DNI MS 1: Exam 5

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? - A 74-year-old with a chronic cough and thick, tenacious secretions - A 68-year-old who has dependent edema and clubbed fingers - A 46-year-old with a 30pack-year history of smoking - A 52-year-old in a tripod position using accessory muscles to breathe

- A 52-year-old in a tripod position using accessory muscles to breathe The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure. The other clients are not in acute distress.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? - A 73-year-old man with type 2 diabetes mellitus - A 55-year-old woman who is 50 pounds overweight - A 26-year-old woman who is 8 months pregnant - A 42-year-old man with gastroesophageal reflux disease

- A 55-year-old woman who is 50 pounds overweight The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

The nurse has received a change-of-shift report about the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? - A patient with loud expiratory wheezes - A patient with jugular vein distention and peripheral edema - A patient with a respiratory rate of 38 - A patient who has a cough productive of thick, green mucus

- A patient with a respiratory rate of 38 A respiratory rate of 38 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 tachypneic patient.

After the nurse has received change-of-shift report, which of these patients should be assessed first? - A patient with pneumonia who has crackles in the right lung base - A patient with possible lung cancer who has just returned after bronchoscopy - A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity - A patient with hemoptysis and a 16-mm induration with tuberculin skin testing

- A patient with possible lung cancer who has just returned after bronchoscopy Since the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway maintenance. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.

A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? - Albumin: 5.1 g/dL - Alanine aminotransferase (ALT): 180 U/L - White blood cell (WBC) count: 12,500/mm3 - Red blood cell (RBC) count: 5.2/mm3

- Alanine aminotransferase (ALT): 180 U/L INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.

Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? - Give ciprofloxacin (Cipro) 400 mg IV. - Obtain blood cultures from two sites. - Administer aspirin suppository. - Send to radiology for chest x-ray.

- Obtain blood cultures from two sites. Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last.

Which of these nursing actions included in the care plan for a patient with chronic obstructive pulmonary disease (COPD) should the nurse delegate to experienced nursing assistive personnel (NAP)? - Adjust oxygen to keep saturation in prescribed parameters. - Obtain oxygen saturation using pulse oximetry. - Monitor for increased oxygen need with exercise. - Teach the patient about safe use of oxygen at home.

- Obtain oxygen saturation using pulse oximetry. NAP can obtain oxygen saturation (after being trained and evaluated in the skill). The other actions require more education scope of practice and should be done by LPN/LVNs or by RNs.

A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain? - Occupation and hobbies - Average daily fluid intake - Height and weight - Neck circumference

- Occupation and hobbies Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a clients occupation and hobbies. Although it will be important for the nurse to assess the clients fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the clients neck circumference will not be an important part of a respiratory assessment.

Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? - BP is 150/90 mm Hg. - Respiratory rate is 24 when lying flat. - Pain level is 5/10 with a deep breath. - Oxygen saturation is 89%

- Oxygen saturation is 89% Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? - Hemoglobin: 14.2 g/dL - Platelet count: 82,000/L - White blood cell count: 8.7/mm3 - Red blood cell count: 4.8/mm3

- Platelet count: 82,000/L This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

The nurse has just received arterial blood gas (ABG) results on four patients. Which result is most important to report rapidly to the health care provider? - pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% - pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% - pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% - pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%

- pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.

A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about - the complaint of chest wall pain. - a large bruised area on the chest. - paradoxic chest movement. - a heart rate of 110 beats/minute.

- paradoxic chest movement. Paradoxic 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 observation that would require an immediate nursing intervention for a client recently returned to the unit following partial laryngectomy is - blood-tinged sputum. - difficulty swallowing. - pulsating tracheostomy tube. - copious respiratory secretions.

- pulsating tracheostomy tube. A pulsating tracheostomy tube may indicate that the tip of the tube is resting on the innominate artery and may cause injury to the artery, resulting in hemorrhage.

A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the - need for annual repeat TB skin testing. - bacille Calmette-Gurin (BCG) vaccine. - standard four-drug therapy for TB. - use and side effects of isoniazid (INH).

- use and side effects of isoniazid (INH). The nurse is considered to have a latent TB infection and should 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 individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection.

When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops - orange-colored sputum. - thickening of the fingernails - changes in hearing. - yellow-tinged skin.

- yellow-tinged skin. Noninfectious hepatitis is a toxic effect of isoniazid (INH), 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. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

Solumedrol 1.5 mg/kg is ordered for a child weighing 74.8 lb. Solumedrol is available as 125 mg / 2mL. How many mL must the nurse administer? - 0.75 - 1.1 - 1.7 - 0.82

- 0.82

A nurse admits a client from the emergency department. Client data are listed below: History: 70 years of age History of diabetes On insulin twice a day Reports new-onset dyspnea and productive cough Physical Assessment: Crackles and rhonchi heard throughout the lungs Dullness to percussion LLL Afebrile Oriented to person only Laboratory Values: WBC: 5,200/mm3 PaO2 on room air 65 mm Hg - Collect a sputum sample for culture. - Start an IV of normal saline at 50 mL/hr. - Administer oxygen at 4 liters per nasal cannula - Begin broad-spectrum antibiotics.

- Administer oxygen at 4 liters per nasal cannula All actions are appropriate for this client who has manifestations of pneumonia. However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? - Ensure informed consent is on the chart. - Administer prescribed anxiolytic medication - Start the preoperative antibiotic infusion. - Reinforce any teaching done previously.

- Ensure informed consent is on the chart. Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease? - Treat workers who inhale dust particles. - Require the use of protective equipment. - Monitor workers for shortness of breath. - Teach about symptoms of lung disease.

- Require the use of protective equipment. 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.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? - I will ask your provider to prescribe you with an antianxiety agent. - Share any thoughts and feelings that cause you to limit social activities. - There are a variety of support groups for people who have COPD. - Friends can be a good support system for clients with chronic disorders.

- Share any thoughts and feelings that cause you to limit social activities. Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy? - Educating the patient about self-care of the tracheostomy - Determining the need for replacement of the tracheostomy tube - Assessing the patients risk for aspiration - Suctioning the tracheostomy when needed

- Suctioning the tracheostomy when needed Suctioning of a stable patient can be delegated to LPN/LVNs. Assessments and patient teaching should be done by the RN.

A lobectomy is scheduled for a patient with stage I nonsmall cell lung cancer. The patient tells the nurse, I would rather have radiation than surgery. Which response by the nurse is most appropriate? - Surgery is the treatment of choice for stage I lung cancer. - Are you afraid that the surgery will be very painful? - Tell me what you know about the various treatments available. - Did you have bad experiences with previous surgeries?

- Tell me what you know about the various treatments available. More assessment of the patients 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. The remaining two answers indicate that the nurse has jumped to conclusions about the patients reasons for not wanting surgery.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? - Skin around the stoma is intact without signs of infection. - The client demonstrates good understanding of stoma care. - The client has joined a book club that meets at the library. - Family members take turns assisting with stoma care.

- The client has joined a book club that meets at the library. The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? - Verify that the client understands all possible complications. - Explain the procedure in detail to the client and the family. - Measure oxygen saturation before and after a 12-minute walk. - Validate that informed consent has been given by the client.

- Validate that informed consent has been given by the client. A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician or nurse practitioner, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? - Community social worker for Meals on Wheels - Visiting Nurses for directly observed therapy - Physical therapy for homebound therapy services - Occupational therapy for job retraining

- Visiting Nurses for directly observed therapy Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate.

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? - When the tube becomes disconnected from the drainage system - When the client experiences pain at the insertion site - When the insertion site becomes red and warm to the touch - When the tube drainage decreases and becomes sanguineous

- When the tube becomes disconnected from the drainage system Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the clients risk for a pneumothorax. Tube drainage should decrease and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the clients risk for a pneumothorax.

The following medications are prescribed by the health care provider for a patient having an acute asthma attack. Which one will the nurse administer first? - methylprednisolone (Solu-Medrol) 60 mg IV - albuterol (Ventolin) 2.5 mg per nebulizer - salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) - triamcinolone (Azmacort) 2 puffs per metered-dose inhaler (MDI)

- albuterol (Ventolin) 2.5 mg per nebulizer 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 recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB - covers the mouth and nose when coughing - washes dishes and personal items after use. - reports daily to the public health department. - demonstrates correct use of a nebulizer.

- covers the mouth and nose when coughing Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurses first action should be to - administer the ordered pain medication. - elevate the head of the bed to 45 to 60 degrees. - offer emotional support and reassurance. - notify the patients health care provider.

- elevate the head of the bed to 45 to 60 degrees. The patient has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started).

The nurse performing a brief physical assessment of an anxious client with asthma would carefully inspect the chest wall primarily to - gain time to calm the client. - observe the client for diaphoresis. - verify bilateral chest expansion. - evaluate the use of intercostal muscles.

- evaluate the use of intercostal muscles. The ongoing assessment of an asthmatic client includes evaluation of the accessory muscles of respiration. The nurse should assess the client frequently, observing the respiratory rate and depth. The breathing pattern is assessed for shortness of breath, pursed-lip breathing, nasal flaring, sternal and intercostal retractions, and a prolonged expiratory phase.

When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about - options for smoking cessation. - erlotinib (Tarceva) therapy to prevent tumor risk. - computed tomography (CT) screening for lung cancer. - reasons for annual sputum cytology testing.

- options for smoking cessation. Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in patients who have lung cancer but not to reduce risk for developing tumors.

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to - document the presence of a large air leak. - notify the surgeon of a possible pneumothorax. - obtain and attach a new collection device. - take no further action with the collection device.

- take no further action with the collection device. Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.

A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if - the patients chest x-ray indicates clear lung fields. - the BP is less than 140/90 mm Hg. - the heart rate is between 60 and 100 beats/minute - the patient reports decreased exertional dyspnea.

- the patient reports decreased exertional dyspnea. Since a major symptom of PPH 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 effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.

Order: Heparin 1400 units q hour IV Standard Solution 25,000 units of Heparin in 250 mL D5W How many mLs/hr will you administer? - 42 - 17 - 14 - 10

- 14

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? - 40-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg - 64-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg - 32-year-old with ABG results: pH 7.50, PaCO2 30 mm Hg, and PaO2 65 mm Hg - 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg

- 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg The pH, PaCO2, and 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. The other patients also should be assessed as quickly as possible, but do not require interventions as quickly as the 20-year-old.

A patient with tachycardia has an order for Brevibloc to be started at 50 mcg/kg/min. The concentration is Brevibloc 5 g in 500ml of D5W. The patient weighs 176 pounds. How many ml/h should the IV pump be programmed for? - 16 - 20 - 24 - 28

- 24

Order: 250ml 5% D/W IV in 2.5 hours. Tubing package reads 15 gtts/ml. How many gtts/min will you adjust the IV? - 35 - 30 - 33 - 25

- 25

The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about - 400 mL of blood in the collection chamber. - complaint of pain with each deep inspiration. - a large air leak in the water-seal chamber. - subcutaneous emphysema at the insertion site.

- 400 mL of blood in the collection chamber. The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax.

Order: Augmentin 12.5mg/kg PO every 12 hours. Child weighs 22 lbs. Mr.Kargar sends a 75 ml bottle of Augmentin labeled 125mg/5ml. How many milliliters will you pour from the bottle? - 5 - 2.5 - 10 - 7.5

- 5

Which of these patients in the respiratory disease clinic should the nurse assess first? - A 34-year-old who has a scratchy throat and a positive rapid strep antigen test - A 23-year-old, complaining of a sore throat, who has a hot potato voice - A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed - A 55-year-old who is receiving radiation for throat cancer and has severe fatigue

- A 23-year-old, complaining of a sore throat, who has a hot potato voice The patients clinical manifestation of a hot potato voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? - A 35-year-old client who has a longer expiratory phase than inspiratory phase - A 48-year-old client with an oxygen saturation level of 92% at rest - A 66-year-old client with a barrel chest and clubbed fingernails - A 27-year-old client with a heart rate of 120 beats/min

- A 27-year-old client with a heart rate of 120 beats/min Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.

The nurse is reviewing the charts for five patients who are scheduled for their yearly physical examinations in October. Which of the following patients will require the inactivated influenza vaccination (select all that apply)? - A 30-year-old patient who takes corticosteroids for rheumatoid arthritis - A 42-year-old patient who has a 15 pack-year smoking history - A 24-year-old patient who has allergies to penicillin and the cephalosporins - A 36-year-old female patient who is pregnant - A 56-year-old patient who is allergic to eggs

- A 30-year-old patient who takes corticosteroids for rheumatoid arthritis - A 36-year-old female patient who is pregnant Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, have chronic medical conditions, or are immunocompromised should receive inactivated vaccine. The corticosteroid use by the 30-year-old increases the risk for infection. Individuals with egg allergies should not receive inactivated flu vaccine because it is made using eggs.

After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first? - A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C) - A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled - A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. - A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes

- A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

The nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? - Review the clients pulmonary function test results. - Consult the provider and request arterial blood gases. - Ask about medications the client is currently taking. - Assess how frequently the client uses a bronchodilator.

- Ask about medications the client is currently taking. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the clients history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.

When the nurse is caring for a patient who has had a total laryngectomy and radical neck dissection during the first 24 hours after surgery, what is the priority nursing action? - Assess breath sounds. - Monitor for bleeding. - Avoid changing the tracheostomy ties. - Clean the inner cannula every 8 hours.

- Assess breath sounds. The most important goals posttracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the breath sounds is the priority action. Maintenance of the tracheostomy ties, cleaning the inner cannula, and checking for bleeding also are appropriate nursing actions but are not of as high a priority.

Unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? - Assess the clients lung sounds. - Assign a different UAP to the client. - Request thicker liquids for meals. - Report the UAP to the manager.

- Assess the clients lung sounds. The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? - Palpate the skin of the upper chest. - Notify the Rapid Response Team. - Oxygenate the client with a bag-valve-mask. - Assess the clients oxygen saturation.

- Assess the clients oxygen saturation. This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? - Ambulate the client in the hallway to assess gait. - Administer prescribed intravenous pain medication. - Assess airway patency, breathing, and circulation. - Assist the client to choose a communication method.

- Assist the client to choose a communication method. The client will not be able to speak after surgery. The nurse should assist the client to choose a communication method that he or she would like to use after surgery. Assessing the clients airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this clients gait should not be impacted by a total laryngectomy and therefore is not a priority.

A patient with newly diagnosed lung cancer tells the nurse, I think I am going to die pretty soon. Which response by the nurse is best? - Do you think that taking an antidepressant medication would be helpful? - Can you tell me what it is that makes you think you will die so soon? - Are you afraid that the treatment for your cancer will not be effective? - Would you like to talk to the hospital chaplain about your feelings?

- Can you tell me what it is that makes you think you will die so soon? The nurses initial response should be to collect more assessment data about the patients statement. The answer beginning Can you tell me what it is is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, Are you afraid implies that the patient thinks that the cancer will be immediately fatal, although the patients statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, I wish I were dead! I cannot do anything for myself anymore. Based on this information, which nursing diagnosis is most appropriate? - Chronic low self-esteem related to increased physical dependence - Deficient knowledge related to lack of education about COPD - Complicated grieving related to expectation of death - Ineffective coping related to unknown outcome of illness

- Chronic low self-esteem related to increased physical dependence The patients statement about not being able to do anything for himself or herself supports this diagnosis. Although deficient knowledge, complicated grieving, and ineffective coping also may be appropriate diagnoses for patients with COPD, the data for this patient do not support these diagnoses.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? - Administer prescribed albuterol nebulizer therapy. - Ask the client to perform deep-breathing exercises. - Place the client in high-Fowlers position. - Contact the provider and prepare for intubation.

- Contact the provider and prepare for intubation. Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, should be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowlers position and asking the client to perform breathing exercises may temporarily improve the clients comfort, these actions will not decrease the underlying problem or improve airway patency.

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? - Assess for drainage from the site. - Reinsert the tube using sterile technique. - Contact the provider and obtain a suture kit. - Cover the insertion site with sterile gauze.

- Cover the insertion site with sterile gauze. Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options.

When assessing the respiratory system of a 78-year-old patient, which finding indicates that the nurse should take immediate action? - The chest appears barrel shaped. - Crackles are heard from the lung bases to the midline. - The patient has a weak cough effort. - Hyperresonance is present across both sides of the chest.

- Crackles are heard from the lung bases to the midline. Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.

A 20-year-old patient with cystic fibrosis (CF) tells the nurse that she is considering having a child. Which initial response by the nurse is best? - Many women with CF do not have difficulty in conceiving children. - Do you need any information to help you with the decision? - Are you aware of the normal lifespan for patients with CF? - You will need to have genetic counseling before making a decision.

- Do you need any information to help you with the decision? The nurses initial response should be to assess the patients knowledge level and need for information. Although the lifespan 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 patients comments. The other responses are accurate, but the nurse should first assess the patients understanding about the issues surrounding pregnancy.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) - Household light bulbs are the fluorescent type. - Electrical cords are in good working order. - Flammable liquids are stored in the garage. - The client does not have pets inside the home. - The client does not allow smoking in the house.

- Electrical cords are in good working order. - Flammable liquids are stored in the garage. - The client does not allow smoking in the house. Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety.

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? - Obtain an oral specimen for culture and sensitivity. - Encourage oral rinsing after fluticasone administration. - Document the finding as a known side effect. - Start the client on a broad-spectrum antibiotic.

- Encourage oral rinsing after fluticasone administration. The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity will not provide information necessary to care for this client.

A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this clients teaching? (Select all that apply.) - Keep snacks like potato chips on hand to nibble on. - Find an activity that you enjoy and will keep your hands busy. - Make a list of reasons you want to stop smoking. - Identify a punishment for yourself in case you backslide. - Drink at least eight glasses of water each day.

- Find an activity that you enjoy and will keep your hands busy. - Make a list of reasons you want to stop smoking. - Drink at least eight glasses of water each day. The nurse should teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least 8 glasses of water each day, and to make a list of reasons for quitting smoking. The nurse should also encourage the client not to be upset if he or she backslides and has a cigarette.

The nurse is obtaining a health history from a 67-year-old patient with a 40 pack-year smoking history, complaints of hoarseness and tightness in the throat, and difficulty swallowing. Which question is most important for the nurse to ask? - Have you had frequent streptococcal throat infections? - Do you use antihistamines for upper airway congestion? - Do you have a family history of head or neck cancer? - How much alcohol do you drink in an average week?

- How much alcohol do you drink in an average week? Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patients 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 patients symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients also will complain of pain and fever.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? - Provide reassurance to the client - Assess the clients lung sounds. - Take a full set of vital signs. - Notify the Rapid Response Team.

- Notify the Rapid Response Team. This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching? - I will take this medication when I start to experience an asthma attack. - I will be weaned off this medication when I no longer need it. - I will take this medication every morning to help prevent an acute attack. - I will carry this medication with me at all times in case I need it.

- I will take this medication every morning to help prevent an acute attack. Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3 = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? - Initiate oxygenation therapy to increase saturation to 92%. - Teach the client diaphragmatic breathing techniques. - Administer a short-acting beta2 agonist inhaler. - Document the findings as normal for a client with COPD

- Initiate oxygenation therapy to increase saturation to 92%. Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the clients hypoxia, which is the priority.

A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? - Insert the obturator and attempt to reinsert the tracheostomy tube. - Assess the patients oxygen saturation and notify the health care provider. - Position the patient in an upright position with the neck extended. - Ventilate the patient with a manual bag until the health care provider arrives.

- Insert the obturator and attempt to reinsert the tracheostomy tube. The first action should be to attempt to reinsert the tracheostomy tube to maintain the patients airway. Assessing the patients oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowlers position if reinsertion of the tracheostomy tube is not successful.

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) - International normalized ratio (INR): 6.3 - Prothrombin time: 35 seconds - Blood urea nitrogen (BUN): 19 mg/dL - Serum sodium: 130 mEq/L - White blood cell (WBC) count: 72,000/mm3

- International normalized ratio (INR): 6.3 - Prothrombin time: 35 seconds Rifampin can cause liver damage, evidenced by the clients high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this clients problem.

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, The medication is too expensive to use every day. I only use my inhaler when I have an attack. How should the nurse respond? - You are using the inhaler incorrectly. - This medication should be taken daily. - Tell me more about your fears related to feelings of breathlessness. - It is important to use this type of inhaler every day. Lets identify potential community services to help you. - If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks.

- It is important to use this type of inhaler every day. Lets identify potential community services to help you. Long-acting beta2 agonists should be used every day to prevent asthma attacks. This medication should not be taken when an attack starts. Asthma medications can be expensive. Telling the client that he or she is using the inhaler incorrectly does not address the clients financial situation, which is the main issue here. Clients with limited incomes should be provided with community resources. Asking the client about fears related to breathlessness does not address the clients immediate concerns.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? - Tell the client that he needs to quit smoking to stop further cancer development. - Encourage the client to be completely honest about both tobacco and marijuana use. - Avoid giving the client false hope regarding cancer treatment and prognosis. - Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

- Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs per day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Quitting smoking may not stop further cancer development. This statement would be giving the client false hope, which should be avoided, but is not as important as maintaining a nonjudgmental attitude.

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? - Keep the clients head elevated. - Make sure the string is taped to the clients cheek. - Assess the clients pain level. - Teach the client about the causes of nasal bleeding.

- Make sure the string is taped to the clients cheek. The string should be attached to the clients cheek to hold the packing in place. The nurse needs to make sure that this does not move because it can occlude the clients airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective.

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? - Encourage between-meal snacks. - Monitor temperature every 4 hours - Report any new onset of cough. - Provide oral care every 4 hours

- Provide oral care every 4 hours Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients is important to detect the onset of possible pneumonia but do not prevent it.

The nurse obtains this information when assessing a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important to report to the health care provider? - Anterior-posterior chest ratio is 1:1. - Lung expansion is decreased bilaterally. - Respirations are 36 breaths/minute. - Hyperresonance to percussion is present.

- Respirations are 36 breaths/minute. The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.

A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? - Cover the sucking chest wound firmly with an occlusive dressing. - Position the patient so that the right chest is dependent. - Tape a nonporous dressing on three sides over the chest wound. - Keep the head of the patients bed at no more than 30 degrees elevation.

- Tape a nonporous dressing on three sides over the chest wound. 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 right 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.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best? - The client needs immediate intubation and mechanical ventilation - The blood clot interferes with perfusion in the lungs. - Maybe the client has respiratory distress syndrome. - Breathing so rapidly interferes with oxygenation.

- The blood clot interferes with perfusion in the lungs. A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of the following assessment findings will require the most immediate action by the nurse? - The oxygen saturation is 89%. - The nose appears red and swollen. - The patients temperature is 100.1 F (37.8 C). - The patient complains of level 7 (0 to 10 scale) pain.

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

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that the problem identified in this nursing diagnosis is resolving? - The patient lets the spouse provide tracheostomy care. - The patient uses a communication board to request No Visitors. - The patient allows the nurse to suction the tracheostomy. - The patient asks how to clean the tracheostomy stoma and tube.

- The patient asks how to clean the tracheostomy stoma and tube. 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.

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene? - The student applies suction for 10 seconds while withdrawing the catheter. - The student preoxygenates the patient for 1 minute before suctioning - The student puts on clean gloves and uses a sterile catheter to suction. - The student inserts the catheter about 5 inches into the tracheostomy tube.

- The student puts on clean gloves and uses a sterile catheter to suction. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but 5 inches would be appropriate for most adult patients.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? - The client rates pain as a 5/10 at the site of the procedure - Pulse oximetry is 93% on 2 liters of oxygen. - The trachea is deviated toward the opposite side of the neck. - A small amount of drainage from the site is noted.

- The trachea is deviated toward the opposite side of the neck. A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal.

A patient with pneumonia has a fever of 101.2 F (38.5 C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is - impaired transfer ability related to weakness - hyperthermia related to infectious illness. - ineffective airway clearance related to thick secretions. - impaired gas exchange related to respiratory congestion.

- impaired gas exchange related to respiratory congestion. All these nursing diagnoses are appropriate for the patient, but the patients oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.