661 Common Problems Exam 1 Review

Treatment COPD: Nursing care:

Avoid tobacco smoke Bronchodilators, antibiotics, vaccines (flu, pneumonia), mucolytics Adequate hydration Chest physiotherapy Cautious use of O2 therapy (low O2 and high CO2 levels is what drives COPD patients to breath) Incentive spirometry, deep breathing, teach pursed lip breathing CPT and postural drainage High calorie, small, frequent meals to conserve energy Alternate rest and activity periods Teach use of MDI

On auscultation, which finding suggests a right pneumothorax? A. Bilateral inspiratory and expiratory crackles B. Absence of breath sounds in the right thorax C. Inspiratory wheezes in the right thorax D. Bilateral pleural friction rub

B. Absence of breath sounds in the right thorax

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? A. A resident with mid-stage Alzheimer disease B. A 92-year-old resident who needs extensive help with ADLs C. A resident with severe and deforming rheumatoid arthritis D. A resident who suffered a severe stroke several weeks ago

D. A resident who suffered a severe stroke several weeks ago

COPD: Generally refers to emphysema and chronic bronchitis, both of which obstruct airflow resulting in difficult expiration --> can lead to respiratory failure and respiratory acidosis. Number one risk factor for both is smoking either direct or secondhand Emphysema Chronic Bronchitis

Emphysema: Abnormal and permanent enlargement of acini and destruction of alveolar walls. The obstruction is caused by tissue changes NOT by excess mucous production. Tripod position, barrel chest - >AP/Lateral diameter with decreased chest expansion, crackles, wheezing, hyperresonnance, clubbing of fingers, DOE, prolonged expiration, tachypnea "Pink puffer" Difficulty with lung elastic recoil, pursed lip breathing Accessory muscle use, anorexia/weight loss Chronic Bronchitis: Chronic inflammation and hypersecretion of mucous in the bronchi and a chronic cough. The excess mucus and chronic inflammation can lead to infections. There is impaired function of the cilia which help clear the mucus "Blue bloater" Accessory muscle use, tick copious mucus production, cyanosis, DOE, malaise, weight gain, tachypnea

Skin test results and Drugs for TB treatment

Skin test results: 5mm or greater induration considered positive in HIV infected persons, or a person who has had contacted with infected, immunocompromised 10mm or greater positive in recent immigrants from high TB infections, IV drug abusers, residents and staff in high risk settings (nursing homes, prisons) Drug regimens: New infection with +culture - INH x6months, Rifampin x6months, Pyrazinamide X2 months, Ethambutol X2 months Rifampin will turn urine orange long regime

Which of the following are actions in verifying the "right patient" before medication administration? (Select all that apply.) a. Ask the client to state his or her name and date of birth. b. Scan the bar code on the client's armband. c. Compare the client's name with the eMAR. d. Skip this step if the patient is asleep.

a, b, c a. Ask the client to state his or her name and date of birth. b. Scan the bar code on the client's armband. c. Compare the client's name with the eMAR.

A nurse checking a client's medication record notices a change in the dose and route for a medication given earlier in the day. What would be the appropriate action by the nurse? A. Check for new orders by the provider. B. Administer the medication as it appears on the medication record. C. Change the medication record back to the dose and route that was administered with the morning dose. D. Ask the client to verify the order.

A. Check for new orders by the provider.

A patient has been scheduled for an Endoscopic Retrograde Cholangiopancreatography (ERCP) the following morning. What should the nurse do in preparation for this diagnostic study? A. Have the patient refrain from food and fluids after midnight. B. Administer the radioactive agent intravenously the evening before the study. C. Administer the contrast agent orally 10 to 12 hours before the study. D. Encourage the intake of 64 ounces of water 8 hours before the study.

A. Have the patient refrain from food and fluids after midnight.

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following? A. Ammonia B. Calcium C. Bicarbonate D. Alcohol

A. Ammonia

During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections? A. Receive vaccinations B. Exercise daily C. Drink six glasses of water daily D. Take all prescribed medications

A. Receive vaccinations

A nurse is administering a new fentanyl patch to a client with chronic back pain. When removing and discarding the previous fentanyl patch, what is the proper disposal technique? A. The nurse should discard the removed patch in the locked sharps container and it must be witnessed by another RN. B. The nurse should discard the removed patch in the trash and it must be witnessed by another RN. C. The nurse should discard the removed patch by flushing it down the toilet and it must be witnessed by the charge nurse. D. The nurse should discard the removed patch in the trash and it must be witnessed by the nursing supervisor.

A. The nurse should discard the removed patch in the locked sharps container and it must be witnessed by another RN. Fentanyl is schedule 2 controlled substance. Discarding any form of this med must be done into a locked waste receptacle and witnessed by another RN

When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows: A. redness and induration B. drainage C. tissue sloughing D. bruising

A. redness and induration

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? A. Shallow respirations B. Bilateral wheezes C. Increased anterior-posterior (AP) diameter D. Bradypnea

B. Bilateral wheezes

Nurse is assessing 79yo patient diagnosed with pneumonia. Which signs and symptoms should they expect to find? A. High fever and chills B. Confusion and lethargy C. Frothy sputum and edema D. Bradypnea and JVD

B. Confusion and lethargy Elderly patient - confusion is more common.

A patient admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the patient with breathing? A. Repositions side to side every 2 hours B. Elevates the head of the bed to 60 degrees C. Auscultate the lung fields every 4 hours D. Encourages deep breathing exercises hourly

B. Elevates the head of the bed to 60 degrees Patient is having difficulty breathing because of upward pressure on diaphragm from ascites. Elevating HOB allows gravity to help relieve some of this pressure. Other options are general measures to promote lung expansion in ascites patients, but priority measure is HOB elevation as it physically relieves the pressure from fluid accumulation

Your patient with COPD is experiencing dyspnea and has low PaO2 level. Your plan is to administer O2 s prescribed. Which statement is true concerning oxygen administration to a patient with COPD? A. High O2 levels will cause coughing and Dyspnea B. High oxygen concentrations may inhibit the hypoxic stimulus to breathe C. Increased O2 use will cause patient to become dependent on the oxygen D. Administration of O2 is contraindicated in patients who are on bronchodilators

B. High oxygen concentrations may inhibit the hypoxic stimulus to breathe

The nurse understands that the priority intervention for the patient with TB is which of the following? A. Antibiotic administration B. Initiation of isolation in negative airflow room C. TB test D. Chest Xray

B. Initiation of isolation in negative airflow room

You must reconstitute a powdered medication. Which action should you implement FIRST? A. Keep needle below the fluid level as the rest of the fluid is injected B. Instill the solvent consistent with manufacturers directions C. Shake the vial to dissolve the powder D. Score the neck of the ampule before breaking it

B. Instill the solvent consistent with manufacturers directions

Mr. Markham has been admitted to your unit with a diagnosis of TB. Which order should you question regarding his care? A. Humidified oxygen via nasal cannula B. NPO C. Vital signs with O2 sat every 4 hours D. Activity as tolerated

B. NPO Should have high calorie, high nutrition dietary orders

Which action should be implemented by the nurse when a medication is to be administered by the Z-track method? A. Use a special syringe designed for Z-track injections B. Pull the skin laterally away from the injection site before inserting the needle C. Administer the injection in the muscle on anterolateral aspect of the thigh D. Insert the needle in a separate spot for each dose

B. Pull the skin laterally away from the injection site before inserting the needle D is correct for all injections not just Z-track. You always want to change injection sites for multiple injections

You are nurse discharging patient with newly diagnosed asthma. The HCP has prescribed Albuterol 2 puffs 2x/day via MDI and Beclomethasone 2 puffs 2x/day via MDI. How would you instruct the patient to take these medications? A. Take medications 1hr apart 2x/day B. Take albuterol first and follow by the beclomethasone C. Take albuterol on awakening and alternate medications every 4 hours D. Take beclomethasone inhaler and follow with the albuterol

B. Take albuterol first and follow by the beclomethasone Albuterol - Beta 2 agonist - rescue inhaler - quick remedy Beclomethasone - steroid inhaler (corticosteroid) - anti inflammatory Necessary to open airways first in order to receive proper inhalation treatment of steroid to alleviate inflammation. Treating with albuterol without treating inflammation can cause remodeling inside lungs (d/t constant inflammation)

A charge nurse is observing a new nurse preparing medications for a patient. Which of the following would require the charge nurse to intervene? A. The new nurse pulls all the medications that are due for that patient. B. The new nurse crushes enteric coated aspirin to put in the client's applesauce. C. The new nurse verifies the order in the computer and on the medication packaging. D. The new nurse wipes down the work station in the med room before preparing medications.

B. The new nurse crushes enteric coated aspirin to put in the client's applesauce. NEVER crush enteric coated tabs --> can cause severe GI upset crushing destroys protective property of enteric coating, so medication released in stomach instead of intestines, where they should be released.

The nurse is preparing DULoxetine. How do the capital letters "DUL" assist the nurse in safe medication administration? A. They help in alphabetizing the medications in the automated medication dispensing machine. B. They alert the nurse of a sound-alike/look-alike medication. C. They are the initials for the medication classification. D. They are the letters that start both the generic and trade name for the medication.

B. They alert the nurse of a sound-alike/look-alike medication.

A patient with suspected esophageal varices is scheduled for an upper endoscopy with moderate sedation. After the procedure is performed, how long should the nurse withhold food and fluids? A. For 2 hours after the last dose of medication is given B. Until the gag reflex returns C. Until the patient expresses thirst D. For 6 hours after the procedure

B. Until the gag reflex returns

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because: A. the attack is over B. the airways are so swollen that no air can get through C. the swelling has decreased D. crackles have replaced wheezes

B. the airways are so swollen that no air can get through

Medications to treat asthma:

Bronchodilators - most common, often single pharm Tx for mild-mod intermittent asthma Corticosteroids - usually combined with bronchodilator in more severe asthmas Leukotrine Modulators (singular)

You teach a patient about taking a sublingual nitroglycerin tablet. Which part of the body identified by the patient indicates that she understands the teaching? A. "On my skin" B. "Inside my cheek" C. "Under my tongue" D. "In my eye under the lower lid"

C. "Under my tongue"

The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this client? A. Signs of oxygen toxicity B. Chronic chest pain C. A barrel chest D. Long, thin fingers

C. A barrel chest

You are assessing a patient with chronic emphysema. Which finding requires immediate intervention? A. Using pursed lip breathing and prolonged expiration B. Circumoral cyanosis C. Crackles auscultated posteriorly halfway up the left lung D. Appearance of a barrel chest

C. Crackles auscultated posteriorly halfway up the left lung Crackles are usually heard in lung bases only. If crackles are heard halfway up the lung, this is causing a significant oxygen deficit. Patient already has an oxygen deficit with emphysema, so this is a significant and serious finding.

The nurse should teach the patient with asthma to avoid which of most common precipitating factors of an acute asthma attack? A. Occupational exposure to toxins B. Valsalva maneuver C. Exposure to cigarette smoke D. Exercising in cold temperatures

C. Exposure to cigarette smoke While some asthmatics are triggered by exercising in cold temperatures, it is not most common precipitating factor. Only some people work in environment with toxin exposure

Which of the following is an example of an appropriate order? A. Furosemide 40 mg by mouth qd B. Furosemide 40 mg by mouth Q.D. C. Furosemide 40 mg by mouth daily D. Furosemide 40 mg by mouth QD

C. Furosemide 40 mg by mouth daily

A patient diagnosed with CAP is being admitted to your unit. Which nursing interventions has highest priority? A. Administer ordered oral Abx immediately B. Order meal tray to be delivered immediately C. Obtain sputum specimen for C+S D. Have the UAP (Unlicensed assistive personnel) weigh the patient

C. Obtain sputum specimen for C+S Important to get C+S quickly to ensure proper treatment and correct Abx selection Quick treatment --> better outcomes

Which term describes the passage of a hollow instrument into a cavity to withdraw fluid? A. Asterixis B. Ascites C. Paracentesis D. Dialysis

C. Paracentesis

After assisting with a needle biopsy of the liver at a patient's bedside, the nurse should A. Put pressure on the biopsy site using a sandbag B. Elevate the head of the bed to facilitate breathing C. Place the patient on the right side with the bed flat D. Check the patient's post-biopsy coagulation studies

C. Place the patient on the right side with the bed flat A major complication of liver biopsy is bleeding. To assist with hemostasis, best position is to place patient on side of biopsy, in flat position. Coagulation studies should be performed before procedure not after .

When caring for a patient with acute pancreatitis, the nurse should use which comfort measure? A. Administering frequent oral feedings B. Encouraging frequent visits from family and friends C. Positioning the patient sitting up and leaning forward D. Positioning the patient lying flat

C. Positioning the patient sitting up and leaning forward

A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? A. "You could have gotten it by using I.V. drugs." B. "You must have received an infected blood transfusion." C. "You probably got it by engaging in unprotected sex." D. "You may have eaten contaminated restaurant food."

D. "You may have eaten contaminated restaurant food." Fecal-Oral transmission route Often from contaminated food or drinking water

The nurse is caring for a patient who is scheduled to have a liver biopsy. Before the procedure, it is most important for the nurse to assess the patient's: A. Tolerance for pain B. Allergy to iodine or shellfish C. History of nausea and vomiting D. Ability to lie still and hold breath

D. Ability to lie still and hold breath When taking the biopsy, the patient must hold their breath and lie still to prevent complications such as puncturing a lung or other organ. Contrast/dye is not used during this procedure - do not need to assess for allergy to iodine/shellfish

The nurse is instructing the patient with COPD how to do pursed lip breathing. What is the expected outcome of this exercise? A. Improve O2 intake B. Deeper diaphragmatic breathing C. Stronger intercostal muscles D. Better elimination of CO2

D. Better elimination of CO2

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? A. Pleural friction rub B. Sibilant wheezes C. Low-pitched rhonchi during expiration D. Crackles in the lung bases

D. Crackles in the lung bases

Which nursing assessment is MOST important in a patient diagnosed with ascites? A. Assessment of the oral cavity for foul-smelling breath B. Auscultation of abdomen C. Palpation of abdomen for a fluid shift D. Daily measurement of weight and abdominal girth

D. Daily measurement of weight and abdominal girth

Which of the following is the priority nursing intervention in helping a patient expectorate thick lung secretions? A. Humidify the oxygen as able B. Administer cough suppressant q4hr C. Teach patient to splint the affected area D. Increase fluid intake to 3 L/day if tolerated

D. Increase fluid intake to 3 L/day if tolerated One of best methods to help clear thick secretions is to increase fluid intake. This helps thin secretions --> making them easier to expectorate. Humidifying will not thin or make easier to clear Splinting helps pain, not clearance Cough suppressants will make more difficult to clear

A patient has a chest tube with water seal drainage. What should you do as his nurse to ensure safe and effective use of the drainage system? A. Check that the air vent on the water seal drainage system is capped when the suction is off B. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs C. Ensure that the chest tube is clamped when moving the client out of bed D. Make sure the drainage apparatus is always below the patient's chest level

D. Make sure the drainage apparatus is always below the patient's chest level Don't strip or clamp when moving. Air vent should be open (want air exchange)

A nurse is administering medications to a client and accidentally drops a pill onto the floor. What is the most appropriate response by the nurse? A. Administer the medication after picking it up because getting a new pill would be wasteful. B. Do not administer the medication and document that the dose was skipped in the medication administration record (MAR). C. Ask the client if they are willing to take the pill that fell on the floor or if they would like a new one. D. Obtain a new pill from the medication dispensary and administer the new pill to the client.

D. Obtain a new pill from the medication dispensary and administer the new pill to the client.

While the nurse is administering morning medications, the client asks, "What is the pill for?" When the nurse explains the pill is for high cholesterol, the client responds, "I have never had a problem with high cholesterol." What is the appropriate action by the nurse? A. Encourage the client to take the medication. B. Leave a note in the client's chart for the prescriber. C. Repeat the three checks for the medication. D. Review the original order for the medication.

D. Review the original order for the medication.

Asthma is caused by increased responsiveness in the airways to various stimuli which cause episodic narrowing and inflammation of airways. These triggers can range from tobacco smoke, allergens, dust, cold air, exercise, medication, fumes. Classified for patients 12 and older as intermittent, mild persistent, moderate persistent, severe persistent. Status asthmaticus is a potential fatal complication from poor gas exchange and increased respiratory effort. S&S Tx and Nursing Care

S&S Wheezing and course ronchi, SOB, tachypnea, tachycardia, coughing, thick yellow sputum chest tightness Tx and Nursing Care: Identifying triggers and avoiding them Medications - albuterol rescue inhaler, steroid inhaler Monitor VS, ABGs, O2 Sat, PFT PRN O2 therapy High Fowler's position - improves ventilation Teaching: meds, MDI use, peak flow meter, adequate hydration to loosen secretions, avoiding triggers

Pneumothorax: Complete or partial collapse of lung from accumulation of air (pneumothorax), blood (hemothorax), or fluid (pleural effusion) S&S Tx (emergent)

S&S: Respiratory distress, gas exchange problems small - mild tachycardia and mild dyspnea large - short shallow rapid respirations, dyspnea, O2 desaturation, absence of BS over affected area Tx: Emergent - cover wound with occlusive dressing covering 3 sides prevents air from entering the chest on inspiration Prepare for insertion of chest tube

Tuberculosis: Acute or chronic infection caused by mycobacterium tuberculi. It infects 1/3 of world population. Transmitted by aerosolized droplets inhaled from an infected person. Most of the bacilli will remain in upper airway and don't cause active disease. If bacilli make way down to alveoli, they are ingested by macrophages and they multiply. In immunocompromised people the bacterium continue to multiply and cause active infection. In non immunocompromised - will cause granulomas in lungs S&S Tx and Nursing Care:

S&S: Unexplained weight loss, night sweats, fever, chills, rust colored sputum (d/t destruction of lung tissue during granuloma formation), pleuritic chest pain (d/t coughing) Tx and Nursing Care: Airborne isolation, humidified O2, antibiotics as ordered, adequate nutrition VS: Temp, O2 sat, Lung sounds (may hear crackles/wheezes d/t fluid), patient wear mask when traveling outside of room Teaching - importance of completing meds. DOT (directly observed therapy) may be needed. Testing family members if living in close proximity

Pneumonia is inflammation of the lung associated with alveolar edema and congestion that impairs gas exchange. It can be caused by bacteria or can be caused by a virus. It is described by the setting in which is was acquired (CAP or HAC) or can be acquired though Aspiration S&S Treatment and Nursing Care

S&S: coughing, SOB, DOE (Dyspnea on exertion), Decreased breath sounds and crackles, fatigue, headache, fever, shaking, chills, pleuritic chest pain, sputum production, decreased appetite Tx and Nursing Care: Sputum culture, chest X-ray, PFT, antimicrobial therapy based on causative agent, IV therapy, O2 therapy, high calorie diet, calm/quiet environment (promote rest), analgesics for pleuritic pain

T/F: A client is ordered for 10 units of NPH insulin SC and 2 units of Regular insulin SC. After injecting air, the nurse should draw up the Regular insulin and then the NPH insulin.

True

You are nurse caring for a patient diagnosed with pneumonia. Which information would you include in your care plan? (SATA) a. Monitor patient's pulse ox readings every 4 hours b. Plan periods of rest during ADLs c. Administer O2 delivered via nasal cannula d. Maintain patient on a fluid restriction of 1000m in 24 hours e. Restrict patient's smoking to 2 cigarettes per day

a, b, c a. Monitor patient's pulse ox readings every 4 hours b. Plan periods of rest during ADLs c. Administer O2 delivered via nasal cannula

Your 75yo patient with newly diagnosed adult onset asthma is being discharged. Which other members of the health care team would you involve in discharge planning? (SATA) a. Pharmacist b. Care coordination nurse c. Respiratory therapist d. Speech therapist e. Physical therapist

a, b, c a. Pharmacist b. Care coordination nurse c. Respiratory therapist

Which of the following are examples of using technology for safe medication administration? (Select all that apply.) a. Electronic medication administration record (eMAR). b. Scanning procedures of the medication package and patient armband. c. Safeguard parameters on the IV pump. d. Automated medication dispensing machines.

a, b, c, d (ALL) a. Electronic medication administration record (eMAR). b. Scanning procedures of the medication package and patient armband. c. Safeguard parameters on the IV pump. d. Automated medication dispensing machines.

To promote airway clearance in a patient with pneumonia and recent abdominal surgery, the nurse instructs the patient to do which of the following (select all that apply)? a. Maintain adequate fluid intake b. Splint the abdomen when coughing c. Maintain a high Fowler's position d. Maintain a Sim's (semi fowlers) position e. Cough at end of exhalation

a, b, c, e a. Maintain adequate fluid intake b. Splint the abdomen when coughing c. Maintain a high Fowler's position e. Cough at end of exhalation