to listen to his lung sounds, besides, you can't purchase stethoscopes from Wal-Mart. If the client has signs and symptoms of an infection, he should contact his physician at once.

The nurse teaches a client with COPD to assess for s/s of right-sided heart failure. Which of the following s/s would be included in the teaching plan? A Clubbing of nail beds B Hypertension C Peripheral edema D Increased appetite

Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.

A heart murmur associated with acute valvular regurgitation is call a. s3 b. S2 c. S1 d. S4

S4

A client comes into the E.R. with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a BP of 85/46, a HR of 122 BPM, and a respiratory rate of 38 breaths/minute. The client's medical history included DM, HTN, and heart failure. Which of the following disorders should the nurse suspect? A-Pulmonary edema B-Pneumothorax C-Cardiac tamponade D-Pulmonary embolus

SOB, tachypnea, low BP, tachycardia, crackles, and a cough producing pink, frothy sputum are late signs of pulmonary edema.

Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible side effect of this drug? A Constipation B Bradycardia C Diplopia D Restlessness

Side effects of pseudoephedrine are experienced primarily in the cardiovascular system and through sympathetic effects on the CNS. The most common CNS effects include restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular side effects include tachycardia, hypertension, palpitations, and arrhythmias. Constipation and diplopia are not side effects of pseudoephedrine. Tachycardia, not bradycardia, is a side effect of pseudoephedrine.

A client is receiving isoetharine hydrochloride (Bronkosol) via a nebulizer. The nurse monitors the client for which side effect of this medication? A Constipation B Diarrhea C Bradycardia Tachycardia

Side effects that can occur from a beta 2 agonist include tremors, nausea, nervousness, palpitations, tachycardia, peripheral vasodilation, and dryness of the mouth or throat.

A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should be taken first? A Take a full medication history B Give a bronchodilator by nebulizer C Apply a cardiac monitor to the client D Provide emotional support to the client

The client is having an acute asthma attack and needs to increase oxygen delivery to the lung and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. First resolve the acute phase of the attack ad how to prevent attacks in the future. It may not be necessary to place the client on a cardiac monitor because he's only 19-years-old, unless he has a past medical history of cardiac problems.

A nurse teaches a client about the use of a respiratory inhaler. Which action by the client indicated a need for further teaching? A Removes the cap and shakes the inhaler well before use B Presses the canister down with finger as he breathes in. C Inhales the mist and quickly exhales D Waits 1 to 2 minutes between puffs if more than one puff has been prescribed

The client should be instructed to hold his or her breath at least 10 to 15 seconds before exhaling the mist.

Which of the following diets would be most appropriate for a client with COPD? A Low fat, low cholesterol B Bland, soft diet C Low-Sodium diet D High calorie, high-protein diet

The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated.

A nurse is assessing a client with chronic airflow limitation and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitation? A Chronic obstructive bronchitis B Emphysema C Bronchial asthma D Bronchial asthma and bronchitis

The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, which is referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.

A client with COPD reports steady weight loss and being "too tired from just breathing to eat." Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this client? A Altered nutrition: Less than body requirements related to fatigue. B Activity intolerance related to dyspnea. C Weight loss related to COPD. D Ineffective breathing pattern related to alveolar hypoventilation.

The client's problem is altered nutrition—specifically, less than required. The cause, as stated by the client, is the fatigue associated with the disease process. Activity intolerance is a likely diagnosis but is not related to the client's nutritional problems. Weight loss is not a nursing diagnosis. Ineffective breathing pattern may be a problem, but this diagnosis does not specifically address the problem of weight loss described by the client.

The nurse is planning to teach a client with COPD how to cough effectively. Which of the following instructions should be included? A Take a deep abdominal breath, bend forward, and cough 3 to 4 times on exhalation B Lie flat on back, splint the thorax, take two deep breaths and cough C Take several rapid, shallow breaths and then cough forcefully D Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing

The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process 3 or 4 times, the client should take a deep abdominal breath, bend forward and cough 3 or 4 times upon exhalation ("huff" cough). Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing.

Acute pulmonary edema caused by heart failure is usually a result of damage to which of the following areas of the heart? A Left atrium B Right atrium Left ventricle D Right ventricle

The left ventricle is responsible for the majority of force for the cardiac output. If the left ventricle is damaged, the output decreases and fluid accumulates in the interstitial and alveolar spaces, causing pulmonary edema. Damage to the left atrium would contribute to heart failure but wouldn't affect cardiac output or, therefore, the onset of pulmonary edema. If the right atrium and right ventricle were damaged, right-sided heart failure would result.

In which of the following disorders would the nurse expect to assess sacral edema in bedridden client? A DM B Pulmonary emboli C Renal failure D Right-sided heart failure

The most accurate area on the body to assed dependent edema in a bedridden client is the sacral area. Sacral, or dependent, edema is secondary to right-sided heart failure. Diabetes mellitus, pulmonary emboli, and renal disease aren't directly linked to sacral edema.

The client with asthma should be taught that which of the following is one of the most common precipitating factors of an acute asthma attack? A Occupational exposure to toxins B Viral respiratory infections C Exposure to cigarette smoke D Exercising in cold temperatures

The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Some asthmatic attacks are triggered by exercising in cold weather.

When developing a teaching plan for a client with endocarditis, which of the following points is most essential for the nurse to include? "Report fever, anorexia, and night sweats to the physician." "Take prophylactic antibiotics after dental work and invasive procedures." C "Include potassium rich foods in your diet." D "Monitor your pulse regularly."

The most essential teaching point is to report signs of relapse, such as fever, anorexia, and night sweats, to the physician. To prevent further endocarditis episodes, prophylactic antibiotics are taken before and sometimes after dental work, childbirth, or GU, GI, or gynecologic procedures. A potassium-rich diet and daily pulse monitoring aren't necessary for a client with endocarditis.

If medical treatments fail, which of the following invasive procedures is necessary for treating cardiomyopathy? A Cardiac catheterization B Coronary artery bypass graft (CABG) C Heart transplantation D Intra-aortic balloon pump (IABP)

The only definitive treatment for cardiomyopathy that can't be controlled medically is a heart transplant because the damage to the heart muscle is irreversible.

If medical treatments fail, which of the following invasive procedures is necessary for treating cardiomyopathy? A Cardiac catheterization B Coronary artery bypass graft (CABG) Heart transplantation Intra-aortic balloon pump (IABP

The only definitive treatment for cardiomyopathy that can't be controlled medically is a heart transplant because the damage to the heart muscle is irreversible.

A female client comes into the emergency room complaining of SOB and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her VS are: 140/80, P 110, R 40. The physician orders ABG's, results are as follows: pH: 7.50; PaCO2 29 mm Hg; PaO2 60 mm Hg; HCO3- 24 mEq/L; SaO2 86%. Considering these results, the first intervention is to: A Begin mechanical ventilation B Place the client on oxygen C Give the client sodium bicarbonate D Monitor for pulmonary embolism

The pH (7.50) reflects alkalosis, and the low PaCO2 indicated the lungs are involved. The client should immediately be placed on oxygen via mask so that the SaO2 is brought up to 95%. Encourage slow, regular breathing to decrease the amount of CO2 she is losing. This client may have pulmonary embolism, so she should be monitored for this condition (4), but it is not the first intervention. Sodium bicarbonate (3) would be given to reverse acidosis; mechanical ventilation (1) may be ordered for acute respiratory acidosis.

A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg IV push. Knowing that the client also will be started on Digoxin (Lanoxin), a nurse checks the client's most recent: A Digoxin level B Sodium level Potassium level D Creatinine level

The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digitalis effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias.

An oxygenated delivery system is prescribed for a client with COPD to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? A Venturi mask B Aerosol mask C Face tent D Tracheostomy collar

The venture mask delivers the most accurate oxygen concentration. The Venturi mask is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, the aerosol mask, and the tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

Theophylline (Theo-Dur) tablets are prescribed for a client with chronic airflow limitation, and the nurse instructs the client about the medication. Which statement by the client indicates a need for further teaching? A "I will take the medication on an empty stomach." B "I will take the medication with food." C "I will continue to take the medication even if I am feeling better." D "Periodic blood levels will need to be obtained."

Theo-Dur is a bronchodilator. The medication should be administered with food such as milk and crackers to prevent GI irritation.

A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He's tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This client has symptoms of which of the following respiratory disorders? A ARDS B Asthma C Chronic obstructive bronchitis D Emphysema

These are classic signs and symptoms of a client with emphysema. Clients with ARDS are acutely short of breath and require emergency care; those with asthma are also acutely short of breath during an attack and appear very frightened. Clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.

Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions? A Pericarditis B Hypertension C MI Heart failure

These are the classic signs of failure. Pericarditis is exhibited by a feeling of fullness in the chest and auscultation of a pericardial friction rub. Hypertension is usually exhibited by headaches, visual disturbances, and a flushed face. MI causes heart failure but isn't related to these symptoms.

A client states that the physician said the tidal volume is slightly diminished and asks the nurse what this means. The nurse explains that the tidal volume is the amount of air: A Exhaled forcibly after a normal expiration B Exhaled after there is a normal inspiration C Trapped in the alveoli that cannot be exhaled D Forcibly inspired over and above a normal respiration

Tidal volume (TV) is defined as the amount of air exhaled after a normal inspiration.

The most reliable index to determine the respiratory status of a client is to: A Observe the chest rising and falling B Observe the skin and mucous membrane color C Listen and feel the air movement D Determine the presence of a femoral pulse

To check for breathing, the nurse places her ear and cheek next to the client's mouth and nose to listen and feel for air movement. The chest rising and falling (1) is not conclusive of a patent airway. Observing skin color (2) is not an accurate assessment of respiratory status, nor is checking the femoral pulse.

A client has been taking flunisolide (Aerobid), two inhalations a day, for treatment of asthma. He tells the nurse that he has painful, white patches in his mouth. Which response by the nurse would be the most appropriate? A "This is an anticipated side-effect of your medication. It should go away in a couple of weeks." B "You are using your inhaler too much and it has irritated your mouth." C "You have developed a fungal infection from your medication. It will need to be treated with an antibiotic." D "Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem."

Use of oral inhalant corticosteroids, such as flunisolide, can lead to the development of oral thrush, a fungal infection. Once developed, thrush must be treated by antibiotic therapy; it will not resolve on its own. Fungal infections can develop even without overuse of the Corticosteroid inhaler. Although good oral hygiene can help prevent development of a fungal infection, it cannot be used alone to treat the problem.

Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? A Angina pectoris B Cardiomyopathy C Left-sided heart failure D Right-sided heart failure

Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure. Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesn't cause weight gain, nausea, or a decrease in urine output.

A nurse in ED is caring for client who was admitted with acute asthma attack. What indicates respiratory status declining? (select all) a. SaO2 95% b. wheezing c. retraction of sternal muscles d. pink mucous membranes e. premature ventricular complexes

Wheezing, retraction, PVCs

A nurse is caring for a client who is scheduled for thoracentesis. Prior to procedure, what should nurse do? a. position client in upright position, leaning over bedside table b. explain procedure to client c. obtain ABGs from client d. administer benzocaine spray to client

a. Position client upright with arms and shoulders raised and supported by pillows and/or bedside table.

A nurse is caring for a child suspected of having CF. Which test should nurse prepare to administer to confirm? a. sweat chloride b. pulmonary function test c. arterial blood gases d. chest percussion

a. sweat test- excrete abnormal amount of sodium and chloride

The type of CM that is characterized by replacement of normal cells by fatty tissue is known as a. restrictive b. hypertrophic c. arrhythmogenic d. dilated

arrhythmogenic

Dilated cardiomyopathy is characterized by dilation of the ventricles and impaired systolic function. Common causes are valvular heart disease and ischemic heart disease. Other causes are idiopathic. The most common cause of idiopathic dilated cardiomyopathy is a. autoimmune b. alcohol c. genetic d. familial

b. alcohol

Diuretics are used in the treatment of CHF. A diuretic that reduced urinary calcium losses is a. Diamax b. Chlorothiazide c. Furosemide d. spironolactone

b. chlorothiazide reduces urinary calcium loss and does not result in profound potassium loss (maintenance diuretic)

Bertha was initially admitted to ED for severe dyspnea and diagnosed with CHF. After further study, its determined she has restrictive CM, a common cause is a. unknown infection b. glycogen storage disease c. a history of diabetes d. unknown

b. glycogen storage disease . Amyloidosis and sarcoidosis, endocardial and myocardial diseases also.

A nurse is reinforcing teaching with client on purpose of taking bronchodilator. Which statement shows effective teaching? a. med decrease immune response b. med prevents asthma attacks c. take with food d. slow onset to treat my symptoms

b. prevents asthma

The nurse is assessing client following bronchoscopy. What findings report to dr? a. blood tinged sputum b. dry, non productive cough c. sore throat d. bronchospams

bronchospasm **preprocedure - alleries, consent form, maintain NPO, remove dentures During - sitting position, sedatives/antianxiety, Post - monitor VS, LOC, presence of gag reflex and ability to swallow (gradual progression diet)

Mariah has been diagnosed with acquired valvular heart disease. The primary cause of acquired valvular heart disease is a. heredity b. drug abuse c. rheumatic fever d. fetal alcohol syndrom

c. Rheumatic fever is most common cause

a nurse is completing discharge teaching with client who has a new prescription for prednisone for asthma. Which client statement need further teaching? a. drink plenty of fluids b. tell dr if black tarry stools c. take on empty stomach d. monitor mouth for canker sores

c. take this med with food because it causes GI distress

Today you are precasting a student nurse. You are preparing to administer Lasix. 40 mg IV. The student asks you how fast the IV dose may be administered. You explain that Lasix must be given slowly because a. lasix may cause nausea b. a rash may develop c. hyperkalemia may occur d. a rapid infusion can lead to hearing loss

d. Rapid infusion can lead to hearing loss and tinnitus. Max speed is 20mg/min

Nurse teaching child about appropriate use of asthma meds. Which should client be instructed to take as needed before exercise? a. fluticasone/salmetrol (advair) b. montekulast (singular) c. prednisone (deltasone) d. albuterol (proventil)

d. albuterol

Nursing caring for client following thoracentesis. Which manifestations should nurse recognize as risk for complications? (select all) a. dyspnea b. localized bloody drainage on the dressing c. fever d. hypotension e. report of pain at the puncture site

dyspnea (pneumothorax), fever (infection) hypotension (shock, internal bleeding)

A client's arterial blood gas levels are as follows: pH 7.31; PaO2 80 mm Hg, PaCO2 65 mm Hg; HCO3- 36 mEq/L. Which of the following signs or symptoms would the nurse expect? A Cyanosis B Flushed skin C Irritability D Anxiety

he high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the CNS. Cyanosis is a late sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but are associated with hypoxia.

Your patient is being treated for severe dyspnea, dysphagia, palpitations, and an intractable cough. On auscultation you hear a loud S1 and a right sided S3 and S4. A pulmonary artery catheter is placed and a large A waves are seen in the PA tracing. The patient probably has a. mitral stenosis b. myocarditis c. atrial stenosis d. mitral insufficiency

mitral stenosis -

Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD? A Increased anteroposterior chest diameter B Underdeveloped neck muscles C Collapsed neck veins D Increased chest excursions with respiration

ncreased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump into pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.

A client is prescribed metaproterenol (Alupent) via a metered dose inhaler (MDI), two puffs every 4 hours. The nurse instructs the client to report side effects. Which of the following are potential side effects of metaproterenol? A Irregular heartbeat B Constipation C Pedal edema D Decreased heart rate

rregular heart rates should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on the beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, petal edema, or bradycardia.

A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client? A "Use your nasal decongestant spray regularly to help clear your nasal passages." B "Ask the doctor for antibiotics. Antibiotics will help decrease the secretion." C "It is important to increase your activity. A daily brisk walk will help promote drainage." D "Keep a diary if when your symptoms occur. This can help you identify what precipitates your attacks."

t is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. Antibiotics are not appropriate. Increasing activity will not control the client's symptoms; in fact, walking outdoors may increase them if the client is allergic to pollen.

Your pt diagnosed with lt vent failure, early signs are a. hypoxemia and peripheral cyanosis b. tachypnea and tachycardia c. dyspnea and profuse sweating d. central cyanosis and paradoxical respirations

tachypnea and tachycardia