HA- chap 25, 26, 27, & 28
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 a. a large air leak in the water-seal chamber. b. 400 mL of blood in the collection chamber. c. complaint of pain with each deep inspiration. d. subcutaneous emphysema at the insertion site.
b. 400 mL of blood in the collection chamber
Which action will the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)? a. Explain reasons for NPO status. b. Administer sedative drug before PFT. c. Assess pulse and BP after the procedure. d. Teach deep inhalation and forceful exhalation.
d. Teach deep inhalation and forceful exhalation
The nurse has completed patient teaching about the administration of salmeterol (Serevent) using a metered-dose inhaler (MDI). Which action by the patient indicates good understanding of the teaching? a. The patient attaches a spacer before using the MDI. b. The patient coughs vigorously after using the inhaler. c. The patient floats the MDI in water to see if it is empty. d. The patient activates the inhaler at the onset of expiration
a. The patient attaches a spacer before using the MDI
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%
a. Weak, nonproductive cough effort
The teaching plan for a patient with acute sinusitis will need to include which of the following interventions (select all that apply)? a. Taking a hot shower will increase sinus drainage and decrease pain. b. Over-the-counter (OTC) antihistamines can be used to relieve congestion and inflammation. c. Saline nasal spray can be made at home and used to wash out secretions. d. Blowing the nose forcefully should be avoided to decrease nosebleed risk. e. You will be more comfortable if you keep your head in an upright position
a. Taking a hot shower will increase sinus drainage and decrease pain. b. Over-the-counter (OTC) antihistamines can be used to relieve congestion and inflammation c. Saline nasal spray can be made at home and used to wash out secretions e. You will be more comfortable if you keep your head in an upright position.
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? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patients temperature is 100.1 F (37.8 C). d. The patient complains of level 7 (0 to 10 scale) pain.
a. The oxygen saturation is 89%
Which of these patients in the respiratory disease clinic should the nurse assess first? a. A 23-year-old, complaining of a sore throat, who has a hot potato voice b. A 34-year-old who has a scratchy throat and a positive rapid strep antigen test c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed
a. A 23-year-old, complaining of a sore throat, who has a hot potato voice
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Administer the prescribed PRN morphine. b. Assist the patient to deep breathe and cough. c. Milk the chest tube gently to remove any clots. d. Tape the area around the insertion site of the chest tube.
a. Administer the prescribed PRN morphine
A patient with chronic hypoxemia (SaO2 levels of 89% to 90%) caused by chronic obstructive pulmonary disease (COPD) has been hospitalized with increasing shortness of breath. In planning for discharge, which of these actions by the nurse will be most effective in improving compliance with discharge teaching? a. Arrange for the patients spouse to be present during the teaching. b. Start giving the patient discharge teaching on the day of admission. c. Accomplish the patient teaching just before the scheduled discharge. d. Have the patient repeat the instructions immediately after the teaching.
a. Arrange for the patients spouse to be present during the teaching
After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Ask the patient whether medications have been taken as directed. b. Discuss the need to use some different medications to treat the TB. c. Schedule the patient for directly observed therapy three times weekly. d. Educate about using a 2-drug regimen for the last 4 months of treatment.
a. Ask the patient whether medications have been taken as directed
A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Educate the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.
a. Assist the patient to splint the chest when coughing
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? a. How much alcohol do you drink in an average week? b. Do you have a family history of head or neck cancer? c. Have you had frequent streptococcal throat infections? d. Do you use antihistamines for upper airway congestion?
a. How much alcohol do you drink in an average week?
After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says, a. I must keep the stoma covered with a loose sterile dressing at all times. b. I can participate in most of my prior fitness activities except swimming. c. I should wear a Medic Alert bracelet that identifies me as a neck breather. d. I need to be sure that I have smoke and carbon monoxide detectors installed
a. I must keep the stoma covered with a loose sterile dressing at all times
A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective? a. I will need to buy a water bottle to carry with me. b. I should not use any lotions on my neck and throat. c. Until the radiation is complete, I may have diarrhea. d. Alcohol-based mouthwashes will help clean oral ulcers.
a. I will need to buy a water bottle to carry with me
A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Insert the obturator and attempt to reinsert the tracheostomy tube. b. Position the patient in an upright position with the neck extended. c. Assess the patients oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag until the health care provider arrives.
a. Insert the obturator and attempt to reinsert the tracheostomy tube
A patient who was admitted the previous day with pneumonia complains of a sharp pain whenever I take a deep breath. Which action will the nurse take next? a. Listen to the patients lungs. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patients health care provider.
a. Listen to the patients lungs
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? a. Respirations are 36 breaths/minute. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.
a. Respirations are 36 breaths/minute
Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis? a. Your urine, sweat, and tears will be orange colored. b. Read a newspaper daily to check for changes in vision. c. Take vitamin B6 daily to prevent peripheral nerve damage. d. Call the health care provider if you notice any hearing loss.
a. Your urine, sweat, and tears will be orange colored
A 32-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of emphysema. The nurse will anticipate teaching the patient about a. a1-antitrypsin testing. b. use of the nicotine patch. c. continuous pulse oximetry. d. effects of leukotriene modifiers.
a. al-antitypsin testing
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 a. elevate the head of the bed to 45 to 60 degrees. b. administer the ordered pain medication. c. notify the patients health care provider. d. offer emotional support and reassurance.
a. elevate the head of the bed to 45 to 60 degrees
The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP a. lower the head of the patients bed to 10 degrees. b. splint the patients chest during coughing. c. help the patient to ambulate to the bathroom. d. assist the patient to a bedside chair for meals.
a. lower the head of the patients bed to 10 degrees
A patient with chronic bronchitis who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that a. one drug decreases inflammation, and the other is a bronchodilator. b. Advair is a combination of long-acting and slow-acting bronchodilators. c. the combination of two drugs works more quickly in an acute asthma attack. d. the two drugs work together to block the effects of histamine on the bronchioles.
a. one drug decreases inflammation, and the other is a bronchodilator
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 a. paradoxic chest movement. b. the complaint of chest wall pain. c. a heart rate of 110 beats/minute. d. a large bruised area on the chest.
a. paradoxic chest movement
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 a. use and side effects of isoniazid (INH). b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. bacille Calmette-Gurin (BCG) vaccine.
a. use and side effects of isoniazid (INH)
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 a. yellow-tinged skin. b. changes in hearing. c. orange-colored sputum. d. thickening of the fingernails.
a. yellow-tinged skin
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. A 56-year-old patient who is allergic to eggs b. A 36-year-old female patient who is pregnant c. A 42-year-old patient who has a 15 pack-year smoking history d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-year-old patient who has allergies to penicillin and the cephalosporins
b. A 36-year-old female patient who is pregnant d. a 30-year-old patient who takes corticosteroids for rheumatoid arthritis
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? a. Monitor for bleeding. b. Assess breath sounds. c. Clean the inner cannula every 8 hours. d. Avoid changing the tracheostomy ties.
b. Assess breath sounds
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? a. Would you like to talk to the hospital chaplain about your feelings? b. Can you tell me what it is that makes you think you will die so soon? c. Are you afraid that the treatment for your cancer will not be effective? d. Do you think that taking an antidepressant medication would be helpful?
b. Can you tell me what it is that makes you think you will die soon?
The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider? a. Fever of 100.4 F (38 C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache
b. Diffuse crackles in the lungs
The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. Is there any family history of TB? b. Have you received the bacille Calmette-Gurin (BCG) vaccine for TB? c. How long have you lived in the United States? d. Do you take any over-the-counter (OTC) medications?
b. Have you received the bacille Calmette-Gurin (BCG) vaccine for TB?
A patient with a chronic cough has a bronchoscopy. Which action will be included in the nursing care plan after the procedure? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours postbronchoscopy. d. Notify the health care provider about blood-tinged mucus.
b. Keep the patient NPO until the gag reflex returns
A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have a. intercostal retractions b. Kussmaul respirations c. a low oxygen saturation (SpO2) d. a decrease in venous O2 pressure.
b. Kussmaul respirations
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? a. BP is 150/90 mm Hg. b. Oxygen saturation is 89%. c. Pain level is 5/10 with a deep breath. d. Respiratory rate is 24 when lying flat.
b. Oxygen saturation is 89%
When the nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack, which finding is the best indicator that the therapy has been effective? a. No wheezes are audible. b. Oxygen saturation is >90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute.
b. Oxygen saturation is >90%
Which action should the nurse take first when a patient develops a nosebleed? a. Pack both nares tightly with 1/2-inch ribbon gauze. b. Pinch the lower portion of the nose for 10 minutes. c. Prepare supplies that will be needed for cauterization. d. Apply ice compresses over the patients nose and cheeks.
b. Pinch the lower portion of the nose for 10 minutes
Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
b. Place patients with altered consciousness in side-lying positions
Which nursing actions will be included when sending a patient for computed tomography (CT) of the chest with contrast (select all that apply)? a. Ask the patient about any claustrophobia. b. Question the patient about allergies to iodine. c. Avoid administration of bronchodilator drugs. d. Have the patient remove wedding bands or any other jewelry. e. Review the recent blood urea nitrogen (BUN) and creatinine levels.
b. Question the patient about allergies to iodine e. Review the recent blood urea nitrogen (BUN) and creatinine levels
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? a. Assessing the patients risk for aspiration b. Suctioning the tracheostomy when needed c. Educating the patient about self-care of the tracheostomy d. Determining the need for replacement of the tracheostomy tube
b. Suctioning the tracheostomy when needed
When the nurse is analyzing the results of a patients arterial blood gases (ABGs), which finding indicates the need for most immediate action? a. The arterial oxygen saturation (SaO2) is 92%. b. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The bicarbonate level (HCO3) is 29 mEq/L.
b. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg
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? a. The student preoxygenates the patient for 1 minute before suctioning. b. The student puts on clean gloves and uses a sterile catheter to suction. c. The student inserts the catheter about 5 inches into the tracheostomy tube. d. The student applies suction for 10 seconds while withdrawing the catheter.
b. The student puts on clean gloves and uses sterile catheter to suction
When performing an assessment of the patients respiratory system, the nurse uses the following illustrated technique to evaluate a. bronchophony. b. chest expansion. c. accessory muscle use. d. diaphragmatic excursion.
b. chest expansion
On auscultation of a patients lungs, the nurse hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. The nurse records this finding as a. expiratory crackles at the bases. b. expiratory wheezes in both lungs. c. abnormal lung sounds in the bases of both lungs. d. pleural friction rub in the right and left lower lobes.
b. expiratory wheezes in both lungs
During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. vesicular breath sounds. b. increased tactile fremitus. c. dry, nonproductive cough. d. hyperresonance to percussion.
b. increased tactile fremitus
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 a. computed tomography (CT) screening for lung cancer. b. options for smoking cessation. c. reasons for annual sputum cytology testing. d. erlotinib (Tarceva) therapy to prevent tumor risk.
b. options for smoking cessation
A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to a. start a peripheral intravenous line to administer the necessary sedative drugs. b. position the patient sitting upright on the edge of the bed and leaning forward. c. remove the water pitcher and remind the patient not to eat or drink anything for 6 hours. d. instruct the patient about the importance of incentive spirometer use after the procedure.
b. position the patient sitting upright on the edge of the bed and leaning forward
A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if a. the BP is less than 140/90 mm Hg. b. the patient reports decreased exertional dyspnea. c. the heart rate is between 60 and 100 beats/minute. d. the patients chest x-ray indicates clear lung fields.
b. the patient reports decreased exertional dyspnea
When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to a. check the pilot balloon after inflation to ensure that it is firm. b. use a manometer to ensure cuff pressure is at an appropriate level. c. check the amount of cuff pressure ordered by the health care provider. d. fill the balloon until minimal air leakage around the cuff is auscultated.
b. use a manometer to ensure cuff pressure is at an appropriate level
After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first? a. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)
c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath
After the nurse has received change-of-shift report, which of these patients should be assessed first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity c. A patient with possible lung cancer who has just returned after bronchoscopy d. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
c. A patient with possible lung cancer who has just returned after bronchoscopy
The nurse palpates the posterior chest while the patient says 99 and notes that no vibration is felt. How should this be charted? a. Diminished expansion b. Dullness to percussion c. Absent tactile fremitus d. Decreased breath sounds
c. Absent tactile fremitus
While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which action should the nurse take next? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.
c. Administer the PRN supplemental O2
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action will be included in the plan of care? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube.
c. Assess the ability to swallow before using the fenestrated tube
The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB a. demonstrates correct use of a nebulizer. b. washes dishes and personal items after use. c. covers the mouth and nose when coughing. d. reports daily to the public health department.
c. Covers the mouth and nose when coughing
When assessing the respiratory system of a 78-year-old patient, which finding indicates that the nurse should take immediate action? a. The chest appears barrel shaped. b. The patient has a weak cough effort. c. Crackles are heard from the lung bases to the midline. d. Hyperresonance is present across both sides of the chest.
c. Crackles are heard from the lung bases to the midline
After discussing management of upper respiratory infections (URI) with a patient who has acute viral rhinitis, the nurse determines that additional teaching is needed when the patient says a. I can take acetaminophen (Tylenol) to treat discomfort. b. I will drink lots of juices and other fluids to stay hydrated. c. I can use my nasal decongestant spray until the congestion is all gone. d. I will watch for changes in nasal secretions or the sputum that I cough up.
c. I can use my nasal decongestant spray until the congestion is all gone
Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? a. I will call the doctor if I still feel tired after a week. b. I will need to use home oxygen therapy for 3 months. c. I will continue to do the deep breathing and coughing exercises at home. d. I will schedule two appointments for the pneumonia and influenza vaccines.
c. I will continue to do the deep breathing and coughing exercises at home
A patient seen in the asthma clinic has recorded daily peak flows that are 85% of the baseline. Which action will the nurse plan to take? a. Teach the patient about the use of oral corticosteroids. b. Administer a bronchodilator and recheck the peak flow. c. Instruct the patient to continue to use current medications. d. Evaluate whether the peak flow meter is being used correctly.
c. Instruct the patient to continue to use current medications
After a patient has undergone a rhinoplasty, which nursing intervention will be included in the plan of care? a. Educate the patient about how to safely remove and reapply nasal packing. b. Reassure the patient that the nose will look normal when the swelling subsides. c. Instruct the patient to keep the head elevated for 48 hours to minimize swelling and pain. d. Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control
c. Instruct the patient to keep the head elevated for 48 hours to minimize swelling and pain
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit up at the bedside. b. Splint the patients chest during coughing. c. Medicate the patient with the prescribed morphine. d. Have the patient use the prescribed incentive spirometer.
c. Medicate the patient with the prescribed morphine
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take? a. Repeat the tuberculin skin testing. b. Teach about the reason for the blood tests. c. Obtain consecutive sputum specimens from the patient for 3 days. d. Instruct the patient to expectorate three specimens as soon as possible
c. Obtain consecutive sputum specimens from the patient for 3 days
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? a. Position the patient so that the right chest is dependent. b. Keep the head of the patients bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.
c. Tape a nonporous dressing on three sides over the chest wound
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? a. The patient lets the spouse provide tracheostomy care. b. The patient allows the nurse to suction the tracheostomy. c. The patient asks how to clean the tracheostomy stoma and tube. d. The patient uses a communication board to request No Visitors.
c. The patient asks how to clean the tracheostomy stoma and tube
A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for a a. positron emission tomography (PET) scan. b. chest x-ray. c. bronchoscopy. d. spiral computed tomography (CT) scan.
d. spiral computed tomography (CT) scan
The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use? a. The patient says there have been no acute asthma attacks during the last year. b. The patient became very short of breath an hour before coming to the hospital. c. The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days. d. The patient has been taking acetaminophen (Tylenol) 650 mg every 6 hours for chest-wall pain.
c. The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days
Which information obtained by the nurse about a patient who has been diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider? a. The Mantoux test had an induration of only 8 mm. b. The chest-x-ray showed infiltrates in the upper lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.
c. The patient is being treated with antiretrovirals for HIV infection
Which action by a patient who has asthma indicates a good understanding of the nurses teaching about peak flow meter use? a. The patient records an average of three peak flow readings every day. b. The patient inhales rapidly through the peak flow meter mouthpiece. c. The patient uses the albuterol (Proventil) metered-dose inhaler (MDI) for peak flows in the yellow zone. d. The patient calls the health care provider when the peak flow is in the green zone.
c. The patient uses the albuterol (Proventil) metered-dose inhaler (MDI) for peak flows in the yellow zone
The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? a. The BP is 98/56 mm Hg. b. The oxygen saturation is 94%. c. The patients central intravenous line is disconnected. d. The international normalized ratio (INR) is prolonged.
c. The patients central intravenous line is disconnected
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patients white blood cell (WBC) count is 9000/l. d. Increased tactile fremitus is palpable over the right chest.
c. The patients white blood cell (WBC) count is 9000/1
The nurse is observing a student who is listening to a patients lungs. Which action by the student indicates a need to review respiratory assessment skills? a. The student compares breath sounds from side to side. b. The student listens only over the posterior part of the chest. c. The student places the stethoscope over the scapulae and then auscultates. d. The student starts at the base of the posterior lung and moves to the apices.
c. The student places the stethoscope over the scapulae and then auscultates
When auscultating a patients chest while the patient takes a deep breath, the nurse hears loud, high-pitched, blowing sounds at both lung bases. The nurse will document these as a. normal sounds. b. vesicular sounds. c. abnormal sounds. d. adventitious sounds.
c. abnormal sounds
A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first? a. guaifenesin (Robitussin) b. acetaminophen (Tylenol) c. azithromycin (Zithromax) d. codeine phosphate (Codeine)
c. azithromycin (Zithromax)
When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes a. positioning on the right side. b. bed rest for the first 24 hours. c. frequent use of an incentive spirometer. d. chest tubes to water-seal chest drainage.
c. frequent use of an incentive spirometer
The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and a. ask the patient to say a few sentences. b. monitor for signs of respiratory distress. c. have the patient drink a small amount of grape juice and observe for coughing. d. auscultate the lungs for crackles after having the patient take a few sips of water.
c. have the patient drink a small amount of grape juice and observe for coughing
When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patients room. b. hands the patient a tissue from the box at the bedside. c. puts on a surgical face mask before visiting the patient. d. brings food from a fast-food restaurant to the patient.
c. puts on a surgical face mask before visiting the patient
When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patients ability to swallow, it is important to a. clean the inner cannula of the tracheostomy tube before deflation. b. deflate the cuff during the inhalation phase of the respiratory cycle. c. suction the patients mouth and trachea before deflation of the cuff. d. insert exactly the same volume of air into the cuff during reinflation.
c. suction the patients mouth and trachea before deflation of the cuff
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Educating the patient about the long-term impact of TB on health b. Giving the patient written instructions about how to take the medications c. Teaching the patient about the high risk for infecting others unless treatment is followed d. Arranging for a daily noontime meal at a community center and giving the medication then
d. Arranging for a daily noontime meal at a community center and giving the medication then
After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states a. I will make an appointment to see the doctor every year. b. I will not turn the home oxygen up higher than 2 L/minute. c. I will not worry if I feel a little short of breath with exercise. d. I will call the health care provider right away if I develop a fever.
d. I will call the health care provider right away if I develop a fever.
Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? a. Administer aspirin suppository. b. Send to radiology for chest x-ray. c. Give ciprofloxacin (Cipro) 400 mg IV. d. Obtain blood cultures from two sites.
d. Obtain blood cultures from two sites
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Complete a full physical examination to determine the systemic effect of the respiratory distress. b. Obtain a comprehensive health history to determine the extent of any prior respiratory problems. c. Delay the physical assessment and ask family members about any history of respiratory problems. d. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.
d. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress
To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make? a. Lung sounds b. Heart sounds c. Blood pressure d. Peripheral edema
d. Peripheral edema
A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 96%. Which action should the nurse take next? a. Initiate rewarming of the patient. b. Complete a head-to-toe assessment. c. Obtain arterial blood gases (ABGs). d. Place the patient on high-flow oxygen.
d. Place the patient on high-flow oxygen
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? a. Teach about symptoms of lung disease. b. Treat workers who inhale dust particles. c. Monitor workers for shortness of breath. d. Require the use of protective equipment.
d. Require the use of protective equipment
When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the nurse position the patient? a. Supine with the head of the bed elevated 45 degrees. b. In the Trendelenburg position with both arms extended. c. On the left side with the right arm extended about the head. d. Sitting upright with the arms supported on an over bed table
d. Sitting upright with the arms supported on an over bed table
A patient with chronic bronchitis has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? a. Titrate oxygen to keep saturation at least 90%. b. Discuss a high-protein, high-calorie diet with the patient. c. Suggest the use of over-the-counter sedative medications. d. Teach the patient how to effectively use pursed lip breathing.
d. Teach the patient how to effectively use pursed lip breathing
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? a. Are you afraid that the surgery will be very painful? b. Did you have bad experiences with previous surgeries? c. Surgery is the treatment of choice for stage I lung cancer. d. Tell me what you know about the various treatments available.
d. Tell me what you know about the various treatments available
When the nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD), which information will help most in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patients history indicates a 40 pack-year cigarette history. c. The patient denies having any respiratory problems until the last 6 months. d. The patient complains about a productive cough every winter for 3 months.
d. The patient complains about a productive cough every winter for 3 months
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is most important to communicate to the health care provider before the CT? a. The apical pulse is 102. b. The respiratory rate is 32. c. The oxygen saturation is 93%. d. The patient is allergic to shellfish.
d. The patient is allergic to shellfish
Which information about a newly admitted patient with chronic obstructive pulmonary disease (COPD) indicates that the nurse should consult with the health care provider before administering the prescribed theophylline? a. The patient has had a recent 10-pound weight gain. b. The patient has a cough productive of green mucus. c. The patient denies any shortness of breath at present. d. The patient takes cimetidine (Tagamet) 150 mg daily.
d. The patient takes cimetidine (Tagamet) 150 mg daily
Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.
d. Three sputum smears for acid-fast bacilli are negative
Which information will the nurse include when teaching the patient with asthma about the prescribed medications? a. Utilize the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry-powder inhaler (DPI). c. Hold your breath for 5 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators
d. Tremors are an expected side effect of rapidly acting bronchodilators
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, How will I talk after the surgery? The best response by the nurse is, a. You will breathe through a permanent opening in your neck, but you will not be able to communicate orally. b. You wont be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed. c. You wont be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally. d. You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.
d. You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.
When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that a. over-the-counter (OTC) antihistamines cause sedation, so prescription antihistamines are usually ordered. b. corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. c. use of oral antihistamines for a few weeks before the allergy season may prevent reactions. d. identification and avoidance of environmental triggers are the best way to avoid symptoms.
d. identification and avoidance of environmental triggers are the best way to avoid symptoms
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 a. hyperthermia related to infectious illness. b. impaired transfer ability related to weakness. c. ineffective airway clearance related to thick secretions. d. impaired gas exchange related to respiratory congestion.
d. impaired gas exchange related to respiratory congestion
When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for a. emergency pericardiocentesis. b. stabilization of the chest wall with tape. c. administration of an inhaled bronchodilator. d. insertion of a chest tube with a chest drainage system.
d. insertion of a chest tube with a chest drainage system
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. An appropriate intervention for this problem is to a. increase the patients intake of fruits and fruit juices. b. have the patient exercise for 10 minutes before meals. c. assist the patient in choosing foods with a lot of texture. d. offer high calorie snacks between meals and at bedtime.
d. offer high calorie snacks between meals and at bedtime
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? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
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 a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the surgeon of a possible pneumothorax. d. take no further action with the collection device.
d. take no further action with the collection device
When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to a. avoid eating or drinking for several hours before the testing. b. use rescue medications immediately before the tests are done. c. take oral corticosteroids at least 2 hours before the examination. d. withhold bronchodilators for 6 to 12 hours before the examination.
d. withhold bronchodilators for 6 to 12 hours before the examination
