Concepts Unit 5

The nurse is providing education for a client on how to avoid contracting influenza and secondary bacterial infection. Which of the following measures should be included in the teaching (Select all) 1- Good hand washing 2 - Avoiding sharing of eating or drinking utensils 3 - Influenza vaccination 4 - Increased intake of vitamin B 5 - Avoiding crows during flu season 6 - Prophylactic antibiotics

1- Good hand washing 2 - Avoiding sharing of eating or drinking utensils 3 - Influenza vaccination 5 - Avoiding crows during flu season

The nurse caring for a diabetic client with chronic renal failure classifies that client's hypertension as 1 - Primary 2 - Secondary 3- Malignant 4 - Genetic

2 - Secondary

The nurse admits a client with the medical diagnosis of pneumonia. Which of the following will the LPN/LVN perform 1 - The head-to-toe assessment of the client 2 - An admission assessment 3 - A focused assessment at the end of the shift 4 - A complete physical examination

3 - A focused assessment at the end of the shift

A nurse in a provider's office is collecting data from a client who is states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? 1 - Pericardial friction rub 2 - Weight gain 3 - Night sweats 4 - Cyanosis of the fingertips

3 - Night sweats Rational 1 - A pericardial friction rub is a clinical manifestation of rheumatic carditis. 2 - Anorexia and weight loss are clinical manifestations of tuberculosis. 3 - Night sweats and fevers are clinical manifestations of tuberculosis. 4 - Cyanosis of the fingertips is a clinical manifestation of Raynaud's disease.

The nurse assesses which of the following clients as being at greatest risk for hypertension 1 - The female adolescent African-American 2 - The Caucasian middle-aged adult who smokes 3 - The Caucasian woman with central obesity who consumes 2-3 drinks per day 4 - The African-American women who enjoys tradition cultural foods and is overweight

4 - The African-American women who enjoys tradition cultural foods and is overweight

The nurse receives a report from the nursing assistant for vital sings from a 43-year old client and reports the abnormal measurement to the physician. The following measurements are normal for the 43-year old client Select all 1- Temperature of 96.8° F oral 2 - Pulse rate of 104 3 - Temperature fo 37°C oral 4 - Blood pressure of 108/50 5 - Respirations of 17/minute

3 - Temperature fo 37°C oral 5 - Respirations of 17/minute

A nurse should recognize that using pseudoephedrine to treat allergic rhinitis requires cautious use with clients who have which of the following conditions? 1 - Peptic ulcer disease 2 - A seizure disorder 3 - Anemia 4 - Coronary artery disease

4 - Coronary artery disease Rational 1 - Peptic ulcer disease is not a contraindication for taking pseudoephedrine. Clients who have hyperthyroidism or prostatic hypertrophy, however, should not take the drug. 2 - A seizure disorder is not a contraindication for taking pseudoephedrine. Clients who have hyperthyroidism or prostatic hypertrophy, however, should not take the drug. 3 - Anemia is not a contraindication for taking pseudoephedrine. Clients who have hyperthyroidism or prostatic hypertrophy, however, should not take the drug. 4 - Because pseudoephedrine, an oral sympathomimetic, can cause systemic vasoconstriction, it requires cautious use with clients who have severe hypertension or coronary artery disease.

A nurse is teaching a client about montelukast. Which of the following instructions should the nurse include? 1 - Use a spacer to improve inhalation 2 - Take the drug at the onset of bronchospasm 3 - Rinse mouth to prevent an oral fungal infection 4 - Take the drug once a day in the evening

4 - Take the drug once a day in the evening Rational 1 - Clients should take montelukast, a leukotriene modifier, orally. 2 - Montelukast, a leukotriene modifier, manages asthma prophylactically. 3 - Oral candidiasis can occur with inhaled glucocorticoids. However, it is not likely with montelukast, a leukotriene modifier. 4 - Montelukast, a leukotriene modifier, is most effective when taken once per day in the evening.

The nurse assesses the infants' respirations as normal when which of the following is noted 1 - intercostal retractions 2 - substernal retractions 3 - use of accessory muscles when breathing 4 - abdominal breathing

4 - abdominal breathing

A nurse is teaching a client who is taking prednisone for chronic asthma. Which of the following instructions should the nurse include? 1 - "Avoid taking non-steroidal anti-inflammatory drugs." 2 - "Rinse your mouth after taking the medication to prevent a yeast infection." 3 - "Stop taking the medication if you become nauseous." 4 - "Change positions slowly when standing up."

1 - "Avoid taking non-steroidal anti-inflammatory drugs." Rational 1 - Gastric protective measures are essential for clients who are taking oral glucocorticoids. Anti-inflammatory drugs can cause GI bleeding, so clients should not take them concurrently with prednisone. 2 - Inhaled, not oral, glucocorticoids can cause oral candidiasis. 3 - To prevent acute adrenal insufficiency, clients should not stop taking the drug abruptly. Taking the drug with food can help minimize GI effects. 4 - Prednisone, an oral glucocorticoid, does not cause postural hypotension. It can, however, cause hyperglycemia.

A nurse on a medical unit is assisting with the care of a client who has possible closed pneumothorax and significant bruising of the left chest of following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should hear which of the following findings when auscultation the client's lung sounds? 1 - Absence of breath sounds 2 - Expiratory wheezing 3 - Inspiratory stridor 4 - Rhonchi

1 - Absence of breath sounds Rational 1 - A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side. 2 - A client who has asthma experiences an expiratory wheezing during an acute asthma attack. 3 - A client who has an airway obstruction experiences inspiratory stridor, which is a loud crowing-like sound often heard without a stethoscope. 4 - A client who has thick sputum production or obstruction from a foreign body has rhonchi, which are dry, low-pitched, snore-like noises produced in the throat.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. The nurse collects additional data from the client. Which of the following findings is an indication of pulmonary embolism? 1 - Sudden onset of dyspnea 2 - Tracheal deviation 3 - Bradycardia 4 - Difficulty swallowing

1 - Sudden onset of dyspnea Rational 1 - Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs. 2 - Tracheal deviation is an indication of tension pneumothorax and is fatal if not promptly treated. 3 - Tachycardia is a clinical manifestation of pulmonary embolism. 4 - Difficulty swallowing is an indication of many conditions, including oral cancer.

A nurse is teaching a client who has a prescription for albuterol via inhaler and fluticasone/salmeterol via inhaler for asthma management. For which of the following reasons should the nurse instruct the client to use the albuterol inhaler before using the fluticasone inhaler? 1 - Albuterol will increase the absorption of fluticasone 2 - Albuterol will decrease inflammation 3 - Albuterol will reduce a nasal secretions 4 - Fluticasone will reduce the adverse effects of albuterol

1 - Albuterol will increase the absorption of fluticasone Rational 1 - Albuterol, an inhaled, short-acting beta2 agonist, causes bronchodilation, which will increase the absorption of fluticasone, an inhaled glucocorticoid. 2 - Fluticasone, an inhaled glucocorticoid, will reduce inflammation. Albuterol relaxes the smooth muscles of the airways. 3 - Although albuterol, an inhaled, short-acting beta2​ agonist, can reduce nasal secretions, this is not the reason it should be used first. 4 - Fluticasone, an inhaled glucocorticoid, will not reduce the adverse effects of albuterol, which are typically minimal but can include cardiac stimulation and tremors, especially with systemic administration.

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? 1 - Dry cough 2 - Rhinitis 3 - Sore throat 4 - Swollen lymph nodes

1 - Dry cough Rational 1 - The client who has a dry cough has a clinical manifestation found in the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis. 2 - The client who has rhinitis is not manifesting findings of inhalation anthrax; however, rhinitis is typically seen with colds and influenza. 3 - The client who has a sore throat is not manifesting findings of inhalation anthrax; however, a sore throat is typically seen with colds and influenza. 4 - Swollen lymph nodes with a swollen edematous lesion can be a clinical manifestation of cutaneous anthrax.

A nurse is assisting with the plan of care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? 1 - Eat high-calorie foods first 2 - Increase intake of water at meal time 3 - Perform active range-of-motion exercise before meals 4 - Keep saltine crackers nearby fro snacking

1 - Eat high-calorie foods first Rational 1 - The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first. 2 - Although it is important for a client who has COPD to maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the client should limit intake of water at meal times to reduce the feeling of early satiety. 3 - The client should rest before meals to decrease dyspnea while eating. 4 - Although the client should keep foods on hand for snacking, she should avoid dry and salty foods, which can place her at risk for aspiration and make her mouth dry.

A nurse is preparing to administer phenylephrine to a client. The nurse should identify that that which of the following manifestations is an adverse effect of this drug? 1 - Headache 2 - Sleepiness 3 - Hypotension 4 - Constipation

1 - Headache Rational 1 - Oral sympathomimetics stimulate the adrenergic receptors, causing blood vessel constriction, which can cause nervousness, headache, blurred vision, and tremors. 2 - The nurse should recognize that phenylephrine has the potential adverse effect of insomnia. 3 - The nurse should recognize that hypertension is an adverse effect of phenylephrine. 4 - The nurse should recognize that nausea, vomiting, and epigastric pain are the gastrointestinal adverse effects of this drug.

For which of the following reasons should a nurse instruct a client to avoid taking guaifenesin with combination over-the-counter cold products? 1 - Over-the-counter cold products can also contain guaifenesin 2 - Blood glucose levels are increased 3 - Rebound congestion is likely 4 - Drug tolerance is likely

1 - Over-the-counter cold products can also contain guaifenesin Rational 1 - Many combination over-the-counter cold products contain guaifenesin. A client taking both might be taking excessive amounts of the drug. Combination products also contain multiple drugs to treat different manifestations, some of which the client might not have. All drugs have potential adverse effects, so the client should use only those drugs required to treat existing symptoms and only in the recommended amounts. 2 - Guaifenesin and over-the-counter cold products do not affect blood glucose levels. Extended therapy with oral glucocorticoids can increase the risk of hyperglycemia (increased blood glucose levels). 3 - Rebound congestion, a recurrent nasal stuffiness that develops from the overuse of decongestant sprays, does not occur due to the concurrent use of combination cold remedies and guaifenesin. 4- Drug tolerance, a reduced physiological response to a drug with repeated use over time, does not occur due to the concurrent use of combination cold remedies and guaifenesin.

The nurse receives a client from the Angiography Department and prioritize care to include which of the following? Select all 1 - Place the client supine for several hours 2 - Check the groin for bleeding or hematoma 3 - Elevate the foot of the bed or place pillows under the leg 4 - Apply heat to the calf of the leg 5 - Place a sandbag on the femoral site

1 - Place the client supine for several hours 2 - Check the groin for bleeding or hematoma 5 - Place a sandbag on the femoral site

A nurse is monitoring plasma drug levels in a client who is taking theophylline. Which of the following findings should the nurse expect to see if the client's drug level indicates toxicity? 1 - Seizures 2 - Constipation 3 - Normal sinus rhythm 4 - Somnolence

1 - Seizures Rational 1 - Seizures are likely when plasma drug levels of theophylline, a methylxanthine, are higher than 30 mcg/mL, which indicates toxicity. 2 - Plasma drug levels of theophylline, a methylxanthine, that exceed the therapeutic level of 5 to 15 mcg/mL are more likely to cause diarrhea than constipation. 3 - Plasma drug levels of theophylline, a methylxanthine, that exceed the therapeutic level of 5 to 15 mcg/mL are likely to cause severe dysrhythmias. 4 - Plasma drug levels of theophylline, a methylxanthine, that exceed the therapeutic level of 5 to 15 mcg/mL are likely to cause restlessness and insomnia.

The nurse admits a client with a diagnosis of pneumonia with moderate respiratory distress requiring oxygen by nasal cannula. What diagnostic test does the nurse anticipate will be ordered to confirm the cause of the infection 1 - Sputum culture 2 - ELISA 3 - Biopsy 4 - CBC with differential

1 - Sputum culture

For which of the following reasons should a client attach a spacer to a metered-dose inhaler? 1 - To increase the amount of drug delivered to the lungs 2 - To increase the amount of drug delivered to the oropharynx 3 - To increase the amount of drug delivered on exhalation 4 - To increase the speed of drug delivery into the mouth

1 - To increase the amount of drug delivered to the lungs Rational 1 - A spacer increases the amount of drug that reaches the lungs. 2 - A spacer reduces the amount of drug that reaches the mouth and oropharynx. 3 - A spacer ensures that the drug enters the oropharynx at the beginning of inhalation. 4 - A spacer slows the delivery of the drug into the mouth.

A nurse is reinforcing teaching with a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of minimum inhalation? 1 - Total lung capacity 2 - Vital lung capacity 3 - Functional residual capacity 4 - Residual volume

1 - Total lung capacity Rational 1 - Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation. 2 - Vital lung capacity measures the amount of air the client can exhale after maximum inhalation. 3 - Functional residual capacity measures the amount of air in the lungs after normal expiration. 4 - Residual volume measures the amount of air in the lungs after forced expiration.

The nurse identifies factors that can cause errors in blood pressure measurement that yield higher results such as select all 1 - Use of an electronic blood pressure device 2 - Use of an aneroid sphygmomanometer 3 - Use of a Doppler ultrasound stethoscope 4 - A blood pressure cuff that is too small for the diameter of the client's arm 5 - A blood pressure cuff that is too long

1 - Use of an electronic blood pressure device 4 - A blood pressure cuff that is too small for the diameter of the client's arm

The nurse conducts a focused assessment fo a client's peripheral vascular system including which of the following Select all 1 - Vital signs 2 - Perfusion 3 - Capillary refill time 4 - Skin color of extremities 5 - Skin turgor

1 - Vital signs 2 - Perfusion 3 - Capillary refill time 4 - Skin color of extremities

A nurse is teaching a client about the adverse effects of pseudoephedrine. Which of the following should the nurse include? (Select all) 1 - Restlessness 2 - Bradycardia 3 - Insomnia 4 - Muscle pain 5 - Anxiety

1, 3 & 5 Rational Restlessness is correct. Restlessness is an adverse effect of pseudoephedrine, an oral sympathomimetic. Bradycardia is incorrect. Pseudoephedrine is more likely to cause tachycardia, not bradycardia. Insomnia is correct. Insomnia is an adverse effect of pseudoephedrine. Muscle pain is incorrect. Muscle pain is not an adverse effect of pseudoephedrine. The drug is more likely to cause numbness of the extremities. Anxiety is correct. Anxiety is an adverse effect of pseudoephedrine.

An 87-year-old client is brought to the emergency room after being rescued from a house fire. Which of the following assessment findings would be of greatest concern to the nurse? 1.Rapid, irregular respiration of 32 breaths/min 2.Heart rate of 124 beats per minute 3.Partial and full thickness burns to the feet and legs 4.Dry, nonproductive cough

1.Rapid, irregular respiration of 32 breaths/min Airway and breathing are always the first priority; elevated heart rate would be the second priority; a dry nonproductive cough is not significant unless it is causing respiratory difficulty. Burns would be treated as the third priority.

A nurse is teaching a client about ipratropium. The nurse should include the this drug has which of the following adverse effects (Select all) 1 - Muscle tremors 2 - Urinary retention 3 - Dry mouth 4 - Insomnia 5 - Tachycardia

2 & 3 Rational Muscle tremors is incorrect. Muscle tremors can occur with beta2 agonists, not with inhaled anticholinergics such as ipratropium. Urinary retention is correct. Urinary retention can occur with ipratropium, an inhaled anticholinergic. Dry mouth is correct. Ipratropium can dry oral secretions. Insomnia is incorrect. Methylxanthines, not inhaled anticholinergics such as ipratropium, can cause insomnia. Tachycardia is incorrect. Tachycardia can occur with beta2 agonists, not with inhaled anticholinergics such as ipratropium.

A nurse is assisting with the development of a teaching plan about how to prevent an acute asthma attack for a young adult client. Which of the following points should the nurse plan to discuss first? 1 - Talk about how to eliminate environmental triggers that precipitate attack. 2 - Determine the client's perception of the disease process and what might have triggered the current attack 3 - Discuss with the client about the client's medication regimen 4 - Review the manifestations of respiratory infections

2 - Determine the client's perception of the disease process and what might have triggered the current attack Rational 1 - Although it is important for the nurse to discuss how to eliminate environmental triggers that precipitate asthma attacks, there is another point the nurse should discuss first. 2 - The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client's current knowledge. 3 - Although it is important for the nurse to discuss the client's medication regimen to ensure understanding of how to use each medication, there is another point the nurse should discuss first. 4 - Although it is important for the nurse to review manifestations of respiratory infections with the client, there is another point the nurse should discuss first.

A nurse is teaching an adult client about diphenhydramine. The nurse should inform the client to expect which of the following adverse effects while takin this drug? 1 - Muscle tremors 2 - Drowsiness 3 - Excitation 4 - Insomnia

2 - Drowsiness Rational 1 - Diphenhydramine, a first-generation antihistamine, does not cause muscle tremors. 2 - The most common adverse effect of diphenhydramine, a first-generation antihistamine, is drowsiness. 3 - Diphenhydramine, a first-generation antihistamine, can cause uncommon paradoxical effects in children, such as excitation. 4 - Diphenhydramine, a first-generation antihistamine, does not cause insomnia.

Legal restrictions apply to the purchase of pseudoephedrine because of which of the following risks? 1 - Respiratory depression 2 - Drug abuse 3 - Drug tolerance 4 - Rebounding congestion

2 - Drug abuse Rational 1 - Pseudoephedrine is more likely to cause generalized stimulation, not respiratory depression. 2 - Because it is possible to alter pseudoephedrine and epinephrine into methamphetamine, a commonly abused drug, the law restricts the drugs' purchase. 3 - The legal restriction of pseudoephedrine is unrelated to drug tolerance, which is a reduced physiological response to a drug with repeated use over time. 4 - The legal restriction of pseudoephedrine is unrelated to rebound congestion, which is a recurrent nasal stuffiness that develops from the overuse of decongestant sprays.

A nurse is reinforcing teaching about pursed-lip breathing for a client who has chronic obstructive pulmonary disease and emphysema. The nurse should explain that this breathing technique does which of the following? 1 - Increases oxygen intake 2 - Keeps the airways open on exhalation 3 - Uses the intercostal muscles 4 - Strengthens the diaphragm

2 - Keeps the airways open on exhalation Rational 1 - The client who uses pursed-lip breathing prolongs exhalation, rather than increasing oxygen intake on inhalation. Increase oxygen cautiously because the client depends on low oxygen to stimulate breathing. 2 - The client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the client's pace of breathing and keeps the airway open on exhalation, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently. 3 - The client who uses pursed-lip breathing breathes in through the nares and out through pursed lips, rather than concentrating on using chest-wall muscles. 4 - The client who uses pursed-lip breathing breathes in through the nares and out through pursed lips, rather than concentrating on using the diaphragm.

A nurse on a medical unit is assisting with the care of a client who aspirated gastric content prior to admission. The provider prescribed 100% oxygen by nonrebreather mask after the client reported sever dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS) 1 - Tympanic temperature 38° C (100.4° F) 2 - PaO2 50 mm Hg 3 - Rhonchi 4 - Hypopnea

2 - PaO2 50 mm Hg Rational 1 - Although this client's temperature is not within the expected reference range, it is not a clinical manifestation of ARDS. 2 - The client who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS. 3 - The client who has ARDS will have clear breath sounds because edema occurs in the interstitial spaces and not in the airway. 4 - The client who has ARDS will manifest hyperpnea, which is an increased rate and depth of breathing, and indicates the presence of an increase in the work of breathing.

A nurse should identify that dextromethorphan can have which of the following effects when combined with morphine? 1 - Reduced antitussive effect of dextromethorphan 2 - Potentiation of depression of CNS actions 3 - Increased renal reabsorption of the dextromethorphan 4 - Delayed analgesic effect of the opioid

2 - Potentiation of depression of CNS actions Rational 1 - Opioids, such as morphine, do not reduce the antitussive effect of dextromethorphan. 2 - Combining dextromethorphan with an opioid, such as morphine, increases the risk for decreased respirations and other depressed CNS responses. 3 - Renal reabsorption is not altered by the administration of an opioid, such as morphine. 4 - The onset of the analgesic effect of an opioid, such as morphine, is not altered by dextromethorphan administration.

A nurse is teaching a client about the use of an expectorant to treat a cough. The nurse should include that an expectorant has which of the following therapeutic effects? 1 - Suppresses the cough stimulus 2 - Reduces surface tension 3 - Reduces inflammation 4 - Dries mucous membranes

2 - Reduces surface tension Rational 1 - An expectorant does not suppress the cough stimulus. Antitussives, such as dextromethorphan, have this therapeutic effect. 2 - Expectorants act by reducing the surface tension and viscosity of respiratory secretions. This results in thinning thick mucus, making it easier to cough out of the lungs and drain out of the nose and sinuses. 3 - An expectorant does not reduce inflammation. Glucocorticoids have this therapeutic effect. 4 - An expectorant does not dry mucous membranes. Anticholinergic drugs have this therapeutic effect.

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease and pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? 1 - Respiratory alkalosis 2 - Respiratory acidosis 3 - Metabolic alkalosis 4 - Metabolic acidosis

2 - Respiratory acidosis Rational 1 - Respiratory alkalosis occurs when a client exhales too much carbon dioxide. Clients who hyperventilate often experience this complication. 2 - Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs. 3 - Metabolic alkalosis occurs when a client has an excess of bicarbonate. Clients who use bicarbonate of soda as an antacid are at risk for the development of metabolic alkalosis. Excessive vomiting also places a client at risk for development of metabolic alkalosis. 4 - Metabolic acidosis occurs when a client has a decrease in bicarbonate. Clients who have severe diarrhea or kidney failure are at risk for the development of metabolic acidosis.

The nurse is explaining the basic physiology and significance of blood pressure to a client who has been hospitalized for hypertension. Information that is important to discuss includes (Select all) 1- Venous blood pressure in a measure of the force exerted by the blood as it flows through the arteries 2 - The systolic pressure is the pressure of the blood as a result of contraction of the ventricles 3 - The diastolic blood pressure is the lower pressure that is present at all times within the arteries 4 - Blood pressure is static 5 - Blood pressure is recorded as a fraction

2 - The systolic pressure is the pressure of the blood as a result of contraction of the ventricles 3 - The diastolic blood pressure is the lower pressure that is present at all times within the arteries 5 - Blood pressure is recorded as a fraction

The nurse notes that the client's respiration increase and decrease in rate and depth with periods of apnea and documents 1 - Kussmaul repsirations 2 - Tachypnea 3 - Cheyne-Stokes respirations 4 - Eupnea

3 - Cheyne-Stokes respirations Cheyne-Stokes respirations alternate rate and depth. This type of breathing is frequently seen prior to death. Kussmaul breathing is hyperventilation associated with respiratory acidosis, tachypnea is a rapid breathing rate, and eupnea is normal respiration.

A nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. The nurse should instruct the client that which of the following is the purpose of these treatments? 1 - To encourage deep breaths 2 - To mobilize secretions in the airways 3 - To dilate the bronchioles 4 - To stimulate the cough reflex

2 - To mobilize secretions in the airways Rational 1 - Chest therapy does not encourage deep breaths. However, once airway secretions are mobilized and expectorated, the client might be able to breathe deeper. 2 - The purpose of chest physiotherapy is to loosen the client's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity. 3 - Chest physiotherapy does not dilate the bronchioles; however, aerosol bronchodilators are often administered to the client to facilitate mobilizing secretions from larger airways. 4 - Chest physiotherapy does not stimulate the cough reflex; however, the mobilization of secretions can increase the client's ability to cough up secretions.

A nurse is teaching a client about ipratropium. Which of the following instructions should the nurse include? 1 - Do not drink anything for 30 min after using the drug 2 - Wait 5 min between using the drug and another inhaled drug 3 - This drug is used to think respiratory secretions 4 - Check pulse rate after inhaling the drug

2 - Wait 5 min between using the drug and another inhaled drug Rational 1 - Ipratropium, an inhaled anticholinergic, does not require fluid restriction after use. Drinking water after use can help minimize the drug's unpleasant taste. 2 - Ipratropium, an inhaled anticholinergic, requires a 5-min wait between its administration and that of another inhaled drug to allow for bronchodilation to take effect. 3 - Ipratropium reduces nasal secretions but does not thin respiratory secretions. 4 - Ipratropium, an inhaled anticholinergic, does not alter heart rate. Tachycardia can occur with beta2 agonists.

The nurse determines that the client with venous stasis ulcers understood dietary teaching when the client says 1 - "I have increased my carbohydrates intake" 2 - "I have reduced my sugar intake" 3 - "I have increased my protein intake" 4 - "I have deceased my fat intake"

3 - "I have increased my protein intake"

A nurse in a clinic is reinforcing teaching with a client who is to have tuberculin skin test. Which of the following information should the nurse include? 1 - "If the test is positive, it means you have an active case of tuberculosis." 2 - "If the test is positive, you should have another tuberculin skin test in 3 weeks." 3 - "You must return to the clinic to have the test red in 2 to 3 days." 4 - "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."

3 - "You must return to the clinic to have the test red in 2 to 3 days." Rational 1 - A positive test means that the client has been exposed to tubercle bacillus, but it does not mean that the client has an active case of tuberculosis. The client should have a chest x-ray to rule-out active tuberculosis. 2 - The client who has a positive tuberculin skin test should have a chest x-ray to rule-out active tuberculosis. When a client has a positive skin test, subsequent skin tests will always be positive. 3 - The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hr indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hr, another skin test is necessary. 4 - The nurse will inject 0.1 mL of purified protein derivative intradermally to the dorsal aspect of the client's forearm.

A nurse is caring for a client who is having difficulty mobilizing thick respiratory secretions. Which of the following drugs should the nurse expect to administer to the client? 1 - Ipratropium 2 - Beclomethasone 3 - Acetylcysteine 4 - Azelastine

3 - Acetylcysteine Rational 1 - Ipratropium reduces nasal secretions and is used to treat allergic and nonallergic rhinorrhea. 2 - Beclomethasone is a glucocorticoid that reduces inflammation. 3 - Acetylcysteine is a mucolytic that loosens thick respiratory secretions. 4 - Azelastine is an intranasal antihistamine that treats allergic rhinitis.

A nurse is teaching a client about using intranasal glucocorticoids. Which of the following instructions should the nurse give? 1 - Start at a low dose and gradually increase it 2 - Take the drug as needed for nasal congestion 3 - Allow at least 2 weeks for the full therapeutic effect 4 - Use the drug prior to exercise

3 - Allow at least 2 weeks for the full therapeutic effect Rational 1 - Providers prescribe higher doses of intranasal glucocorticoids initially and then reduce them over time. 2 - Clients use intranasal glucocorticoids prophylactically to control allergic rhinitis, not nasal congestion. 3 - It can take 2 or 3 weeks to see the full therapeutic effect of intranasal glucocorticoids. 4 - Intranasal glucocorticoids do not prevent exercise-induced bronchospasm. Better choices for this purpose are inhaled cromolyn sodium and albuterol.

The nurse has completed reinforcing information with a client about the thallium scan they are to undergo tomorrow, and determines the client understood when they tell their spouses the purpose of the test is to detect 1 - Abnormalities in cardiac structure 2 - Any flaws in the pulmonary circulation 3 - Areas of the heart not getting adequate oxygenation 4- Abnormalities in electrical conduction in the heart

3 - Areas of the heart not getting adequate oxygenation

A nurse is preparing to assist a provider to withdraw arterial blood from a client's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? 1 - Hyperventilate the client with 100% oxygen prior to obtaining the specimen 2 - Apply ice to the site after obtaining the specimen 3 - Check the circulation in the client's ulnar artery prior to obtaining the specimen 4 - Release pressure applied to the puncture site 1 min after the needle is withdrawn

3 - Check the circulation in the client's ulnar artery prior to obtaining the specimen Rational 1 - The nurse should not administer oxygen prior to the blood draw, because the test measures the client's blood gases when breathing room air. 2- The nurse should use ice to preserve the arterial blood gas specimen during transport to the laboratory. If the sample is not placed on ice, the pH and PO2 values can be inaccurate. It is not necessary to place ice to the withdrawal site. 3 - The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery. 4 - The nurse should apply pressure to the puncture site for 5 to 10 min after the needle is withdrawn. High pressure of the blood in the arteries places the client at risk for hemorrhage from the withdrawal site.

A nurse is assisting with the care for a client who has a chest tube inserted 12 hr ago. The nurse notes a crackling sensation upon palpation of the skin on the right side of the client's chest. The nurse should notify the charge nurse that the client is demonstrating a clinical manifestation of which of the following complications? 1 - Friction rub 2 - Crackles 3 - Crepitus 4 - Tactile fremitus

3 - Crepitus Rational 1 - A friction rub is a scratching or squeaking sound the nurse can hear when auscultating the client's lungs. This condition occurs due to the pleural surfaces rubbing together. A friction rub is a clinical manifestation of pleurisy. 2 - Crackles, which are sometimes called rales, are wet popping sounds the nurse can hear when auscultating the client's lungs. This condition occurs when there is fluid in the client's airways or alveoli. Crackles are a clinical manifestation of pneumonia. 3 - Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax. 4 - Tactile fremitus is a vibration of the chest wall that the nurse can feel when palpating the client's chest as the client repeats a syllable such as 'nine-nine'. Increased tactile fremitus is a clinical manifestation of pneumonia.

A nurse is teaching a client about the use of beclomethasone to treat asthma. The nurse should explain that the drug has which of the following therapeutic effects? 1 - Thins mucus 2 - Relaxes bronchial smooth muscle 3 - Decreases inflammation 4 - Increases the cough threshold

3 - Decreases inflammation Rational 1 - Mucolytics thin mucus to increase expectoration. 2 - Beta2 agonists and methylxanthines cause bronchodilation by relaxing bronchial smooth muscle. 3 - Beclomethasone, an intranasal glucocorticoid, treats asthma by reducing inflammation. 4 - Opioid antitussives relieve a cough by increasing the cough threshold in the CNS.

A nurse is teaching a client about the use of antihistamines to treat allergic rhinitis. The nurse should explain that these drugs are effective because they perform which of the following actions? 1 - Decreased viscosity of nasal secretions 2 - Block H2 receptors 3 - Prevent histamine from binding to receptors 4 - Reduce nasal congestion

3 - Prevent histamine from binding to receptors Rational 1 - Expectorants, not antihistamines, decrease the viscosity of nasal secretions. 2 - H2 receptor antagonists block H2 receptors to treat peptic ulcer disease 3 - Antihistamines treat allergic rhinitis and reduce swelling by blocking histamine from binding to the receptor sites. 4 - Decongestants, not antihistamines, reduce nasal congestion.

The nurse admits an alert client with a diagnosis of pneumonia and assesses vital signs and oxygen saturations. The client's respiratory rate is 26, and oxygen saturations of 89%. What actions can the nurse take independently to support respiration and reduce hypoxia 1 - Insert an oral airway 2 - Administer a bronchodilator 3 - Raise the had of the bed 4 - Apply oxygen

3 - Raise the had of the bed

A nurse is caring for a client who is taking codeine. The nurse should identify that which of the following assessments is priority to make? 1 - Blood pressure 2 - Apical heart rate 3 - Respirations 4 - Level of consciousness

3 - Respirations Rational 1 - Although it is important to check the client's blood pressure because codeine can cause hypotension, it is not the priority assessment. 2 - Although it is important to check the client's apical heart rate because codeine can slow the heart rate, it is not the priority assessment. 3 - The greatest risk to clients who are taking codeine, an opioid agonist, is severe respiratory depression. Therefore, the respiratory rate is the priority assessment. 4 - Although it is important to check the client's level of consciousness because codeine can cause sedation, it is not the priority assessment.

A nurse is assisting with the plan of care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? 1 - Clamp the chest tube if there is continuous bubbling in the water seal chamber 2 - Keep the chest tube drainage system at the level of the right atrium 3 - Tape all connections between the chest tube and drainage system 4 - Empty the collection chamber and record the amount of drainage every 8 hr

3 - Tape all connections between the chest tube and drainage system Rational 1 - The nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. Additionally, the nurse should avoid clamping the chest tube unless it becomes necessary to replace the drainage unit or locate an air leak. 2 - The nurse should ensure the chest tube drainage system is below the level of the chest at all times to facilitate proper drainage by gravity. 3 - The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting. 4 - The nurse should not empty the collection chamber or change the system unless it is almost full.

The nurse counts the clients pulse rate and anticipates a faster rate in which of the following client's 1 - The sleeping client 2 - The sedated client 3 - The client with a fever 4 - The client with hypothyroidism

3 - The client with a fever

A nurse is teaching a client about the use of a mucolytic to treat a cough. The nurse should include that ta mucolytic has which of the following therapeutic effects? 1 - Suppresses the cough stimulus 2 - Reduced inflammation 3 - Things and loosens mucus 4 - Dries secretions

3 - Things and loosens mucus Rational 1 - A mucolytic does not suppress the cough stimulus. Antitussives, such as dextromethorphan, have this therapeutic effect. 2 - A mucolytic does not reduce inflammation. Glucocorticoids have this therapeutic effect. 3 - Mucolytics make mucus less viscous to increase a cough's productivity. 4 - A mucolytic does not dry secretions. Anticholinergic drugs have this therapeutic effect.

The nurse has been summoned to the room of a client who has been resident of the long term care facility for 6 months is complaining of shortness of breath. The nurse will perform a focused assessment that includes 1 - Assucultation of the hypogastric region 2 - Clients lifestyle 3 - Use of a pulse oximeter 4 - Shape of pupils

3 - Use of a pulse oximeter

The community health nurse is holding a blood pressure chick at a community center. Which of the following measurements indicated Stage 1 hypertension? 1 - 115/76 2 - 136/88 3- 154/90 4 - 162/90

3- 154/90

The nurse is caring for a client admitted or control of unstable angina. The nurse answers the call bell and the client reports severe pain (10 on a 1-10 scale, with 10 being worst) n the left leg. The nurse assesses the left leg and finds it cold, pale and pulseless, with no popliteal, dorsalis pedis, or posterior tibial pulse by palpation or doppler. The nurse's priority intervention is to 1 - Elevated the leg and apply heat 2 - Have the client walk to improve circulation 3- Notify the RN or physician immediately 4 - Administer an analgesic to control pain

3- Notify the RN or physician immediately

A nurse is reinforcing preoperative teaching with a client who is to undergo a pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery." Which of the following statements should the nurse make? 1 - "After the surgeon removes the lung, you will not need to cough." 2 - "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." 3 - "Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain." 4 - "I will show you how to splint your incision while coughing."

4 - "I will show you how to splint your incision while coughing." Rational 1 - The client who had a pneumonectomy must cough to clear secretions from the remaining lung. 2 - The client who had a pneumonectomy must cough to clear secretions from the remaining lung. 3 - Pain medication reduces pain to a tolerable level; however, it does not necessarily keep the client pain-free. Additionally, telling the client not to worry is a barrier to communication and provides false reassurance. 4 - The client who had a pneumonectomy must cough to clear secretions from the remaining lung. The nurse should show the client how to splint her incision to reduce pain when coughing.

A nurse is assisting with discharge teaching for a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? 1 - "Apply warm compresses to the face." 2 - "Take aspirin 650 milligrams by mouth for mild pain." 3 - "Close your mouth when sneezing." 4 - "Lie on your back with your head elevated 30° when resting."

4 - "Lie on your back with your head elevated 30° when resting." Rational 1 - The client should apply cold compresses to his face to decrease swelling 2 - .The client should avoid taking aspirin, because it increases the risk of bleeding by decreasing platelet aggregation. 3 - The client should open his mouth when sneezing to reduce straining on the incisional site. 4 - The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.

The nurse is caring for a client with dyspnea and recognizes that the client is experiencing othopnea when the client demonstrates which of the following? 1 - Blood pressure decrease when standing upright 2 - Blood gases indicate respiratory acidosis 3 - Periods of apnea 4 - Difficulty breathing unless sitting upright

4 - Difficulty breathing unless sitting upright Orthopnea is needing to sit upright to facilitate breathing. Changes in blood pressure on standing are orthostatic hypotension. A breathing pattern related to respiratory acidosis is Kussmaul breathing; breathing with periods of apnea is called Cheyne-Stokes breathing.

The nurse working in a long-term care facility is talking with a client diagnosed with congestive heart failure, diabetes, hypertension, and chronic renal failure, and notes mild edema of the ankles while the client is sitting in the chair. Breath sounds are clear and equal, with good chest excursion, and the client denies any feelings of shortness of breath. The nurse reviews he medical record and sees no significant change in the client's daily weights over the last week. What are the nurse's priority interventions for this client (select all) 1-Call the doctor for an order to increase the client's diuretic 2 - Review the client's diet to determine sodium intake 3 - Review the client's BUN and creatine 4 - Encourage the client to elevate her feet when sitting 5 - Apply anti-embolism stocking

4 - Encourage the client to elevate her feet when sitting 5 - Apply anti-embolism stocking

A nurse is teaching a client who has a prescription for zileuton. Which of the following instructions should the nurse include? 1 - Check apical pulse before taking the drug 2 - Take the drug only as needed before exercising 3 - Rinse mouth after using the drug 4 - Have laboratory tests performed at regular intervals

4 - Have laboratory tests performed at regular intervals Rational 1 - Zileuton, a leukotriene modifier, should not affect heart rate, but it can cause chest pain. 2 - Clients should take zileuton, a leukotriene modifier, on a regular schedule throughout the day to decrease bronchoconstriction and inflammation. 3 - Clients should take zileuton, a leukotriene modifier, orally. It is not necessary to rinse the mouth after taking the drug, which is a precaution necessary with inhaled glucocorticoids. 4 - Zileuton, a leukotriene modifier, can cause liver injury. The nurse should monitor liver function once a month for 3 months, then every 2 to 3 months during the first year of treatment.

The nurse helps the client to optimize oxygenation by placing the client in what position 1 - Trendelebnurg 2 - Low Fowlers 3- Sims 4 - High Fowlers

4 - High Fowlers Both low and high Fowler's promote lung expansion, although high Fowler's is most effective. In the Trendelenburg position, the head is lower than the feet; this promotes lung drainage, not lung expansion. Sims' position is side lying. It is not a good position for bilateral lung expansion.

A nurse is teaching a client who is beginning flutixasone propionate/salmeterol therapy. Which of the following instructions should the nurse include? 1 - Take the drug as needed for acute asthma 2 - Following a low-sodium diet 3 - Use an alternate-day dosing schedule 4 - Increase weight-bearing activity

4 - Increase weight-bearing activity Rational 1 - Clients should use fluticasone propionate/salmeterol on a regular schedule to treat chronic asthma. 2 - It is not necessary to follow a low-sodium diet when taking fluticasone propionate/salmeterol, an inhaled glucocorticoid. 3 - Clients may take prednisone, an oral glucocorticoid, on an alternate-day dosing schedule to reduce adrenal suppression. 4 - Weight-bearing activity can help minimize bone loss, which is an adverse effect of fluticasone propionate/salmeterol, an inhaled glucocorticoid.

A nurse is teaching a client about albuterol. The nurse should instruct the client to monitor for and report which of the following as an adverse effect of this drug? 1 - Fever 2 - Bruising 3 - Polyuria 4 - Palpitations

4 - Palpitations Rational 1 - Fever is not an adverse effect of albuterol, a beta2 agonist. However, the drug can cause headache. 2 - Bruising is not an adverse effect of albuterol, a beta2 agonist. However, the drug can cause muscle cramps. 3 - Polyuria is not an adverse effect of albuterol, a beta2 agonist. However, the drug can cause nausea and vomiting. 4 - Although not common at therapeutic doses, beta2 agonists can cause cardiac stimulation, resulting in chest pain, palpitations, hypertension, and arrhythmias.

A nurse is teaching a client about the use of cromolyn sodium to prevent bronchospasm. The nurse should explain that the drug has which of the following therapeutic effects. 1 - Increased leukocyte activity 2 - Blocks muscarinic receptos 3 - Causes bronchodilation 4 - Reduces inflammation

4 - Reduces inflammation Rational 1 - Cromolyn sodium decreases activity of leukocytes and eosinophils. 2 - Anticholinergic drugs block muscarinic receptors to cause bronchial dilation. 3 - Cromolyn sodium, a mast cell stabilizer, does not cause bronchodilation. Beta2 agonists achieve this therapeutic effect. 4 - Cromolyn sodium, a mast cell stabilizer, reduces inflammation by inhibiting the inflammatory response.

A nurse is assisting the provider to prepare a client for a thoracentesis. The nurse should instruct the client that which of the following positions will be used for this procedure? 1 - Lying flat on the affected side 2 - Prone with the arms raised over the head 3 - Supine with the had of the bed elevated 4 - Sitting while leaning forward over the bedside table

4 - Sitting while leaning forward over the bedside table Rational 1 - When preparing a client for a thoracentesis, the nurse should not position the client lying flat on the affected side, because it does not allow access for draining the accumulated fluid and air. 2 - When preparing a client for a thoracentesis, the nurse should not place the client prone, because it does not position the client for appropriate access for draining the accumulated fluid and air. 3 - When preparing a client for a thoracentesis, the nurse should not place the client supine, because it does not position the client for appropriate access for draining accumulated fluid and air. 4 - When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the client's ribs and allows for aspiration of accumulated fluid and air.

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicated that the nurse should suction the client's airway secretions? 1 - The client is unable to speak 2 - The client's airway secretions were last suctioned 2 hr ago 3 - The client coughs and expectorates a large mucous plug 4 - The client has coarse crackles in the lung fields

4 - The client has coarse crackles in the lung fields Rational 1 - The client who has a tracheostomy with an inflated cuff in place is unable to speak. 2 - The nurse should assess the need for suctioning every 2 hr and then suction as necessary. 3 - The nurse should check the client's airway after coughing and only suction the client's secretions, if the client is able to cough and expectorate secretions. 4 - The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.

A nurse is assigned to are for a client with a closed head injury who must be carefully monitored by the nurse because they could stop breathing or have inadequate respiratory effort due to 1- The client's reduced level of consciousness might cause the tongue to clock the airway 2 - The accident that injured the head might also have injured the chest 3 - Closed head injuries mainly occur in very young children whose airways are very narrow and easily occluded. 4 - The respiratory control mechanism is in the brain, and increased cerebral edema could damage the function

4 - The respiratory control mechanism is in the brain, and increased cerebral edema could damage the function

A nurse is collecting data from a client who has a prescription for cisplatin IV to treat lung cancer. Which of the following client findings is an adverse effect of this medication? 1 - Hallucinations 2 - Pruritus 3 - Hand and foot syndrome 4 - Tinnitus

4 - Tinnitus Rational 1 - Hallucinations are an adverse effect of asparaginase, which is an antineoplastic medication used to treat acute lymphocytic leukemia. 2 - Pruritus is an adverse effect of methotrexate, which is used to treat cancer and rheumatoid arthritis. 3 - Hand and foot syndrome is an adverse effect of capecitabine, an antineoplastic medication used to treat breast and colorectal cancer. 4 - An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.