Chapter 21
A patient's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? A) Administer the treatment with the patient in a high Fowler's or semi-Fowler's position. B) Perform the procedure immediately following the patient's meals. C) Apply percussion firmly to bare skin to facilitate drainage. D) Assist the patient into a position that will allow gravity to move secretions.
Ans: Assist the patient into a position that will allow gravity to move secretions. Feedback: The patient uses gravity to facilitate postural draining.
The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patient's needs? A) Non-rebreathing mask B) Nasal cannula C) Simple mask D) Partial-rebreathing mask
Ans: Nasal cannula Feedback: A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential.
A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient? A) "Hold the spirometer at your lips and breathe in and out like you normally would." B) "When you're ready, blow hard into the spirometer for as long as you can." C) "Take a deep breath and then blow short, forceful breaths into the spirometer." D) "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."
Ans: "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." Feedback: The patient should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath
The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis? A) Asthma B) Pneumonia C) Lung cancer D) COPD
Ans: COPD Feedback: Breathing retraining is especially indicated in patients with COPD and dyspnea.
Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment? A) Chest auscultation B) Pulmonary function testing C) Chest percussion D) Thoracic palpation
Ans: Chest auscultation Feedback: Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity? A) Bradycardia and frontal headache B) Dyspnea and substernal pain C) Peripheral cyanosis and restlessness D) Hypotension and tachycardia
Ans: Dyspnea and substernal pain Feedback: Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty.
The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patient's discharge teaching? A) How to count her respirations accurately B) How to collect serial sputum samples C) How to independently wean herself from treatment D) How to perform diaphragmatic breathing
Ans: How to perform diaphragmatic breathing Feedback: Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer.
A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? A) Determine whether the patient can now perform forced expiratory technique (FET). B) Percuss the patient's lungs and thorax. C) Measure the patient's oxygen saturation. D) Have the patient perform incentive spirometry.
Ans: Measure the patient's oxygen saturation. Feedback: The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation.
The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? A) Pulmonary function studies B) Exercise tolerance tests C) Arterial blood gas values D) Chest x-ray
Ans: Pulmonary function studies Feedback: Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the patient who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities.
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? A) Non-rebreather air mask B) Tracheostomy collar C) Venturi mask D) Face tent
Ans: Venturi mask Feedback: The Venturi mask provides the most accurate method of oxygen delivery.