adult health 1 module 4: oxygenation

The nurse is teaching a patient how to self-administer ipratropium via a metered-dose inhaler (MDI). Which instruction is most appropriate to help the patient learn the proper inhalation technique? "Avoid shaking the inhaler before use." "Breathe out slowly before positioning the inhaler." "Using a spacer should be avoided for this type of medication." "After taking a puff, hold the breath for 30 seconds before exhaling."

"Breathe out slowly before positioning the inhaler." Rationale: It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication, thus enhancing the effectiveness of the dose. The inhaler should be shaken well. A spacer may be used. Holding the breath after the inhalation of medication helps keep the medication in the lungs, but 30 seconds will not be possible for a patient with COPD.

The provider has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions would the nurse provide? "Close lips tightly around the mouthpiece and breathe in deeply and quickly." "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."

"Close lips tightly around the mouthpiece and breathe in deeply and quickly." Rationale: The patient would be instructed to tightly close the lips around the mouthpiece and breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.

The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to an employee. Which question would the nurse ask before administering the vaccine? "Are you allergic to chicken?" "Could you be pregnant now?" "Did you ever have influenza?" "Have you ever had hepatitis B?"

"Could you be pregnant now?" Rationale: The live attenuated influenza vaccine (LAIV) is given by nasal spray and approved for healthy people age 2 to 49 years. The LAIV is given only to nonpregnant, healthy people. The inactivated vaccine is given by injection and is approved for use in people 6 months or older. The inactivated vaccine can be used in pregnancy, in people with chronic conditions, or in people who are immunosuppressed. Influenza vaccination is contraindicated if the person has a history of Guillain-Barré syndrome or a hypersensitivity to eggs.

The nurse determines that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? "I will seek immediate medical treatment for any upper respiratory infections." "I should continue to do deep breathing and coughing exercises for at least 12 weeks." "I will increase my food intake to 2400 calories a day to keep my immune system well." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." Rationale: The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of a fungal lung infection with Candida albicans. What patient statement indicates to the nurse that further teaching is required? "I will be given amphotericin B to treat the fungus." "I got this fungus because I am immunocompromised." "I need to be isolated from my family and friends so they won't get it." "The effectiveness of my therapy can be monitored with fungal serology titers."

"I need to be isolated from my family and friends so they won't get it." Rationale: The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.

The nurse teaches a patient with chronic obstructive pulmonary disease (COPD) how to administer fluticasone by metered-dose inhaler (MDI). Which statement indicates a correct understanding of the instructions? "I should not use a spacer device with this inhaler." "I will rinse my mouth each time after I use this inhaler." "I will feel my breathing improve over the next 2 to 3 days." "I should use this inhaler immediately if I have trouble breathing."

"I will rinse my mouth each time after I use this inhaler." Rationale: Fluticasone may cause oral candidiasis (thrush). The patient should rinse the mouth with water or mouthwash after use or use a spacer device to prevent oral fungal infections. Fluticasone is an inhaled corticosteroid and it may take 2 weeks of regular use for effects to be evident. This medication is not recommended for an acute asthma attack.

The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? "My liver function will be checked with blood tests every 2 to 3 months." "The medication will decrease the congestion within 3 to 5 minutes after use." "I may develop a serious infection because the medication reduces my immunity." "I will use the medication every day of the season whether I have symptoms or not."

"I will use the medication every day of the season whether I have symptoms or not." Rationale: Budesonide should be started 2 weeks before pollen season starts and used on a regular basis, not as needed. The spray acts to decrease inflammation and the effect is not immediate as with decongestant sprays. At recommended doses, budesonide has only local effects and will not result in immunosuppression or a systemic infection. Zafirlukast (Accolate) is a leukotriene receptor antagonist and may alter liver function tests (LFTs). LFTs must be monitored periodically in the patient taking zafirlukast.

The nurse teaches a patient with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which patient statement indicates further teaching is required? "I should avoid using ibuprofen for pain and discomfort." "It is important for me to take my blood pressure medication every day." "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." "If I get a nosebleed, I will lie down flat and raise my feet above my heart."

"If I get a nosebleed, I will lie down flat and raise my feet above my heart." Rationale: A simple measure to control epistaxis (or a nosebleed) is for the patient to remain quiet in a sitting position. Another measure is to apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. Aspirin and nonsteroidal antiinflammatory drugs such as ibuprofen increase the bleeding time and should be avoided. Elevated blood pressure makes epistaxis more difficult to control. The patient should continue with antihypertensive medications as prescribed.

Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching about the use of an ipratropium inhaler? "I should wait at least 1 to 2 minutes between each puff of the inhaler." "I can rinse my mouth following the two puffs to get rid of the bad taste." "Because this medication is not fast acting, I cannot use it in an emergency if my breathing is worse." "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."

"If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily." Rationale: The patient should not just keep taking extra puffs of the inhaler to make breathing easier. Excessive treatment could trigger paradoxical bronchospasm, which would worsen the patient's respiratory status. Rinsing the mouth after the puffs will eliminate a bad taste. Waiting 1 to 2 minutes between each puff will facilitate the effectiveness of the administration. Ipratropium is not used in an emergency for COPD.

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications if the patient states: "I will pay less for medication because it will last longer." "More of the medication will get down into my lungs to help my breathing." "Now I will not need to breathe in as deeply when taking the inhaler medications." "This device will make it so much easier and faster to take my inhaled medications."

"More of the medication will get down into my lungs to help my breathing." Rationale: A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. It does not affect the cost or increase the speed of using the inhaler

An adolescent patient with a history of frequent lung and sinus infections has symptoms consistent with undiagnosed cystic fibrosis (CF). Which information would be accurate for the nurse to include when teaching the patient about a scheduled sweat chloride test? "Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF." "The test measures the amount of sodium chloride in your postexercise sweat." "If sweating occurs after an oral dose of pilocarpine, the test result for CP is positive." "If the sweat chloride test result is positive on two occasions, genetic testing will be necessary."

"Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF." Rationale: The diagnostic criteria for CF involve a combination of clinical presentation, sweat chloride testing, and genetic testing to confirm the diagnosis. Values above 60 mmol/L for sweat chloride are consistent with the diagnosis of CF. However, a second sweat chloride test is recommended to confirm the diagnosis, unless genetic testing identifies a CF mutation. Genetic testing is used if the results from a sweat chloride test are unclear.

The nurse teaches a patient with a pulmonary embolism how to administer enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? "I need to take this medicine with meals." "The medicine will be prescribed for 10 days." "I will inject this medicine into my upper arm." "The medicine will dissolve the clot in my lung."

"The medicine will be prescribed for 10 days." Rationale: Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.

A patient has been receiving oxygen per nasal cannula while hospitalized for chronic obstructive pulmonary disease (COPD). The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? "Long-term home oxygen therapy should be used to prevent respiratory failure." "Oxygen will not be needed unless you are in the terminal stages of this disease." "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."

"You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia." Rationale: Long-term oxygen therapy in the home will not be considered until the oxygen saturation is less than or equal to 88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status. PaO2 less than 55 mm Hg will also allow home oxygen therapy to be considered.

1. A patient with asthma has a personal best peak expiratory flow rate (PEFR) of 400 L/min. When explaining the asthma action plan, the nurse will teach the patient that a change in therapy is needed when the PEFR is less than________ L/minute.

ANS: 320 A PEFR less than 80% of the personal best indicates that the patient is in the yellow zone where changes in therapy are needed to prevent progression of the airway narrowing.

The nurse is caring for a group of patients. Which patient is at risk of aspiration? A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery A 26-yr-old patient with continuous enteral feedings through a nasogastric tube A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

A 26-yr-old patient with continuous enteral feedings through a nasogastric tube Rationale: Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without enteral nutrition. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration

Which test result identifies that a patient with asthma is responding to treatment? An increase in CO2 levels A decreased exhaled nitric oxide A decrease in white blood cell count An increase in serum bicarbonate levels

A decreased exhaled nitric oxide Rationale: Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma and adherence to treatment. An increase in CO2 levels, decreased white blood cell count, and increased serum bicarbonate levels do not indicate a positive response to treatment in a patient with asthma.

Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? a. Cough productive of bloody, purulent mucus b. Report of sharp chest pain with deep breathing c. Scattered crackles and wheezes heard bilaterally d. Respiratory rate 28 breaths/min while ambulating

ANS: A Hemoptysis may indicate life-threatening hemorrhage and would be reported immediately to the health care provider. The other findings are frequently noted in patients with bronchiectasis and may need further assessment but are not indicators of life-threatening complications.

The nurse is caring for a patient with a fever due to pneumonia. What assessment data does the nurse obtain that correlates with the patient having a fever? (Select all that apply.) A temperature of 101.4°F Heart rate of 120 beats/min Respiratory rate of 20 breaths/min A productive cough with yellow sputum Unable to have a bowel movement for 2 days

A temperature of 101.4°F Heart rate of 120 beats/min A productive cough with yellow sputum Rationale: A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.

Which patient in the ear, nose, and throat clinic would the nurse assess first? a. A patient who reports difficulty swallowing and has a muffled voice b. A patient with a history of a total laryngectomy whose stoma is red c. A patient who has a "scratchy throat" and a positive rapid strep antigen test d. A patient who is receiving radiation for throat cancer and has severe fatigue

ANS: A A muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. A tracheal stoma is normally red. Strep throat and fatigue do not indicate life-threatening problems.

Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced assistive personnel (AP)? a. Measure O2 saturation using pulse oximetry. b. Monitor for increased O2 need with exercise. c. Teach the patient about safe use of O2 at home. d. Adjust O2 to keep saturation in prescribed parameters.

ANS: A AP can obtain O2 saturation (after being trained and evaluated in the skill). The other actions require more education and a scope of practice that licensed practical/vocational nurses (LPN/VNs) or registered nurses (RNs) would have.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (AP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

ANS: A AP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment would the nurse complete first? a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Measure forced expiratory volume (FEV) flow rate.

ANS: A Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.

A patient arrives in the emergency department with a possible nasal fracture after being hit by a baseball. Which finding by the nurse is most important to communicate to the health care provider? a. Clear thin nasal drainage b. Patient reports of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose

ANS: A Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate complications.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.

ANS: A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

ANS: A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

An older adult is receiving standard multidrug therapy for tuberculosis (TB). Which finding would the nurse report to the health care provider? a. Yellow-tinged sclera b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices

ANS: A Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding requires the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient reports level 8 (0 to 10 scale) pain. d. The patient's temperature is 100.1F (37.8C).

ANS: A Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data indicate a need for nursing action but not as immediately as the low O2 saturation.

Which action by the nurse would support ventilation for a patient with chronic obstructive pulmonary disease (COPD).? a. Encourage the patient to sit upright and lean forward. b. Have the patient rest with the head elevated 15 degrees. c. Place the patient in the Trendelenburg position with pillows behind the head. d. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed.

ANS: A Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated in a semi-Fowler's position would be an alternative position if the patient was confined to bed but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well.

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient reports hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask? a. "How much alcohol do you drink in an average week?" b. "Do you have a family history of head or neck cancer?" c. "Have you had frequent streptococcal throat infections?" d. "Do you use antihistamines for upper airway congestion?"

ANS: A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Patients with streptococcal throat infections will also have pain and a fever.

The emergency department nurse is evaluating the outcomes for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. O2 saturation is >90%. b. No wheezes are audible. c. Respiratory rate is 16 breaths/min. d. Accessory muscle use has decreased.

ANS: A The goal for treatment of an asthma attack is to keep the O2 saturation above 90%. Absence of wheezes, slower respiratory rate, and decreased accessory muscle use may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.

The nurse in the emergency department receives arterial blood gas results for 4 recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg b. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

ANS: A The low pH, high PaCO2, and low PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis.

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The staff nurse has no symptoms of TB and has not had a positive TB skin test before. Which information would the occupational health nurse plan to teach the staff nurse? a. Use and side effects of isoniazid b. Standard four-drug therapy for TB c. Need for annual repeat TB skin testing d. Bacille Calmette-Guérin (BCG) vaccine

ANS: A The nurse is considered to have a latent TB infection and would be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for those who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action would the nurse take first? a. Notify the health care provider. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (Solu-Medrol).

ANS: A The patient's assessment indicates impending respiratory failure, and the nurse would prepare to assist with intubation and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time.

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath. " Which action will the nurse take first? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed, and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Pneumonia does not usually cause severe pain, so assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction would the nurse include in the discharge teaching? a. O2 use can improve the patient's quality of life. b. Travel is not possible with the use of O2 devices. c. O2 flow should be increased if the patient has more dyspnea. d. Storage of O2 requires large metal tanks that last 4 to 6 hours.

ANS: A The use of home O2 improves quality of life and prognosis. Because increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the health care provider rather than increasing the O2 flowrate if dyspnea becomes worse. O2 can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible using portable O2 concentrators.

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/min d. Resting pulse oximetry (SpO2) of 85%

ANS: A The weak cough effort indicates that the patient is unable to clear the airway effectively. A patient who produces profuse sputum may be able to clear it with effective coughing. An increased respiratory rate or low SpO2 suggest problems with gas exchange.

A 30-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which topic would the nurse plan to teach the patient? a. 1-Antitrypsin testing b. Leukotriene modifiers c. Use of the nicotine patch d. Continuous pulse oximetry

ANS: A When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in 1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with COPD.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select all that apply.) a. Age b. Blood pressure c. Respiratory rate d. O2 saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level

ANS: A, B, C, E, F Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). Oxygenation is also essential to assess but is not used for CURB-65 scoring.

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination instead of the live attenuated influenza vaccine? (Select all that apply.) a. A 76-yr-old nursing home resident b. A 36-yr-old female patient who is pregnant c. A 42-yr-old patient who has a 15 pack-year smoking history d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-yr-old patient who has allergies to penicillin and cephalosporins

ANS: A, B, D Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old patient increases the risk for infection. Current guidelines suggest that healthy individuals between 6 months and age 49 years receive intranasal immunization with live, attenuated influenza vaccine.

The clinic nurse is teaching a patient with acute sinusitis. Which interventions would the nurse plan to include in the teaching session? (Select all that apply.) a. Decongestants can be used to relieve swelling. b. Avoid blowing the nose to decrease the risk of nosebleed. c. Taking a hot shower will promote sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.

ANS: A, C, D, E The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

Which action, if performed by a nurse who is assigned to take care of a patient with active tuberculosis (TB), would require an intervention by the nurse supervisor? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.

ANS: B A high-efficiency particulate-absorbing (HEPA) mask or N95 mask, rather than a standard surgical mask, should be used when entering the patient's room. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The nurse would perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

The home health nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? a. The patient lies in supine position when using the nebulizer. b. The patient removes the facial mask when the misting stops. c. The patient reports washing the nebulizer mouthpiece weekly. d. The patient inhales while holding the mask 4 inches away from the face.

ANS: B A mist is seen when the medication is aerosolized, and when all the medication has been used, the misting stops. The mask should be placed securely on the patient's face or the mouthpiece held between the teeth with the lips closed around the device. The patient should be positioned sitting upright. The home nebulize equipment should be washed and dried daily.

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient would the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38 breaths/min c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema

ANS: B A respiratory rate of 38/min indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the patient with tachypnea.

A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action would the nurse take? a. Teach the patient signs of hypoglycemia. b. Have the patient add dietary salt to meals. c. Suggest decreasing intake of dietary fat and calories. d. Teach the patient about pancreatic enzyme replacement.

ANS: B Added dietary salt is indicated whenever sweating is excessive, such as during hot weather, when fever is present, or from intense physical activity. The management of pancreatic insufficiency includes pancreatic enzyme replacement before each meal and snack. This patient is at risk for hyponatremia based on reported symptoms. Adequate intake of fat, calories, protein, and vitamins is important. Fat-soluble vitamins (vitamins A, D, E, and K) must be supplemented because they are malabsorbed. Use of caloric supplements improves nutritional status. Hyperglycemia caused by pancreatic insufficiency is more likely to occur than hypoglycemia.

The nurse teaches a patient who has chronic bronchitis about a new prescription for combined fluticasone and salmeterol (Advair Diskus) in a dry powder inhaler. Which patient action indicates to the nurse that teaching about medication administration has been successful? a. The patient shakes the device before use. b. The patient rapidly inhales the medication. c. The patient attaches a spacer to the device. d. The patient performs huff coughing after inhalation.

ANS: B Advair Diskus is a dry powder inhaler; the patient should inhale the medication rapidly, or the dry particles will stick to the tongue and oral mucosa. Shaking dry powder inhalers is not recommended. Spacers are not used with dry powder inhalers. Huff coughing is a technique to move mucus into larger airways to expectorate. The patient should not huff cough or exhale forcefully after taking Advair to keep the medication in the lungs.

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication would the nurse administer first? a. Methylprednisolone (Solu-Medrol) 60 mg IV b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) d. Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)

ANS: B Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly.

The nurse provides discharge instructions for a patient after a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. "I can participate in fitness activities except swimming." b. "I must keep the stoma covered with an occlusive dressing." c. "I need to have smoke and carbon monoxide detectors installed." d. "I will wear a Medic-Alert bracelet to identify me as a neck breather."

ANS: B An occlusive dressing will completely block the patient's airway. The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective.

Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? a. Pain at injection site b. Flushing and dizziness c. Respiratory rate 24 breaths/min d. Peak flow reading 75% of normal

ANS: B Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction, and immediate intervention is needed. The other information would also be reported, but do not indicate possibly life-threatening complications of omalizumab therapy.

The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? a. "I will drink lots of fluids with mymeals." b. "I can have ice cream as a snack every day." c. "I will exercise for 15 minutes before meals." d. "I will decrease my intake of beef and poultry."

ANS: B High-calorie foods such as ice cream are an appropriate snack for underweight patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which prescribed action would the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) suppository

ANS: B Initiating antibiotic therapy rapidly is essential, but it is important to obtain the cultures before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

The nurse receives change-of-shift report on the following four patients. Which patient would the nurse assess first? a. A 77-yr-old patient with tuberculosis (TB) who has four medications due b. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath c. A 35-yr-old patient with pneumonia who has a temperature of 100.2F (37.8C) d. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled

ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

Which action would the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Raise the head of the bed for a patient who is receiving tube feedings. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.

ANS: B Patients who have an orogastric or nasogastric tube are at risk for aspiration pneumonia. Elevating the head of the bed can help prevent this complication. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action would the nurse recommended to prevent lung disease? a. Teach about symptoms of lung disease. b. Require the use of protective equipment. c. Treat workers who have pulmonary fibrosis. d. Monitor workers for coughing and wheezing.

ANS: B Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions in a private hospital room c. Monitoring patient serology results to identify the infecting organism d. Titrating the O2 flowrate as prescribed to keep the O2 saturation over 90%

ANS: B Pulmonary fungal infections are acquired by inhaling spores. They are not transmitted from person to person. The patient does not have to be placed in isolation. Assessing lung sounds, monitoring serology results, and titrating oxygen are expected actions.

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which action would the nurse implement for a patient who has an impaired breathing pattern due to anxiety? a. Titrate O2 to keep saturation at least 90%. b. Teach the patient how to use the pursed-lip technique. c. Discuss a high-protein, high-calorie diet with the patient. d. Suggest the use of over-the-counter sedative medications.

ANS: B Pursed-lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires O2 therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.

Which assessment finding is most useful in evaluating the effectiveness of treatment to improve gas exchange? a. Even, unlabored respirations b. Pulse oximetry reading of 92% c. Absence of wheezes or crackles d. Respiratory rate of 18 breaths/min

ANS: B The best data for evaluation of gas exchange are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How would the nurse determine the appropriate O2 flowrate? a. Minimize O2 use to avoid O2 dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer O2 according to the patient's level of dyspnea. d. Avoid administration of O2 at a rate of more than 2 L/min.

ANS: B The best way to determine the appropriate O2 flowrate is by monitoring the patient's oxygenation either by arterial blood gases (ABGs) or pulse oximetry. An O2 saturation of 90% indicates adequate blood O2 level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an O2 flowrate of 2 L/min may not be adequate. Because O2 use improves survival rate in patients with COPD, there is no concern about O2 dependency. The patient's perceived dyspnea level may be affected by other factors (e.g., anxiety) besides blood O2 level.

Which information is most important for the nurse to communicate to the health care provider about an older patient who has influenza? a. Fever of 100.4F (38C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

ANS: B The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter pain relievers and increased fluid intake.

Which action would the nurse take first when a patient develops epistaxis? a. Pack the affected nare tightly with an epistaxis balloon. b. Apply squeezing pressure to the nostrils for 10 minutes. c. Obtain silver nitrate that may be needed for cauterization. d. Instill a vasoconstrictor medication into the affected nare.

ANS: B The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area but will not be sufficient to stop bleeding. Cauterization, nasal packing, and vasoconstrictors are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.

The nurse plans to teach a patient how to manage allergic rhinitis. Which information would the nurse include in the teaching plan? a. Using oral antihistamines for 2 weeks before the allergy season may prevent reactions. b. Identifying and avoiding environmental triggers is the best way to prevent symptoms. c. Frequent hand washing is the primary way to prevent spreading the condition to others. d. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.

ANS: B The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinopharyngitis (common cold) can be prevented by washing hands, but allergic rhinitis cannot.

The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. "I will drink lots of juices and other fluids to stay well hydrated." b. "I can use nasal decongestant spray until the congestion is gone." c. "I can take acetaminophen (Tylenol) to treat my sinus discomfort." d. "I will watch for changes in nasal secretions or the sputum that I cough up."

ANS: B The nurse should clarify that nasal decongestant sprays should be used for no more than 5 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering trying to become pregnant. Which initial response would the nurse provide? a. "Are you aware of the normal lifespan for patients with CF?" b. "Would like more information to help you with that decision?" c. "You should have genetic counseling before making that choice." d. "Many women with CF do not have difficulty conceiving children."

ANS: B The nurse's initial response should be to assess the patient's knowledge level and need for information. Although the life span for patients with CF is likely to be shorter than normal, it would not be appropriate for the nurse to address this as the initial response to the patient's comments. The other responses have accurate information, but the nurse should first assess the patient's understanding about the issues surrounding pregnancy.

Which patient statement indicates that teaching about radiation therapy of the larynx was effective? a. "I should not use any lotions on my neck." b. "I will need to carry a water bottle with me." c. "Until the radiation is complete, I may have diarrhea." d. "Alcohol-based mouthwashes will help clean my mouth."

ANS: B Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which initial response would the nurse provide? a. "Are you ready to talk with family members about dying?" b. "Can you tell me what makes you think you will die so soon?" c. "Do you think that an antidepressant medication would be helpful?" d. "Would you like to talk to the hospital chaplain about your feelings?"

ANS: B The nurse's initial response would be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what" is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6F (38.7C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: B The patient's clinical manifestations are consistent with streptococcal pharyngitis, and the nurse will anticipate the need for a rapid strep antigen test or cultures (or both). Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing out the mouth after inhaler use may prevent fungal oral infections, but the patient's assessment data are not consistent with a fungal infection. NSAIDs are often prescribed for pain and fever relief with pharyngitis.

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action would the nurse take first? a. Tell the patient to go to the hospital emergency department. b. Teach the patient to use the prescribed albuterol (Ventolin HFA). c. Ask about recent exposure to any new allergens or asthma triggers. d. Question the patient about use of the prescribed inhaled corticosteroids.

ANS: B The patient's peak flow is 70% of normal, indicating a need for immediate use of short-acting 2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens is appropriate but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed at this point.

A patient seen in the asthma clinic has recorded daily peak flowrates that are 70% of the baseline. Which action will the nurse plan to take next? a. Teach the patient about the use of oral corticosteroids. b. Administer a bronchodilator and recheck the spirometry. c. Recommend increasing the dose of the leukotriene inhibitor. d. Instruct the patient to keep the scheduled follow-up appointment.

ANS: B The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient would take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient first needs to be taught how to control symptoms now and use the bronchodilator.

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which patient problem would the nurse identify? a. Fear of death b. Low self-esteem c. Anticipatory grieving d. Lack of knowledge

ANS: B The patient's statement about not being able to do anything for himself or herself reflects low self-esteem. Although lack of knowledge, anticipatory grieving, and fear of death may be problems for some patients who have COPD, the data for this patient do not support these problems.

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action would the nurse take? a. Turn and reposition the patient. b. Administer prescribed morphine. c. Clamp the chest tube in two places. d. Assist the patient with incentive spirometry.

ANS: B Treat the pain. The patient is unlikely to take deep breaths or cough or tolerate repositioning until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.

ANS: C -Blockers such as propranolol inhibit bronchodilation. The other information will be documented in the health history but does not indicate a need for a change in therapy.

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is specific in confirming a diagnosis of chronic bronchitis? a. The patient relates a family history of bronchitis. b. The patient has a 30 pack-year cigarette smoking history. c. The patient reports a productive cough for 3 months of every winter. d. The patient has respiratory problems that began during the past 12 months.

ANS: C A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no family tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action would the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.

Which finding indicates to the nurse that the administered nifedipine (Procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH)? a. Heart rate is between 60 and 100 beats/min. b. Patient's chest x-ray indicates clear lung fields. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg.

ANS: C Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray may show clear lung fields even if the therapy is not effective.

Which action would the nurse take to prepare a patient for spirometry? a. Give the rescue medication immediately before testing. b. Administer oral corticosteroids 2 hours before the procedure. c. Withhold bronchodilators for 6 to 12 hours before the examination. d. Ensure that the patient has been NPO for several hours before the test.

ANS: C Bronchodilators are held before spirometry so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should be held before spirometry. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.

Which finding would the nurse expect when assessing a patient with cor pulmonale? a. Chest pain b. Finger clubbing c. Peripheral edema d. Elevated temperature

ANS: C Cor pulmonale causes clinical manifestations of right ventricular failure, such as peripheral edema. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease but are not indicators of cor pulmonale.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic would the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home O2 therapy

ANS: C Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home O2 is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action would the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.

ANS: C Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of chronic alcohol use. Which intervention by the nurse expect to be most effective in ensuring adherence with the TB treatment regimen? a. Repeat warnings about the high risk for infecting others several times. b. Give the patient written instructions about how to take the medications. c. Arrange for a daily meal and drug administration at a community center. d. Arrange for the patient's friend to administer the medication on schedule.

ANS: C Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen. Arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient's situation.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care? a. Walk until pulse rate exceeds 130 beats/min. b. Stop exercising when you feel short of breath. c. Walk 15 to 20 minutes a day at least 3 times/wk. d. Limit exercise to activities of daily living (ADLs).

ANS: C Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increases. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-yr-old patient should have a pulse rate of 120 beats/min or less with exercise (80% of the maximal heart rate of 150 beats/min).

A patient who had a total laryngectomy has previously expressed hopelessness about the loss of control over personal care. Which information obtained by the nurse indicates that this identified problem is resolving? a. The patient allows the nurse to suction the tracheostomy. b. The patient's spouse provides the daily tracheostomy care. c. The patient asks to learn how to clean the tracheostomy stoma. d. The patient uses a communication board to request "No Visitors."

ANS: C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which initial response would the nurse provide? a. "Are you afraid that it will be very painful?" b. "Did you have bad experiences with surgeries?" c. "Tell me what you know about the treatments available." d. "Surgery is the treatment of choice for stage I lung cancer."

ANS: C More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. Non-small cell lung cancer does not respond well to chemotherapy, but chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery and would not be useful unless the patient describes specific concerns.

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a. Report of chest wall pain b. Heart rate of 110 beats/min c. Paradoxical chest movement d. Large, bruised area on the chest

ANS: C Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? a. "I will call my health care provider if I still feel tired after a week." b. "I will cancel my follow-up chest x-ray appointment if I feel better." c. "I will continue to do deep breathing and coughing exercises at home." d. "I will schedule two appointments for the pneumonia and influenza vaccines."

ANS: C Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6F with a frequent cough and severe pleuritic chest pain. Which prescribed medication would the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

ANS: D Early initiation of antibiotic therapy has been shown to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flowmeter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone. d. The patient calls the health care provider when the peak flow is in the green zone.

ANS: C Readings in the yellow zone indicate a decrease in peak flow. The patient should use short-acting 2-adrenergic (SABA) medications. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flowmeter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow, and the patient should take a fast-acting bronchodilator and call the health care provider for further instructions. Singulair is not indicated for acute attacks but is used for maintenance therapy.

When preparing a clinic patient who has chronic obstructive pulmonary disease (COPD) for pulmonary spirometry, which question would the nurse ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Have you taken any bronchodilators today?" d. "Do you have any metal implants or prostheses?"

ANS: C Spirometry will help establish the COPD diagnosis. Bronchodilators should be avoided at least 6 hours before the test. Spirometry does not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast dye is not used for spirometry. The patient may still have spirometry done if metal implants or prostheses are present because they are contraindications for an MRI.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action would the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach the patient about providing specimens for 3 consecutive days. d. Instruct the patient to collect several separate sputum specimens today.

ANS: C Sputum specimens are obtained on 3 consecutive days, each collected at 8- to 24-hour intervals, with at least 1 early morning specimen for bacteriologic testing for Mycobacterium tuberculosis. Blood cultures are not used to test for tuberculosis. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement by the patient indicates that teaching was effective? a. "I will take the bus instead of driving." b. "I will stay indoors whenever possible." c. "My spouse will sleep in another room." d. "I will keep the windows closed at home."

ANS: C Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

A patient with cystic fibrosis has blood glucose levels that are consistently between 180 to 250 mg/dL. Which action will the nurse expect to implement? a. Discuss the role of diet in blood glucose control. b. Evaluate the patient's use of pancreatic enzymes. c. Teach the patient about administration of insulin. d. Give oral hypoglycemic medications before meals.

ANS: C The glucose levels indicate that the patient has developed cystic fibrosis (CF) related diabetes, and insulin therapy is required. Because the etiology of diabetes in CF is inadequate insulin production, oral hypoglycemic agents are not effective. Patients with CF need a high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of hyperglycemia in a patient with CF.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse? a. The O2 saturation is 90%. b. The blood pressure is 98/56 mm Hg. c. The epoprostenol (Flolan) infusion is disconnected. d. The international normalized ratio (INR) is prolonged.

ANS: C The half-life of epoprostenol is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics

ANS: C The increased rate of pertussis in adults is thought to be caused by decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.

A patient newly diagnosed with asthma is being discharged. Which topic would the nurse include in the discharge teaching? a. Complications associated with O2 therapy b. Use of long-acting -adrenergic medications c. Side effects of sustained-release theophylline d. Self-administration of inhaled corticosteroids

ANS: D Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma.

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site

ANS: C The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain would be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema would be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. Which action is the priority during the first 24 hours after surgery? a. Monitor the incision for bleeding. b. Maintain adequate IV fluid intake. c. Keep the patient in semi-Fowler's position. d. Teach the patient to suction the tracheostomy.

ANS: C The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube. The patient may be taught to suction after the tracheostomy is stable, if needed, but not during the immediate postoperative period.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 6000/L. d. Increased tactile fremitus is palpable over the right chest.

ANS: C The normal WBC count indicates that the antibiotics have been effective. Bronchial breath sounds, green mucus, or tactile fremitus suggest that different or additional treatment is needed.

After change-of-shift report, which patient would the nurse assess first? a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101F (38.3C)

ANS: C The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

A middle aged patient with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which finding would be an early sign of an asthma exacerbation? Anxiety Cyanosis Bradycardia Hypercapnia

Anxiety Rationale: An early manifestation of an asthma attack is anxiety because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.

A patient with chronic obstructive pulmonary disease (COPD) has been eating very little and has lost weight. Which intervention would be most important for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patient's menu order of fruits and fruit juices. c. Offer high-calorie protein snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable content.

ANS: C Underweight patients need extra protein and calories; eating small amounts more often (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Whole grains, fruits, and vegetables are part of a well-balanced diet, but the patient with COPD who is underweight needs an emphasis on protein to maintain muscle tissue needed for breathing.

Which instruction would the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. "Avoid upper body exercises to prevent dyspnea." b. "Stop exercising if you start to feel short of breath." c. "Use the bronchodilator before you start to exercise." d. "Breathe in and out through the mouth while exercising."

ANS: C Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.

Which assessment finding for a patient with a history of asthma indicates that the nurse would take immediate action? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/min c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/min

ANS: C Use of accessory muscle indicates that the patient with asthma is experiencing respiratory distress, and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" Which response by the nurse would be the most accurate? a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c. "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration." d. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally."

ANS: C Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.

A patient with pneumonia has a fever of 101.4F (38.6C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem would the nurse assign as the priority? a. Fatigue b. Altered temperature c. Musculoskeletal problem d. Impaired respiratory function

ANS: D All these problems are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the respiratory function is improved.

A patient arrives in the ear, nose, and throat clinic with foul-smelling nasal drainage from the right nare, reporting a piece of tissue being "stuck up my nose." Which action would the nurse take first? a. Notify the clinic health care provider. b. Obtain aerobic culture specimens of the drainage. c. Ask the patient about how the cotton got into the nose. d. Have the patient occlude the left nare and blow the nose.

ANS: D Because the highest priority action is to remove the foreign object from the nare, the nurse's first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose.

The nurse completes an admission assessment on a patient with asthma. Which information indicates a need for discussion with the health care provider about a change in therapy? a. The patient uses an albuterol inhaler before aerobic exercise. b. The patient's only medications are albuterol and salmeterol inhalers. c. The patient's heart rate increases slightly after using the albuterol inhaler. d. The patient used albuterol more often when symptoms were worse in the spring.

ANS: D Long-acting 2-agonists would be used only in patients who also are using an inhaled corticosteroid for long-term control; salmeterol would not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is appropriate. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma.

Which intervention would the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Assist the patient with chest physiotherapy and postural drainage. b. Teach the patient to avoid the use of over-the-counter expectorants. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

ANS: D Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul-smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates that the teaching has been effective? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

ANS: D Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.

The nurse provides discharge instructions after a rhinoplasty. Which statement by the patient indicates an accurate understanding of the instructions? a. "My nose will look normal after 24 to 48 hours." b. "I can take 800 mg ibuprofen every 6 hours for pain." c. "I should remove and reapply the nasal packing every day." d. "I will elevate my head for 48 hours to minimize swelling."

ANS: D Maintaining the head in an elevated position will decrease the amount of nasal swelling. Nonsteroidal antiinflammatory drugs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery.

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action would the nurse include in the plan of care? a. Assess patient for allergies to penicillin antibiotics. b. Teach the patient to sleep in a warm, dry environment. c. Avoid giving the patient warm food or warm liquids to drink. d. Teach patient to "swish and swallow" prescribed oral nystatin.

ANS: D Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the "swish and swallow" technique is to expose all the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin allergy because C. albicans infection is treated with antifungals.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? a. Asking the patient about any visual changes in red-green color discrimination b. Questioning the patient about experiencing shortness of breath, hives, or itching c. Advising the patient to stop the drug and report the symptoms to the health care provider d. Explaining that orange discolored urine and tears are normal while taking this medication

ANS: D Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occur when taking ethambutol, which is a different tuberculosis medication.

The nurse supervises assistive personnel (AP) providing care for a patient who has right lower lobe pneumonia. Which action by the AP requires the nurse to intervene? a. AP assists the patient to ambulate to the bathroom. b. AP helps splint the patient's chest during coughing. c. AP transfers the patient to a bedside chair for meals. d. AP lowers the head of the patient's bed to 15 degrees.

ANS: D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.

A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Sputum smears for acid-fast bacilli are negative.

ANS: D Repeated negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention would the nurse include in the plan of care? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.

ANS: D Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium.

A patient is admitted to the emergency department with an open stab wound to the left chest. Which action would the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.

ANS: D The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

After 2 months of prescribed treatment with isoniazid, rifampin, pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action would the nurse take next? a. Teach about drug-resistant TB. b. Schedule directly observed therapy. c. Discuss injectable antibiotics with the health care provider. d. Ask the patient whether medications were taken as directed.

ANS: D The first action would be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the NursingProcess. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action would the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

ANS: D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be performed after the head is elevated and O2 is started. The health care provider may order a spiral CT to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.

Which information will the nurse include in the teaching plan for a patient newly diagnosed with asthma? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 2 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators.

ANS: D Tremors are a common side effect of short-acting 2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.

The patient with cystic fibrosis (CF) has been admitted to the unit. What intervention would the nurse include in the plan of care? Strict bedrest Fluid restrictions of 1500 mL a day Aggressive chest physical therapy (CPT) Limit diet intake of sodium-containing foods

Aggressive chest physical therapy (CPT) Rationale: Acute care for the patient with CF includes relief of bronchoconstriction, airway obstruction, and airflow limitation. Interventions include aggressive CPT, antibiotics, and O2 therapy in severe disease. Measures to optimize nutrition are important. There is no reason to limit foods containing sodium.

When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? Patient comfort Airway patency Incisional drainage Blood pressure and heart rate

Airway patency Rationale: Remember the ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. Comfort, drainage, and vital signs follow the ABCs in priority.

The patient has an order for multiiple inhalers. Which one would the nurse offer to the patient at the onset of an asthma attack? Albuterol Ipratropium bromide Salmeterol (Serevent) Beclomethasone (Qvar)

Albuterol Rationale: Albuterol is a short-acting bronchodilator that would be given initially when the patient has an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide is an anticholinergic agent that is less effective than β2-adrenergic agonists. It may be used in an emergency with a patient unable to tolerate short-acting β2-adrenergic agonists (SABAs).

A patient with a persistent cough is diagnosed with pertussis. What medication does the nurse anticipate administering to this patient? Antibiotic Corticosteroid Bronchodilator Cough suppressant

Antibiotic Rationale: Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordetella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.

A patient newly admitted with community acquired pneumonia is non ambulatory. What intervention would the nurse include in the plan of care to decrease the risk for a pulmonary embolism (PE)? Strict bed rest. Administer supplemental oxygen. Encourage coughing and deep breathing. Apply intermittent pneumatic compression devices.

Apply intermittent pneumatic compression devices. Rationale: Prevention of PE begins with prevention of DVT. Identification of the "at risk" patient is essential. Nursing measures aimed at prevention of PE are similar to those for prophylaxis of VTE. These include the use of intermittent pneumatic compression devices, early ambulation, and anticoagulant medications.

A patient with chronic obstructive pulmonary disease (COPD) becomes dyspneic at rest. The baseline ABG results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. After assessing the patient, what new finding would require the nurse's priority intervention? Arterial pH 7.26 PaCO2 50 mm Hg Patient in tripod position Increased sputum expectoration

Arterial pH 7.26 Rationale: The patient's pH shows acidosis that supports an exacerbation of COPD along with the worsening dyspnea. The PaCO2 has improved from baseline, the tripod position helps the patient's breathing, and the increase in sputum expectoration will improve the patient's ventilation.

During admission of a patient diagnosed with non-small cell lung cancer, the nurse asks the patient about which risk factors for this type of cancer? (Select all that apply.) Asbestos exposure Exposure to uranium Chronic interstitial fibrosis History of cigarette smoking Geographic area in which they were born

Asbestos exposure Exposure to uranium History of cigarette smoking Rationale: Non-small cell cancer is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk but not necessarily where the patient was born.

The nurse is performing a respiratory assessment. Which finding best supports the presence of impaired airway clearance? Basilar crackles Oxygen saturation of 85% Presence of greenish sputum Respiratory rate of 28 breaths/min

Basilar crackles Rationale: The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with impaired airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with other lower respiratory problems.

Which health promotion information would the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination

Because smoking is the major cause of lung cancer, an important role for the nurse is teaching patients about the benefits of and means of smoking cessation. Screening for using low-dose CT is recommended for high-risk patients Encourage those at risk for pneumonia (e.g., those who smoke) to obtain both influenza and pneumococcal vaccines. Sputum cytology is a diagnostic test but is not used for cancer screening. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.

A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and now has exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? Pulmonary infarction Pulmonary hypertension Cytomegalovirus (CMV) Bronchiolitis obliterans (BOS)

Bronchiolitis obliterans (BOS) Rationale: BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant

The nurse has administered a first dose of oral prednisone to a patient with asthma. What parameter would the nurse begin to monitor? Apical pulse Daily weight Bowel sounds Deep tendon reflexes

Daily weight Rationale: Corticosteroids such as prednisone can lead to weight gain. For this reason, it is important to monitor the patient's daily weight. The drug should not affect the apical pulse, bowel sounds, or deep tendon reflexes.

The nurse is admitting a patient with a pulmonary embolism. Which risk factors are a priority for the nurse to assess? (Select all that apply.) Cancer Obesity Pneumonia Cigarette smoking Prolonged air travel

Cancer Obesity Cigarette smoking Prolonged air travel Rationale: An increased risk of pulmonary embolism is associated with obesity, cancer, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

The nurse is reviewing the health history of a patient with laryngeal cancer. Which finding would the nurse expect? Family history of lung cancer Recent inhalation of noxious fumes Frequent straining of the vocal cords Chronic use of alcohol and tobacco products

Chronic use of alcohol and tobacco products Rationale: Tobacco use causes 85% of head and neck cancers. Excess alcohol use is another major risk factor. Other risk factors include exposure to the sun, asbestos, industrial carcinogens, marijuana use, radiation therapy to the head and neck, and poor oral hygiene.

A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? Bilateral erythema of especially large tonsils Temperature 102.2°F, diaphoresis, and chills Contraction of neck muscles during inspiration β-Hemolytic streptococcus in the throat culture

Contraction of neck muscles during inspiration Rationale: Contraction of neck muscles during inspiration indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress. The reddened and enlarged tonsils indicate pharyngitis. The increased temperature, diaphoresis, and chills indicate an infection, which could be β-hemolytic streptococcus or fungal infection, but not an emergency situation for the patient.

A patient with a gunshot wound to the right side of the chest arrives in the emergency department with severe shortness of breath and decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? Cover the chest wound with a nonporous dressing taped on three sides. Pack the chest wound with sterile saline soaked gauze and tape securely. Stabilize the chest wall with tape and initiate positive pressure ventilation. Apply a pressure dressing over the wound to prevent excessive loss of blood.

Cover the chest wound with a nonporous dressing taped on three sides. Rationale: The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.

A school nurse is providing information to high school students about influenza prevention. What would the nurse emphasize in teaching to prevent the transmission of the virus? (Select all that apply.) Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic. Drink noncaffeinated fluids daily. Obtain antibiotic therapy promptly.

Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic. Rationale: Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.

When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information would the nurse include about the effects of smoking on the lungs? Smoking causes a hoarse voice. Cough will become nonproductive. Decreased alveolar macrophage function. Sense of smell is decreased with smoking.

Decreased alveolar macrophage function. Rationale: The damage to the lungs includes alveolar macrophage dysfunction that increases the incidence of infections and thus increases patient discomfort and cost to treat the infections. Other lung damage that contributes to infections includes cilia paralysis or destruction, increased mucus secretion, and bronchospasms that lead to sputum accumulation and increased cough. The patient may already be aware of respiratory mucosa damage with hoarseness and decreased sense of smell and taste, but these do not increase the incidence of pulmonary infection.

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with chronic obstructive pulmonary disease (COPD) are successful based on which finding? Absence of dyspnea Improved mental status Effective and productive coughing PaO2 within normal range for the patient

Effective and productive coughing Rationale: Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing. Absence of dyspnea, improved mental status, and PaO2 within normal range for the patient show improved respiratory status but do not evaluate airway clearance.

The nurse is assigned to care for a patient who has anxiety and an asthma exacerbation. What is the primary reason for the nurse to carefully inspect the patient's chest wall? Giving care will calm the patient Observing for signs of diaphoresis Evaluating the use of intercostal muscles Monitoring the patient for bilateral chest expansion

Evaluating the use of intercostal muscles Rationale: The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress. The other options may also occur, but they are not the primary reason for inspecting the chest wall of this patient.

When admitting a patient with a diagnosis of asthma exacerbation, the nurse would assess for what potential triggers? (Select all that apply.) Exercise Allergies Emotional stress Decreased humidity Upper respiratory infections

Exercise Allergies Emotional stress Upper respiratory infections Rationale: Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, stress, and gastroesophageal reflux disease (GERD).

Assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? Acute respiratory failure Secondary respiratory infection Fluid volume excess from cor pulmonale Pulmonary edema caused by left-sided heart failure

Fluid volume excess from cor pulmonale Rationale: Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment would the nurse expect to teach the patient about? Nasal packing Epistaxis balloon Gastrostomy tube Peripheral skin care

Gastrostomy tube Rationale: Many patients with head and neck cancer are malnourished even before treatment begins. Treatment modalities increase the risk for malnutrition. For example, after radical neck surgery, the patient may be unable to consume nutrients orally because of swelling, the location of sutures, or difficulty with swallowing. Side effects from chemotherapy and radiation therapy can impair the patient's ability to maintain adequate nutrition. Painful oral mucositis often leads to breaks in treatment if the patient is relying solely on oral intake for nutrition. A thorough nutrition assessment and prophylactic placement of a gastrostomy tube in high-risk patients are vital to maintaining adequate nutrition. Enteral nutrition (EN) may be started before treatment to obtain and maintain optimal nutrition needed for tissue repair. Nasal packing could be used with epistaxis or with nasal or sinus problems. Peripheral skin care would not be expected because it is not related to head and neck cancer.

In which position would the nurse place a patient experiencing an asthma exacerbation? Supine Lithotomy High Fowler's Reverse Trendelenburg

High Fowler's Rationale: The patient experiencing an asthma attack would be placed in high Fowler's position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation.

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine? Age older than 80 years History of upper respiratory infections Chronic obstructive pulmonary disease (COPD) History of a severe allergic reaction to the vaccine

History of a severe allergic reaction to the vaccine Rationale: Contraindications to vaccination include a history of severe allergic reactions to previous flu vaccine. Patients with anaphylactic hypersensitivity to eggs should discuss the vaccine with their HCP, as alternatives for vaccinating patients with egg allergies are now available. Advanced age and a history of respiratory illness are not contraindications for influenza vaccination.

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands the manifestations of the disease are related to what process? An overproduction of the antiprotease a1-antitrypsin Hyperinflation of alveoli and destruction of alveolar walls Hypertrophy and hyperplasia of goblet cells in the bronchi Collapse and hypoventilation of the terminal respiratory unit

Hyperinflation of alveoli and destruction of alveolar walls Rationale: In COPD, structural changes include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.

A patient is diagnosed with a lung abscess. What would the nurse include when teaching the patient about this diagnosis? IV antibiotic therapy will be started as soon as possible. Lobectomy surgery is usually needed to drain the abscess. Oral antibiotics will be used until there is evidence of improvement. Culture and sensitivity tests are needed for 1 year after resolving the abscess.

IV antibiotic therapy will be started as soon as possible. Rationale: IV antibiotics are used until the patient and radiographs show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.

The nurse is caring for a patient with impaired airway clearance. What is the priority nursing action to assist the patient to expectorate thick lung secretions? Humidify the oxygen as able. Administer a cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.

Increase fluid intake to 3 L/day if tolerated. Rationale: Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

A patient with bronchiectasis has copious thick respiratory secretions. Which intervention would the nurse include in the plan of care? Use the incentive spirometer for at least 10 breaths every 2 hours. Give prescribed antibiotics and antitussives on a scheduled basis. Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. Provide nutritional supplements that are high in protein and carbohydrates.

Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. Rationale: Adequate hydration helps to liquefy secretions and thus make it easier to remove them. Unless there are contraindications, the nurse should teach the patient to drink at least 3 L of fluid daily. Although nutrition, breathing exercises, and antibiotics may be indicated, these interventions will not liquefy or thin secretions. Antitussives may reduce the urge to cough and clear sputum, increasing congestion. Expectorants may be used to liquefy and facilitate clearing secretions.

The nurse determines that therapy with ipratropium is effective after noting which assessment finding? Decreased respiratory rate Increased respiratory rate Increased peak flow readings Decreased sputum production

Increased peak flow readings Rationale: Ipratropium is a bronchodilator that should result in increased peak expiratory flow rates.

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation would the nurse expect to find? Hyperresonance on percussion Vesicular breath sounds in all lobes Increased vocal fremitus on palpation Fine crackles in all lobes on auscultation

Increased vocal fremitus on palpation Rationale: A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.

What symptoms would the nurse teach the patient with bronchiectasis to report to the health care provider? Increasing dyspnea Temperature below 98.6°F Decreased sputum production Unable to drink 3 L of low-sodium fluids

Increasing dyspnea Rationale: The significant manifestations to report to the health care provider include increasing dyspnea, fever, chills, increased sputum production, bloody sputum, and chest pain. Although drinking at least 3 L of low-sodium fluid will help liquefy secretions to make them easier to expectorate, the health care provider does not need to be notified if the patient cannot do this one day.

While teaching a patient with asthma about the appropriate use of a peak flow meter, what would the nurse teach the patient to do? Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. Increase the dose of the long-term control medication if the peak flow numbers decrease. Use the flowmeter each morning after taking medications to evaluate their effectiveness. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.

Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. Rationale: It is important to keep track of peak flow readings daily, especially when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the provider based on personal peak flow numbers. Peak flow is measured by exhaling into the flowmeter and would be assessed before and after medications to evaluate their effectiveness.

The nurse is evaluating if a patient understands how to safely determine whether a metered-dose inhaler (MDI) is empty. The nurse decides the patient understands this important information when the patient describes which method to check the inhaler? Place it in water to see if it floats. Keep track of the number of inhalations used. Shake the canister while holding it next to the ear. Check the indicator line on the side of the canister.

Keep track of the number of inhalations used. Rationale: It is no longer appropriate to see if a canister floats in water or not because this is not an accurate way to determine the remaining inhaler doses. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing it after the number of days when those inhalations have been used (100 puffs/2 puffs each day = 50 days).

The nurse is teaching a patient how to self-administer beclomethasone, 2 puffs inhaled every 6 hours. What would the nurse teach the patient to do to prevent oral infection while taking this medication? Chew a hard candy before the first puff of medication. Ask for a breath mint after the second puff of medication. Rinse the mouth with water before each puff of medication. Rinse the mouth with water after the second puff of medication.

Rinse the mouth with water after the second puff of medication. Rationale: Because beclomethasone is a corticosteroid, the patient should rinse the mouth with water after the second puff of medication to reduce the risk of fungal overgrowth and oral infection.

The nurse supervises a team including another registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and assistive personnel (AP) on a medical unit in caring for many patients with respiratory problems. In what situation would the nurse intervene? LPN/VN obtained a pulse oximetry reading of 94% but did not report it. AP report to the nurse that the patient is reporting of difficulty breathing. RN taught the patient about home oxygen safety in preparation for discharge. LPN/VN changed the type of oxygen device based on arterial blood gas results.

LPN/VN changed the type of oxygen device based on arterial blood gas results. Rationale: It is not within the LPN scope to change oxygen devices based on analysis of lab results. It is within the scope of practice of the RN to assess, teach, and evaluate. The LPN provides care for stable patients and may adjust oxygen flow rates depending on desired oxygen saturation levels of stable patients. The AP may obtain oxygen saturation levels, assist patients with comfort adjustment of oxygen devices, and report changes in patient's level of consciousness or difficulty breathing.

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse understand is the reason for using this type of surgery? The patient has lung cancer. The incision will be medial sternal or lateral. Chest tubes will not be needed postoperatively. Less discomfort and faster return to normal activity.

Less discomfort and faster return to normal activity. Rationale: The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.

The nurse is caring for a postoperative patient with impaired airway clearance. What nursing actions would promote airway clearance? (Select all that apply.) Maintain adequate fluid intake. Maintain a 15-degree elevation. Splint the chest when coughing. Have the patient use incentive spirometry. Teach the patient to cough at end of exhalation.

Maintain adequate fluid intake. Splint the chest when coughing. Teach the patient to cough at end of exhalation. Rationale: Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should teach the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. Incentive spirometry promotes lung expansion. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

A patient had an open reduction repair of a bilateral nasal fracture. Which intervention would the nurse implement? Apply an external splint to the nose. Insert plastic nasal implant surgically. Humidify the air for mouth breathing. Maintain surgical packing in the nose.

Maintain surgical packing in the nose. Rationale: A goal that is common to nursing and medical management of a patient after rhinoplasty is to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma. Therefore, the nurse helps to keep the nasal packing in the nose. The packing applies direct pressure to oozing blood vessels to stop postoperative bleeding. A medical goal includes realigning the fracture with an external or internal splint. The nurse helps maintain the airway by humidifying inspired air because the nose is unable to do so following surgery because it is swollen and packed with gauze.

The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment would the nurse use to help determine if the URI has developed into acute sinusitis? Coughing Fever, chills Dust allergy Maxillary pain

Maxillary pain Rationale: The nurse would assess the patient for sinus pain or pressure as a clinical indicator of acute sinusitis. Coughing and fever are nonspecific clinical indicators of a URI. A history of an allergy that is likely to affect the upper respiratory tract is supportive of the sinusitis diagnosis but is not specific for sinusitis.

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. What would the nurse assess this patient for? Cough reflex Mucociliary clearance Reflex bronchoconstriction Ability to filter particles from the air

Mucociliary clearace Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

During an assessment of a patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? Laryngospasm Pulmonary edema Narrowing of the airway Overdistention of the alveoli

Narrowing of the airway Rationale: Narrowing of the airway by persistent but variable inflammation leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing. Laryngospasm, pulmonary edema, and overdistention of the alveoli do not produce wheezing

While ambulating a patient with metastatic lung cancer, the nurse observes a decrease in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? Continue with ambulation. Obtain a provider's order for arterial blood gas. Obtain a provider's order for supplemental oxygen. Move the oximetry probe from the finger to the earlobe.

Obtain a provider's order for supplemental oxygen. Rationale: An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.

The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? Teach the patient to cough and deep breathe. Take the temperature, pulse, and respiratory rate. Obtain a sputum specimen for culture and Gram stain. Check the patient's oxygen saturation by pulse oximetry.

Obtain a sputum specimen for culture and Gram stain. Rationale: A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse determines that the patient's nutrition status is impaired after noting a weight loss of 30 lb. Which intervention would the nurse add to the plan of care? Order fruits and fruit juices to be offered between meals. Order a high-calorie, high-protein diet with six small meals a day. Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet. Encourage the patient to double carbohydrate consumption and decrease fat intake.

Order a high-calorie, high-protein diet with six small meals a day. Rationale: Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, thus interfering with the work of breathing. For these reasons, the patient with COPD would eat 6 small meals per day taking in a high-calorie, high-protein diet, with nonprotein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient's caloric intake.

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone after what occurs? Hypertension and pulmonary edema Oropharyngeal candidiasis and hoarseness Elevation of blood glucose and calcium levels Adrenocortical dysfunction and hyperglycemia

Oropharyngeal candidiasis and hoarseness Rationale: Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.

When teaching the patient with cystic fibrosis about diet and medications, what priority information would the nurse include? Fat-soluble vitamins and dietary salt should be avoided. Insulin may be needed with a diabetic diet if diabetes develops. Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.

Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. Rationale: The patient must take pancreatic enzymes before each meal and snack and adequate fat, calories, protein, and vitamins should be eaten. Fat-soluble vitamins are needed because they are malabsorbed with the excess mucus in the gastrointestinal system. Insulin may be needed, but there is no longer a diabetic diet, and this is not priority information at this time. DIOS develops in the terminal ileum and is treated with balanced polyethylene glycol electrolyte solution (MiraLAX) to thin bowel contents.

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is important for the nurse to ask before the skin test? a. "Do you take any over-the-counter (OTC) medications?" b. "Do you have any family members with a history of TB?" c. "How long has it been since you moved to the United States?" d. "Did you receive the Bacille Calmette-Guérin (BCG) vaccine for TB?"

Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

An older adult patient is admitted with acute respiratory distress from cor pulmonale. Which nursing action is most appropriate during admission of this patient? Perform a comprehensive health history with the patient to review prior respiratory problems. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. Rationale: Because the patient is having respiratory difficulty, the nurse would ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed.

During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine would the nurse recommend that this patient receive? Pneumococcal Staphylococcus aureus Haemophilus influenzae Bacille-Calmette-Guérin (BCG)

Pneumococcal Rationale: The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, or living in a long-term care facility. A S. aureus vaccine has been researched but not yet been effective. The H. influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis is prevalent.

The nurse is caring for a patient with right lower lobe lung cancer. What is the priority nursing action to enhance oxygenation in this patient? Positioning patient on right side Maintaining adequate fluid intake Positioning patient with the left side down Performing postural drainage every 4 hours

Positioning patient with the left side down Rationale: Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? Temperature of 98.4°F Oxygen saturation 96% Pulse rate of 72 beats/min Respiratory rate of 18/breaths/min

Pulse rate of 72 beats/min Rationale: Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 72 beats/min indicates that the patient does not have tachycardia as an adverse effect.

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Notify the health care provider. Administer a nitroglycerin tablet sublingually. Conduct a thorough assessment of the chest pain. Sit the patient up in bed as tolerated and apply oxygen.

Sit the patient up in bed as tolerated and apply oxygen. Rationale: The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse would sit the patient up as tolerated and apply oxygen before notifying the health care provider. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which provider orders must the nurse verify have been completed before administering a dose of cefuroxime? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum laboratory studies ordered for AM

Sputum culture and sensitivity Rationale: The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

An older adult patient living alone is admitted to the hospital with pneumococcal pneumonia. Which clinical manifestation is consistent with the patient being hypoxic? Sudden onset of confusion Oral temperature of 102.3°F Coarse crackles in lung bases Clutching chest on inspiration

Sudden onset of confusion Rationale: Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.

The nurse is assigned to care for a patient in the emergency department with an asthma exacerbation. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, what would the nurse anticipate as the most likely next step in treatment? IV fluids Biofeedback therapy Systemic corticosteroids Pulmonary function testing

Systemic corticosteroids Rationale: Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. IV fluids may be used but not to improve ventilation. Biofeedback therapy and pulmonary function testing may be used after recovery to assist the patient and monitor the asthma.

The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurse's priority action? Test the drainage for the presence of glucose. Suction the nose to maintain airway clearance. Document the findings and continue monitoring. Apply a drip pad and reassure the patient this is normal.

Test the drainage for the presence of glucose. Rationale: Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.

A patient is being discharged from the emergency department after being treated for epistaxis. In teaching first aid measures in the event the epistaxis would recur, what measures will the nurse suggest? (Select all that apply.) Tilt patient's head backwards. Apply ice compresses to the nose. Tilt head forward while sitting upright. Pinch the entire soft lower portion of the nose. Lying down until 15 minutes after the bleeding ceases.

Tilt head forward while sitting upright. Pinch the entire soft lower portion of the nose. Rationale: Use simple first aid measures to control nosebleeds. These include: (1) placing the patient in a sitting position, leaning slightly forward with head tilted forward and (2) applying direct pressure by squeezing the entire soft lower portion of the nose (nostrils) together for 5 to 15 minutes. Tilting the head back does not stop the bleeding but allows the blood to enter the nasopharynx, which could result in aspiration or nausea or vomiting from swallowing blood. Lying down also will not decrease the bleeding.

The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? Electromyography Intraoral electrolarynx Neck type electrolarynx Transesophageal puncture

Transesophageal puncture Rationale: The transesophageal puncture provides a fistula between the esophagus and trachea with a one-way valved prosthesis to prevent aspiration from the esophagus to the trachea. Air moves from the lungs and vibrates against the esophagus, and words are formed with the tongue and lips as the air moves out the mouth. TEP offers the best speech quality with the highest degree of patient satisfaction. The electromyography and both electrolarynx methods produce low-pitched mechanical sounds.

Before discharge, the nurse discusses activity levels with an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate after the patient has recovered from this episode of illness? Slightly increase activity over the current level. Swim for 10 min/day, gradually increasing to 30 min/day. Limit exercise to activities of daily living to conserve energy. Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

Walk for 20 min/day, keeping the pulse rate less than 130 beats/min. Rationale: The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220—patient's age).

The nurse is caring for a patient with an acute exacerbation of asthma. After initial treatment, what assessment finding indicates to the nurse that the patient's respiratory status is improving? Wheezing becomes louder. Cough remains nonproductive. Vesicular breath sounds decrease. Aerosol bronchodilators stimulate coughing.

Wheezing becomes louder. Rationale: The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Vesicular breath sounds will increase with improved respiratory status. After a severe asthma exacerbation, the cough may be productive and stringy. Coughing after aerosol bronchodilators may indicate a problem with the inhaler or its use.

The nurse determines the patient with asthma has activity intolerance. What is the most likely reason for this problem? Work of breathing Fear of suffocation Effects of medications Anxiety and restlessness

Work of breathing Rationale: When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity. Fear of suffocation, effects of medications or anxiety, and restlessness are not etiologies for activity intolerance for a patient with asthma.