Exam 1: Oxygenation
What is the pathophysiology of an acute attack of extrinsic asthma? A. A hypersensitivity reaction involving the release of chemical mediators B. Gradual degeneration and fibrosis C. Continuous severe attacks unresponsive to medication D. Hyper-responsive mucosa
A
A 35-year-old recent immigrant is being seen in the clinic for symptoms of a cough associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. Based on these findings, what is the most likely cause? A. Tuberculosis B. Pulmonary edema C. Pneumonia D. Bronchitis
A
Destruction of alveolar walls and septae is a typical change in: A. Acute asthma B. Chronic bronchitis C. Asbestosis D. Emphysema
D
A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)? A. Turn the client every 2 hours or as needed B. Apply water-soluble ointment to nares and lips C. Periodically turn the oxyygen down or off D. Replaces the oxygen tubing with a different type
B
A nurse is teaching a client about the importance of using a spacer on their inhaler. The nurse should explain that a spacer is useful because: A. allows a greater amount of medication to be delivered into the lungs B. keeps the mouthpiece sterile C. allows for activating the medication cannister by simply inhaling D. allows the client to see the medication as it is being delived
A
A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication? A. Sedation B. Constipation C. Hypertension D. Bradycardia
A Diphenhydramine can cause sedation. It is used to treat rhinitis, allergies, and insomnia. Diphenhydramine can cause diarrhea, hypotension, and palpitations.
A nurse preparing to administer intravenous gentamicin to a patient notes that the dose is half the usual dose for an adult. The nurse suspects that this is because this patient has a history of: A. antibiotic resistance B. interpatient variation C. liver disease D. renal disease
D Gentamicin is an aminoglycoside (a - Mean - O), which can be mean to the kidneys and ears.
The central chemoreceptors in the medulla are normally most sensitive to: A. low oxygen level B. low concentration of hydrogen ions C. elevated oxygen level D. elevated carbon dioxide level
D We talked about this in class today - in a healthy person, increasing CO2 (acid) levels cause increase in RR; people who have chronic CO2 retention (hypercapnia) will flip to an O2 drive - meaning a low oxygen saturation level stimulates breathing. We gave credit for all answers on this one.
A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? A. Carries out gas exchange B. Regulates tidal volume C. Produces hemoglobin D. Stores oxygen
A
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment B. A room with another nonsurgical client C. A room in the ICU D. A room that is within view of the nurses station
A
A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching? A. The client holds his breath for 10 seconds after inhaling the medication B. The client takes a quick inhalation while releasing the medication from the inhaler C. The client exhales as the medication is released from the inhaler D. The client waits 10 minutes between inhalations
A
What are the primary muscles of respiration? A. Diaphragm and intercostals B. Sternomastoids and scaleni C. External obliques and pectoralis major D. Trapezii and rectus abdominis
A
What causes the expanded anteroposterior (A-P) thoracic diameter (barrel chest) in patients with emphysema? A. Air trapping and hyperinflation B. Persistent coughing to remove mucus C. Recurrent damage to lung tissues D. Dilated bronchi and increased mucous secretions
A
Why does cor pulmonale (right-sided heart failure) develop with chronic pulmonary disease? A. Pulmonary fibrosis and vasoconstriction increase vascular resistance B. Demands on the left ventricle are excessive C. The right ventricle pumps more blood than the left ventricle D. Blood viscosity is increased, adding to cardiac workload
A
A nurse is caring for a client who is receiving oxygen at 2L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration? A. 28% B. 36% C. 50% D. 70%
A A flow rate of 4L/minute delivers an oxygen concentration of about 36%. Simple face masks deliver oxygen of 40%-60% with flow rates of 5L/min or greater. A nonrebreather mask with a reservoir bag with a minimum flow rate of 10 L/min can deliver oxygen concentrations of 60%-80%.
A nurse is auscultating a clients lung sounds and identified crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breathe deeply and cough B. Instruct the client to limit fluid intake to less than 2,000 mL/day C. Prepare to administer antibiotics D. Place the client on bed rest in semi-Fowlers position
A Although crackles can indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or cough. It is premature to impose fluid restrictions based on a one-time finding of adventitious lung sounds. Although pulmonary infections such as pneumonia and bronchitis can cause crackles, it is premature to assume that infection is the cause of this clients crackles. It is premature to impose activity restrictions at this time. Semi-fowlers position can help ease breathing, but it will not resolve crackles.
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Suction 2-3 times with a 60 second pause between passes B. Perform chest physiotherapy prior to suctioning C. Lubricate the suction catheter tip with sterile saline D. Hyperventilate the client on 100% oxygen prior to suctioning
A Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia. Chest physiotherapy mobilizes secretions, but does not remove them. Lubricating the tip has no effect on the removal of secretions. Hyperventilating has no effect on the removal of secretions.
A nurse is auscultating the lungs of a client who has pleurisy. Which of the following sounds should the nurse expect to hear? A. Loud, scratchy sounds B. Squeaky, musical sounds C. Popping sounds D. Snoring sounds
A Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy. Squeaky, musical sounds caused by the air whoosh through narrowed airways are a manifestation of bronchospasms. Popping sounds caused by moving into deflated airways are a manifestation of atelectasis and pneumonia. Snoring sounds, known as rhonchi, are heard when a client has thick, tenacious secretions.
A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect? A. Lethargy B. High-grade fever C. Weight gain D. Dry cough
A Manifestations of pulmonary tuberculosis include lethargy, and fatigue. A low-grade fever is a manifestation of pulmonary tuberculosis. Weight loss is a manifestation of pulmonary TB. A productive cough is a manifestation of pulmonary TB. The client who has pulmonary TB often has purulent sputum streaked with blood.
A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5L/min via a nasal cannula. Which of the following actions should the nurse take? A. Attach a humidifier bottle to the base of the flow meter B. Remove the nasal cannula while the client eats C. Secure the oxygen tubing to the bed sheet near the clients head D. Apply petroleum jelly to the nares as needed to soothe mucous membranes
A Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4L/min via a nasal cannula. An advantage of the nasal cannula is that the client can continue to receive oxygen therapy while eating, drinking, and speaking. The nurse should maintain sufficient slack and secure the oxygen tubing to the clients clothing. The nurse should apply water soluble lubricant as needed to soothe mucous membranes.
A nurse is caring for a client who has hypertension and asks the nurse about a prescription for Propanolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions? A. Asthma B. Glaucoma C. Depression D. Migraines
A Propanolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause bronchospams. Propanolol blocks the sympathetic stimulation, which prevents smooth muscle relaxation. Beta-blockers are contraindicated in clients who have cardiogenic shock, AV heart block. Beta-blockers are used for prophylactic treatment of migraine headaches.
A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-base imbalances should the nurse identify the client as being at risk for developing initially? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids. Alkalosis occurs when there is an imbalance in the amount or strength of the bases. In cases of respiratory alkalosis, this occurs because of an excessive loss of CO2 through hyperventilation. It can occur in clients as a response to fear, anxiety, from a fever or salicylate overdose. Metabolic acidosis results due to an increase in the amount of acid or a decrease in the amount of base available. Its seen in starvation, diabetic ketoacidosis, renal failure, dehydration, and diarrhea. Metabolic alkalosis results from an increase in the amount of bases seen in massive blood transfusion or the administration of sodium bicarbonate, or a bicarbonate containing antacid. It can also occur related to an acid deficit, seen with prolonged vomiting, the use of thiazide diuretics, or prolonged gastric suctioning.
Obstruction in the upper airway is usually indicated by: A. stridor B. Rales C. wheezing D. orthopnea
A Stridor sounds like a donkey braying and indicates an obstruction in the larynx, like edema or a hot dog. It can also be associated with upper airway injury (punch) or epiglottitis in kids. Wheezing is a whistling sound associated with narrowing of the bronchi. Trending from least concerning to most: expiratory wheezing>>>>inspiratory and expiratory wheezing>>>>absent breath sounds. We accepted A & C.
A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching? A. "Do not adjust the oxygen flow rate." B. "Check your oxygen equipment once each week." C. "Store unused oxygen tanks horizontally." D. "Use wool blankets on your bed."
A The nurse should instruct the client not to adjust the flow rate to ensure that the client receives the prescribed rate. The client or caregiver should check equipment daily to ensure proper functioning. Store unused tanks upright to prevent injury to the client or the clients home. The client should avoid wool or material that can generate static electricity to reduce the risk for a fire.
A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate? A. Withhold food and liquids until the clients gag reflex returns B. Irrigate the clients throat every 4 hours C. Have the client refrain from talking for 24 hours D. Suction the clients oropharynx frequently
A Until the gag reflex returns, and the sedation effects have been resolved, the client is at high risk for aspirating food or fluids. Also, oxygen saturation should be checked every 15 minutes for 2 hours. Throat irrigations are unnecessary and could cause aspiration. Limitations on talking are unnecessary. Unless complications develop, suctioning is unnecessary.
A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Friction rub
B Atelectasis refers to the closure or collapse of the alveoli resulting in hypoxia. A client may develop cyanosis as a result. The postoperative client is at increased risk for developing atelectasis because of a blunted cough reflex or shallow breathing due to anesthesia, opioids, or pain medication. Common manifestations include shortness of breath and pleural pain. Because of the decreased oxygen exchange caused by the atelectasis, the client will be tachypneic in an effort to meet the bodys oxygen needs. A friction rub is grating or creaking sound heard when a client has inflammation of the pleura. For the client who has atelectasis, auscultation may reveal decreased breath sounds and crackles.
A nurse in a providers office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? SATA A. Night sweats B. Low grade fever C. Weight gain D. Flushed cheeks E. Blood in the sputum
A, B, E Weight loss, not weight fain, is a manifestation of TB. Flushed cheeks are a manifestation of pneumonia.
A nurse assisting a nursing student with medications asks the student to describe how penicillins (PCNs) work to treat bacterial infections. The student is correct in responding that penicillins: A. disinhibit transpetidases B. disrupt bacterial cell wall synthesis C. inhibit autolysins D. inhibit cell wall synthesis
B/D
A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? SATA A. Dyspnea B. Bradycardia C. Barrel chest D. Clubbing of the fingers E. Deep respirations
A, C, D Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Clients with emphysema lose lung elasticity, the diaphragm becomes permanently flatted by hyperinflation of the lungs, the muscles of the rib cage become rigid, and the ribs flare outwards. This produces the barrel chest. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back. Clients with emphysema lose lung elasticity and have muscle fatigue, consequently, respirations become increasingly shallow.
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next? A. Let the client have a small cup of water to see whether he or she can swallow B. Assess the client's gag reflex before giving any food or water C. Provide the client with ice chips instead o fa drink of water D. Call the primary health provider and request food and water for the client
B
A nurse is providing teaching instructions to a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack? A. Formoterol B. Albuterol C. Fluticasone D. Salmeterol
B
Orthopnea is: A. very, deep rapid respirations B. difficulty breathing when lying down C. waking up suddenly, coughing and struggling for breath D. noisy breathing with stridor or rhonchi
B
Oxygen diffuses from the alveoli to the blood because: A. P02 is higher in the blood B. PO2 is lower in the blood C. CO2 is diffusing out of the blood D. more CO2 is diffusing out of the cells into the blood
B
What is the cause of chronic bronchitis? A. Deficit of enzymes, preventing tissue degeneration B. Chronic irritation, inflammation, and recurrent infection of the larger airways C.A genetic defect causing excessive production of mucus D.Hypersensitivity to parasympathetic stimulation in the bronchi
B
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? A. A 26-year-old woman is 8 months pregant B. A 42-year-old woman with gastroesophageal reflux disease C. A 55-year-old woman who is 50 lbs overweight D. A 73-year-old man with type 2 diabetes mellitus
C
A nurse is preoviding discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? A. "If my breathing begins to feel tight, I will use the cromolyn immediately." B. "I will be sure to take the albuterol before taking the cromolyn." C. "I will use both medications immediately after exercising." D. "I will administer the medications 10 minutes apart."
B Cromolyn, a leukotriene modifier, is used for prophylaxis treatment of asthma, not acute attacks. Alburterol, a short acting bronchodilator, should be used for the treatment of acute bronchospasms. The client should always use the bronchodilator prior to using the leukotriene modifier because it allows the airways to be opened, ensuring the maximum dose of medication will get to the clients lungs. Both albuterol and cromolyn are used to prevent exercuse induced bronchospasm, but administration should be made prior to exercising. Inhalations of different medications should be administered 2 to 5 minutes apart.
A nurse is preparing to measure a clients level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apple the pulse oximeter to which of the following locations? A. Finger B. Earlobe C. Toe D. Skin Fold
B Edema of the hands and fingers interferes with blood circulation in the capillary bed. The oximeter probe many not be able to adequately detect hemoglobin molecules to provide an accurate reading. The earlobe is rarely edematous, is least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation. Thickening of the nails interferes with blood circulation in the capillary probe. A skin fold might not have adequate capillary circulation of hemoglobin molecules.
A patient with a cough has been advised to use guaifenesin. The patient asks the nurse to explain the purpose of the drug. The nurse will explain that guaifenesin: A. dries secretions to help suppress coughing so patients can rest B. helps stimulate the flow of secretions to increase cough productivity C. stimulates the body's natural immune responses. D. helps to relieve chest pain associated with a cough
B Guaifenesin liquefies secretions, helping the patient cough them up.
A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide the clients parent on administering the medication? A. give the medication in the morning daily B. Administer the medication 2 hours before exercise C. Give the medication at the onset of wheezing D. Administer the granules mixed with 20 oz of water
B Montelukast is a leukotriene receptor antagonist that is used to prevent asthma symptoms. It works by blocking the actions of leukotrienes (substances that cause inflammation, fluid retention, mucous secretion, and constriction) in the clients lungs. Due to the side effect of drowsiness, it is usually taken once a day in the evening. Montelukast should be given daily during the evening, except when being used for exercise-induced bronchospasm. It should then be given 2 hours before exercise and not given again for 24 hours. Montelukast is ineffective as a rescue medication. Montelukast granules should be taken directly or mixed with certain soft foods (applesauce, carrots, rice, or icecream).
A nurse is teaching a client who has COPD about ways to facilitate eating. Which of the following statements indicates a need for further teaching? A. "I will rest for at least 30 minutes before eating." B. "I will take my bronchodilators after meals." C. "I will eat five or six meals each day." D. "I will choose foods that are not gas forming."
B Resting before meals decreases fatigue, providing more energy during meals. Bronchodilators should be taken before meals, not after, in order to reduce shortness of breath. Eating small, frequent meals decreases shortness of breath. Abdominal bloating and a feeling of fullness often prevent clients from eating a full meal. They tire easily and tend to have anorexia.
A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? A. 14% B. 21% C. 28% D. 32%
B Room air is 21% oxygen. Each liter of oxygen on top of that is a 3 - 4% increase based on delivery device.
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurses priority? A. Increase the oxygen flow to 3 L/min B. Assess the clients respiratory status C. Call emergency services for the client D. Have the client cough and expectorate secretions
B The nurse might need to increase the oxygen flow, but this is not the priority action. For clients who have COPD, an oxygen flow of 2-4 L/min is appropriate. The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the clients respiratory status before determining the appropriate interventions. The nurse might have to call emergency services for the client, but this is not the priority action. The nurse might have to ask the client to cough effectively and expectorate secretions, but this is not the priority.
A nurse on a medical surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. Respiratory alkalosis B. Increased anteroposterior diameter of the chest C. Oxygen saturation level 96% D. Petechiae on chest
B The nurse should anticipate the clients arterial blood gases will report respiratory acidosis because there is increased arterial carbon dioxide. The nurse should anticipate an increased anteroposterior diameter of the chest because of the chronic hyperinflation of the lungs. The oxygen saturation level is within the expected reference range. The nurse should anticipate a decreased oxygen saturation level. The nurse should anticipate petechiae on the chest and abdomen for a client who has pulmonary embolism.
What is ipratropium bromide [Atrovent]? A. A cholinergic agent used for perennial rhinitis B. An anticholinergic used for allergic rhinitis and colds C. A medication that is used only in patients with asthma D. A drug that is inappropriate for use in patients with allergic rhinitis
B Think about the actions of anticholinergics - can't see, can't pee, can't spit, can't .... This works to decrease bronchoconstriction and airway edema.
A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? A. Patient is coughing B. Blood pressure increases to 120/86 C. Oxygen saturation decreases to 86% D. Heart rate increases to 85 bpm
C
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the clients recovery? A. It decreases the clients level of anxiety B. It facilitates the clients deep breathing C. It enhanced the clients ability to sleep D. It reduces the clients blood pressure
B When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids besides pain relief. Following thoracic type surgeries, the client has increased pain with moving, deep breathing, and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. All other answers are true, but not top priority.
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (SATA) A. Verify the oxygen flow rate every other day B. Check the cannula position on a regular basis C. Check the tops of the ears for skin breakdown D. Post "no smoking" signs in a prominent location in the home E. Apply petroleum jelly to nares if they become dry and irritated
B, C, D The rate of oxygen flow should be checked daily. The position of the nasal cannula should be verified every 8 hours or more often if needed. The tops of the ears, nares, and nasal mucous membranes should be assessed regularly for skin breakdown. The family is instructed to post "no smoking" signs in a prominent location in the home because oxygen increases the risk of fire injuries. Protecting the nares is important, but the client should use a water-based lubricant or saline nasal spray to reduce dryness and irritation. Oxygen has a high combustion potential, and petroleum products are combustible.
A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? SATA A. The medication will stimulate the flow of mucus B. The medication will prevent wheezing C. The medication will open the airways D. The medication will reduce inflammation E. The medication will decrease coughing episodes
B, C, E Expectorants stimulate the flow of mucus. Albuterol does not reduce inflammation. Coughing is often an early indicator of bronchospasm. Albuterol provides a rapid response to relax smooth muscle and reduce bronchoconstriction, which will decrease coughing
A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? A. Delivers a constant rate of a specific concentration of oxygen B. Delivers a high concentration of oxygen C. Delivers a low concentration of oxygen D. Restricts the clients ability to eat, speak, and drink
C A venturi mask delivers a specific concentration of oxygen at a constant rate of flow. A nonrebreather mask with a reservoir bag delivers a high concentration of oxygen. A nasal cannula delivers a low concentration of oxygen (24%-44%). The use of a face mask restricts the clients ability to eat, speak, or drink.
A nurse is caring for a client who is vomiting. Which of the following actions should the nurse take first? A. Provide the client with an emesis basin B. Notify housekeeping C. Prevent the client from aspirating D. Administer an antiemetic to the client
C All other answers are true, but not top priority.
A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? A. Pertussis B. Mycoplasma pneumonia C. Tuberculosis D. Respiratory Syncytial Virus
C All other choices are transmitted by large droplets and do not require the use of an N95 mask. The nurse should wear a fluid-resistant surgical mask when caring for a client who has pertussis, Mycoplasma pneumonia, or RSV.
A nurse is caring for a client with a tracheostomy. The clients partner had been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the clients discharge? A. Attending a class given about tracheostomy care B. Verbalizing all stages of the procedure C. Performing the procedure independently D. Asking appropriate questions about suctioning
C All other choices do not require the spouse to demonstrate competence in the procedure.
A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A. Observing for confusion B. Auscultating breath sounds C. Confirming the gag reflex D. Measuring blood pressure
C All other choices should be performed, but are not priority.
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently B. Encourage coughing and deep breathing C. Encourage the client to increase fluid intake D. Encourage regular use of the incentive spirometer
C Ambulation prevents the accumulation of respiratory secretions, but not thinning. Coughing and deep breathing promotes expectoration. Increasing fluid intake to 1500 to 2000 mL/day promotes liquefaction and thinning of pulmonary secretions which improves the clients ability to cough and remove their secretions. Using an incentive spirometer promotes expectoration, not thinning.
A nurse is providing discharge teaching instructions to a client who has asthma and a new prescription for fluticasone/ Salmeterol (Advair). For which of the following adverse effects should the nurse instruct the client to report to the provider? A. Sedation B. Increased appetite C. White coating in the mouth D. Dry oral mucous membranes
C Fluticasone is a steroid, which can cause thrush.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises B. Place suction equipment at the bedside C. Encourage the use of an incentive spirometer D. Administer an expectorant
C Range of motion exercises are not indicated to prevent pulmonary complications, but early ambulation is helpful to promote lung expansion and remove secretions. Suction equipment should be readily available, but its presence does not prevent pulmonary complications. Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent complications. Administering an expectorant is not indicated to prevent pulmonary complications, but the nurse should encourage the client to cough and deep breathe.
Select the statement related to tuberculosis: A. The microbe is present in the sputum of all patients with a positive TB skin test. B. The infection is transmitted primarily by blood from an infected person. C. TB is usually caused by an acid-fast bacillus, resistant to many disinfectants. D. The microbe is quickly destroyed by the immune response.
C Remember - a TB skin test tells you if the antibody is present, which could mean an old infection or an inactive infection. Sputum is only positive when there is an active infection in the lungs.
Light bubbly or crackling breathing sounds associated with serous secretions are called: A. rhonchi B. stridor C. rales D. wheezing
C Rhonchi is associated with thick secretion - sounds like blowing bubbles in a milk shake. Rales (AKA crackles) can be associated with thinner secretions, like water or blood, or atelectasis. We accepted A and C.
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? A. Maintenance of ideal weight B. Annual influenza immunization C. Smoking cessation D. Regular moderate exercise
C Staying at an ideal weight for height, frame, and gender will help most people maintain optimal health in general and cope with many chronic illnesses, but it is not a preventative strategy. Receiving an annual influenza vaccination is important for clients who have chronic bronchitis, but it will not prevent the development of chronic bronchitis. Smoking is a major cause of chronic bronchitis, therefore, smoking cessation is an effective preventative strategy. Regular moderate exercise is a healthful practice, but will not prevent the development of chronic bronchitis.
A nurse in a providers office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client? A. Bradycardia B. Night sweats C. Confusion D. Narrowed pulse pressure
C Tachycardia is a manifestation of pneumonia. Night sweats are manifestation of pulmonary tuberculosis. Confusion, weakness, and anorexia are manifestations of pneumonia in an older adult client. Narrowed pulse pressure is a manifestation of hypovolemic shock.
A nurse is evaluating teaching on a client who has a new prescription for Montelukast to treat asthma. Which of the following statements by the client indicates a good understanding of the teaching. A. I'll rinse my mouth after taking this medication B. I will take this medication when I get an asthma attack C. I'll take this medication once a day in the evening D. I'll use a spacer device when I inhaler this medication
C The 2nd most frequent response was rinsing the mouth (A). Montelukast is not an inhaled medication (A & D). It is not a "rescue" medication.... EBP shows it is more effective if taken at night.
A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? A. "I will inhale slowly through pursed-lips to help me breathe better." B. "I will avoid getting a flu shot." C. "I will follow a daily diet high in calories and protein." D. "I will lie on my stomach to practice abdominal breathing every day."
C The client should first inhale through the nose, then exhale through pursed lips. The client is at risk for respiratory infections. Therfore, the client should avoid crowds and should get an annual vaccination against influenza. Clients who have emphysema have greater than usual nutritional requirement for calories and protein and often need nutritional supplements between meals. The client should practice abdominal breathing exercises daily while lying on his back.
A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? A. Apnea B. Dysphagia C. Hypoxemia D. Pleural Effusion
C The nurse can expect to find the client with hypoxemia, which is decreased oxygenation of the RBC's and cyanosis due to poor oxygen exchange. The nurse can expect tachypnea, dyspnea, and pleural pain.
A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide? A. Consume a high-protein diet B. Administer the medication with food C. Avoid caffeine while taking this medication D. increase fluids to 1 L/day
C The nurse should instruct the client that a high-protein diet should be avoided, as it decreases theophyllines duration of action. The nurse should instruct the client that theophylline should be administered with 8 oz of water if GI upset occurs. It should not be administered with food. The nurse should instruct the client that caffeine should be avoided because it can increase central nervous system stimulation. The nurse should instruct the client to increase fluid intake to 2L/day to decrease the thickness of mucous secretions related to emphysema.
A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care? A. Use aseptic technique B. Clean the inner cannula with mild soap and water C. Secure new tracheostomy ties before removing old ones D. Apply suction when inserting the catheter
C The nurse should maintain sterile technique when providing tracheostomy care. The nurse should clean the inner cannula with sterile saline. Tube dislodgment and accidental decannulation are potential complications of a tracheostomy. Both can be prevented by securing the tube in place. By keeping the old ties in place while applying the new ties, the nurse can secure the tube and prevent dislodgment. The nurse should apply suction only when withdrawing the catheter. Applying suction during catheter insertion causes trauma to the tracheal mucosa.
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension
C The nurse would not expect the client to be nauseated during an asthma attack. The nurse should expect the client to display dyspnea, not dysphagia, during an asthma attack. The nurse should expect agitation due to neurological changes from poor oxygen exchange. The nurse should expect hypertension due to increased work load of the heart from decreased oxygenation.
A nurse is caring for a client whos arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mmHg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
C With uncompensated metabolic acidosis, the pH is less than 7.35 and the PaCO2 is less than 35 mmHg or within the expected range. With uncompensated metabolic alkalosis, the pH is greater than 7.45 and the PaCO2 is greater than 45 mmHg or within the expected reference range. With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mmHg. With uncompensated respiratory alkalosis, the pH is greater than 7.45 and the PaCO2 is less than 45 mmHg.
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? A. Crackles B. Rhonchi C. Stridor D. Wheezes
D Crackles are a series of short, interrupted, high-pitched sounds audible before the end of inspiration. The sound is similar to that of rolling hair between the fingers just behind the ear. Rhonchi are continuous rumbling, snoring, or rattling sounds resulting from fluid or mucus. Stridor is a continuous, shrill musical sound of constant pitch
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. What do these findings suggest? A. Lobar pneumonia B. Heart failure C. Atelectasis D. Asthma
D
A nurse is prioritizing care after receiving change of shift report. Which of the following clients should the nurse plan to see first? A. A client who is scheduled for an abdominal x-ray and is awaiting transport B. A client who has a prescription for discharge C. A client who received an oral pain medication 30 minutes ago D. A client who told an assistive personnel he is short of breath
D A client who is schedules for an abdominal x-ray and is awaiting transport is stable. The nurse should see the client before allowing her to leave the unit, however there is another client the nurse should see first. A client who has a prescription for discharge is stable. A client who received an oral pain medication 30 minutes ago is stable. The nurse should expect oral analgesia to reach peak effect after 1 hour. A client who has shortness of breath is unstable.
A patient with asthma will be using a metered-dose inhaler (MDI) for delivery of an inhaled medication. The provider has ordered 2 puffs to be given twice daily. It is important for the nurse to teach this patient that: A. the patient should inhale suddenly to receive the maximum dose. B. the patient should activate the device and then inhale. C. the patient should store the MDI in the refrigerator between doses. D. the patient should wait 1 minute between puffs.
D Allows for absorption of first puff. The patient should inhale slowly and deeply, holding the breath for several seconds to maximize dosing. MDIs don't need to be activated; dry powder inhalants do. MDIs do not need to be stored in the fridge.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a Semi-Fowlers position as often as possible B. Administering oxygen via a nasal cannula a 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2-3L of water daily
D Although a Semi-Fowlers position can help the client to breathe more easily, it will not alter the consistency of secretions. Administration of oxygen helps correct hypoxemia, but will not alter consistency of secretions. Although a low-salt diet can help limit peripheral edema, it will not alter consistency of secretions. Adequate fluid intake will help liquefy thick secretions and facilitate their expectoration.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurses highest priority? A. Initiating oxygen therapy B. Providing immediate rest for the client C. Positioning the client in high-Fowlers D. Administering a nebulized beta-adrenergic
D Clients who have an acute asthma exacerbation may require oxygen therapy, but this is not the highest priority. Adequate rest is essential for the clients recovery, but will not relieve the clients dyspnea and wheezing, so it is not the top priority. Although not the highest priority when a client has an acute exacerbation, it is important to position in High fowlers to manage dyspnea. This position promotes chest expansion and optimal gas exchange. The greatest risk to the clients safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority.
A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects? A. Hypoglycemia B. Hypertension C. Polyuria D. Oral Candidiasis
D Fluticasone, a corticosteroid, can cause hyperglycemia. Fluticasone does not cause hypertension. Fluticasone does not cause polyuria. Fluticasone can cause oral candidiasis, or thrush, therefore the client should rinse her mouth with water
A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? A. Reduces inflammation B. Suppresses the urge to cough C. Dries mucous membranes D. Stimulates secretions
D Glucocorticoids reduce inflammation. Antitussives suppress the cough stimulus. Anticholinergic medications dry mucous membranes and reduce secretions. Expectorants act by increasing secretions to improve a coughs productivity.
A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel
D Pectus cainatum is an overgrowth of cartilage that causes the sternum to protrude forward, creating a pigeon-shaped chest. Pectus excavatum is a congenital chest deformity that causes a funnel or concave chest shape. A kyphotic chest results from curvature of the spine that produces a hunchback effect. Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped.
A nurse is caring for a client who has been diagnosed with tuberculosis and has been given new prescriptions for rifampin and pyrazinamide. Which of the following laboratory test should the nurse inform the client will be required while on this medication? A. Thyroid function studies B. Hemoglobin and hemacrit C. Blood glucose levels D. Liver function studies
D Pyrazinamide can cause liver toxicity and LFTs need to be monitored.
A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation? A. Restlessness B. Retractions C. Dependent edema D. Clubbing of the fingers
D Restlessness is an early manifestation of inadequate oxygenation. Retractions are a manifestation of increased work with breathing or dyspnea, not chronic respiratory insufficiency. Dependent edema is a manifestation of heart failure, not chronic respiratory insufficiency. The nurse should expect the client who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen and the ends of the fingers and toes can increase in size.
A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication? A. Constipation B. Black-colored stools C. Staining of teeth D. Red-colored urine
D Rifampin does not cause constipation. More common gastrointestinal effects are diarrhea and nausea. It is most commonly iron supplements that cause stools to turn black. Teeth may be stained from taking liquid iron preparations. Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." B. "I'll sleep better if I take a sleeping pill at night." C. "I'll get a humidifier to run at my bedside at night." D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
D The flat, supine position increases the chance of obstructing the airway. Hypnotics aggravate sleep apnea and can also cause increased daytime somnolence. Bedside humidifiers are an effective way to help clients who have thick pulmonary secretions, but they do not help sleep apnea. Excessive weight is one of the three major risk factors associated with sleep apnea and is the only one the client can modify.
A nurse is caring for a client who has returned to the unit following a surgical procedure. The clients oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2L/min B. Administer prescribed analgesic medication C. Encourage coughing and deep breathing D. Raise the head of the bed
D The nurse should assess the client further and implement less invasive interventions before applying oxygen at 2 L/min. Pain management promotes increased participation by the client in coughing and deep breathing, frequent position changes, and the use of the incentive spirometer, but this is not the action the nurse should take first. Coughing and deep breathing promotes lung expansion and prevents respiratory infection, but these actions are not effective immediately by increasing oxygen saturation. Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway.
A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia
D The nurse should expect to find rapid, shallow respirations and dyspnea, not bradypnea. The nurse should expect to find restlessness and agitation, not somnolence. The nurse should expect to find cyanosis in late stages of hypoxia. The nurse should expect the client with hypoxia to manifest tachycardia.
A nurse in the emergency department is assessing an older adult client who has community acquired pneumonia. Which of the following findings should the nurse expect? A. Unequal pupils B. Hypertension C. Tympany upon chest percussion D. Confusion
D Unequal pupils are an expected finding for a client who has increased intracranial pressure. Hypotension is an expected finding for a client who has pneumonia. Dull sounds upon chest percussion is an expected finding for a client with pneumonia. Confusion due to hypoxemia is an expected finding for an older adult who has pneumonia.
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the clients fluid intake to less than 2 L/day B. Provide the client with a low-protein diet C. Have the client use the early-morning hours for exercise and activity D. Instruct the client to use pursed-lip breathing
D Unless the client has another medical disorder that warrants fluid restriction, he should drink 2-3L if fluid daily. Clients who have COPD should consume a high-calorie, high-protein diet to prevent weight loss. Clients who have COPD have poor exercise tolerance in the early morning due to the pulmonary secretions that accumulate while the client has been recumbent. Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This reduces airway resistance and decreases trapped air for clients who have COPD.
